Oncovascular Surgery for Soft-Tissue Sarcomas of the Lower Limbs with Vascular Contact: Comparison of Arterial Reconstruction and Arterial Subadventitial Dissection

BACKGROUND

Soft-tissue sarcomas represent approximately 1% of adult malignancies. When they involve the lower limbs (LLs) and come into contact with blood vessels, the therapeutic choice was historically a primary amputation. Today, radical surgical resection with wide margins of safety is the primary therapeutic option for multidisciplinary limb-salvage surgery. The aim was to compare the morbidity and mortality results of an oncologic resection of LL soft-tissue sarcomas with arterial replacement (AR) to that obtained with arterial subadventitial dissection (ASD).

METHODS

All consecutive patients with arterial close contact soft-tissue sarcomas of LL were included. Two groups were formed: an AR group where AR was performed following surgical resection and an ASD group in which the artery in contact with the tumor was preserved by ASD. Fisher's exact test was used.

RESULTS

Eighteen patients with a median age of 61.50 (interquartile range [IQR] 54.25-69.75) years underwent oncovascular surgery with orthopedic and vascular surgeons between August 2013 and May 2022. Sarcomas were all located in the thigh. Nine patients were enrolled in each of the 2 groups. The 6-month survival rate was 77.78% in the AR group and 100% in the ASD group (P = 0.4). In the AR group, 2 patients presented local recurrence, with a median recurrence-free time of 24.48 (IQR 14.08-34.87) months, and 2 patients presented distant metastases, with metastasis-free time of 13.45 (IQR 8.12-35.11) months. In the ASD group, no local recurrence was observed, and 2 patients presented metastases with a median metastasis-free time of 3.90 (IQR 3.18-4.61) months. Six patients in the AR group and 7 in the ASD group required surgical revision (P = 0.017). No major amputation was necessary.

CONCLUSIONS

Oncovascular surgery for LL sarcomas with ASD is certainly more locally morbid perioperatively than that with AR but provides patients with better medium-term survival.

Surgical Treatment of Multiple Venous and Arterial Aneurysms Due to Arteriovenous Malformations of the Arm

Introduction

Arteriovenous malformations (AVMs) are rare, especially in elderly patients. Occasionally, AVM can produce aneurysmal degenerations, which can lead to bleeding or rupture. The aim of this case report was to describe the surgical treatment of large arterial and venous aneurysms in the arm associated with an AVM.

Report

An 83 year old woman of White ethnicity who was a non-smoker presented with a large pulsatile aneurysm at the left elbow with paresis of the first three fingers. The diagnosis was made by duplex ultrasonography (DUS), computed tomography angiography (CTA), and arteriography. Additional tests confirmed aneurysms of the brachial artery and the outflow veins, with the largest more than 7 cm in diameter. A very proximal brachial artery bifurcation and increased venous flow were noted. DUS confirmed the AVM by showing continuous flow in the axillary vein. The decision for surgical resection involved vascular surgeons, radiologists, angiologists, and anaesthetists. Treatment involved opening and excision of multiple venous aneurysms and AVMs. A short segment of the aneurysmal brachial artery was also resected and repaired with end to end anastomosis. The deep brachial artery which supplied AVMs and venous aneurysms was ligated and excision of these lesions was performed. At one year follow up, there were no complications and the revascularisation was patent.

Discussion

Arterial and venous aneurysms occurring together with AVMs are rare and not well documented in the medical literature. In this case, surgical intervention, including resection with direct anastomosis of the arterial aneurysm coupled with excision of venous aneurysms and AVM, proved to be effective, as evidenced by stable post-operative outcomes after one year.

Editor's Choice - Infra-inguinal Endovascular Revascularisation and Bypass Surgery for Chronic Limb Threatening Ischaemia: a Retrospective European Multicentre Cohort Study with Propensity Score Matching

OBJECTIVE

The aim of this study was to compare the long term efficacy of lower limb bypass with that of endovascular treatment (EVT) in patients with chronic limb threatening ischaemia (CLTI).

METHODS

This retrospective, multicentre study evaluated the outcomes of patients with CLTI who underwent first time infra-inguinal bypass or EVT. The primary outcome was to compare amputation free survival (AFS) rates between the two propensity score matched groups. The secondary outcome was to compare wound healing within the first six months. Major adverse events were compared according to the type of revascularisation.

RESULTS

Overall, 793 patients fulfilled the eligibility criteria, from whom 236 propensity score matched pairs were analysed. The mean follow up was 52 months. The 236 bypass procedures included 190 autogenous bypass grafts (80.5%), 151 (64.0%) of which were infrapopliteal. Among the 236 EVT procedures, the target lesion was the femoropopliteal segment in 81 patients (34.3%), the femoropopliteal and infrapopliteal segments in 101 patients (42.8%), and the infrapopliteal segment in 54 patients (22.9%). AFS was significantly better in the bypass group at five years (60.5 ± 3.6%) compared with the EVT group (35.3 ± 3.6%) (p < .001). Major amputation occurred in 61 patients (25.8%) in the bypass group and 85 patients (36.0%) in the EVT group (HR 0.66, 95% CI 0.47 - 0.92; p = .014). The probability of healing was significantly better in the bypass group at six months compared with the EVT group (p = .003). The median length of stay was shorter for the EVT group (4 days) than for the bypass group (8 days) (p = .001). Urgent re-intervention and re-admission rates were high and did not differ significantly between the groups.

CONCLUSION

This study has shown that lower limb bypass surgery offered a significantly higher probability of AFS and wound healing compared with EVT in patients with CLTI.

Calcium in the (Big) Pipes: Intra-TEVAR Calcifications!

Introduction

Calcification of a vascular endograft and adjacent tissues (adventitia, media, and neointima) can result in graft failure. This report shows a rare case of intraluminal calcifications in the distal end of a thoracic endovascular aortic repair (TEVAR) endograft implanted 11 years previously for grade IV blunt traumatic aortic injury (BTAI) in a young patient.

Report

A 24 year old man required TEVAR for a BTAI caused by a motorcycle accident. The procedure consisted of TEVAR and an emergency left carotid subclavian venous bypass. Eleven years after the procedure, he had severe hypertension. Intra-TEVAR calcifications appeared, gradually increasing on computed tomography angiography (CTA). Calcifications in the distal luminal end of the TEVAR were responsible for a 60% stenosis on CTA. An open approach was indicated after multidisciplinary discussion, based on the gradient value. The patient underwent explantation, with total replacement of the aortic arch and descending thoracic aorta with re-implantation of the supra-aortic vessels, under extracorporeal circulation. Macroscopic analysis showed no device degeneration but revealed a solid mass at the distal end of the TEVAR. Both microcomputed tomography and histopathology confirmed the calcific nature of the lesions.

Conclusion

This case highlights a rare long term graft failure due to calcified neo-atherosclerosis in a TEVAR.

Mortality and Delays of Management of Acute Mesenteric Ischemia: The Need of a Dedicated Program

BACKGROUND

To study the mortality and delays of management of patients with acute mesenteric ischemia (AMI) admitted to the emergency department of a tertiary hospital and identify risk factors for 1-month mortality.

METHODS

A single-center and retrospective study including all consecutive patients treated for AMI from January 2008 to December 2018 was conducted. Short- and medium-term survival was studied with a Kaplan-Meier analysis. Delays before diagnosis and surgical intervention were collected. To determine factors associated with mortality at 1 month postoperatively, univariate and multivariate analyzes were performed.

RESULTS

The survival rate of the 67 included patients was 55.22% at 1 month and 37.31% at 1 year. In-hospital mortality was 50.74%. The average delay between admission and diagnosis was 4.83 ± 5.03 hr (95% confidence interval [CI], 3.60-6.05), and the delay between admission and surgical treatment was 10.64 ± 8.80 hr (95% CI, 8.49-12.79). The independent variables associated with an increased mortality at 1 month postoperatively in the univariate analysis were age >65 years old (odds ratio [OR] = 3.52; P = 0.046), lactate >3.31 mmol/l at admission (H₀) (OR = 7.38; P < 0.001), lactate >3.32 mmol/l on day 1 (H₂₄) (OR = 5.60; P = 0.002), creatinine >95.9 μmol/l at H₀ (OR = 4.66; P = 0.004), aspartate aminotransferase (AST) >59 U/l at H₀ (OR = 3.55; P = 0.017), and having hypertension as comorbidity (OR = 9.32; P = 0.040). Early curative anticoagulation (z = -2.4; P = 0.016) was an independent protective factor for mortality, and lactate >3.31 mmol/l at H₀ (z = 2.62; P = 0.009) was an independent predictor factor of mortality at 1 month postoperatively in the multivariate analysis.

CONCLUSION

AMI remains a serious and lethal condition with delays of surgical management remaining too long due to a lack of a dedicated therapeutic protocol allowing an early diagnosis.

Efficacy of a Drug-Eluting Stent Versus Bare Metal Stents for Symptomatic Femoropopliteal Peripheral Artery Disease: Primary Results of the EMINENT Randomized Trial

BACKGROUND

A clear patency benefit of a drug-eluting stent (DES) over bare metal stents (BMSs) for treating peripheral artery disease of the femoropopliteal segment has not been definitively demonstrated. The EMINENT study (Trial Comparing Eluvia Versus Bare Metal Stent in Treatment of Superficial Femoral and/or Proximal Popliteal Artery) was designed to evaluate the patency of the Eluvia DES (Boston Scientific, Marlborough, MA), a polymer-coated paclitaxel-eluting stent, compared with BMSs for the treatment of femoropopliteal artery lesions.

METHODS

EMINENT is a prospective, randomized, controlled, multicenter European study with blinded participants and outcome assessment. Patients with symptomatic peripheral artery disease (Rutherford category 2, 3, or 4) of the native superficial femoral artery or proximal popliteal artery with stenosis ≥70%, vessel diameter of 4 to 6 mm, and total lesion length of 30 to 210 mm were randomly assigned 2:1 to treatment with DES or BMS. The primary effectiveness outcome was primary patency at 12 months, defined as independent core laboratory-assessed duplex ultrasound peak systolic velocity ratio ≤2.4 in the absence of clinically driven target lesion revascularization or surgical bypass of the target lesion. Primary sustained clinical improvement was a secondary outcome defined as a decrease in Rutherford classification of ≥1 categories compared with baseline without a repeat target lesion revascularization. Health-related quality of life and walking function were assessed.

RESULTS

A total of 775 patients were randomly assigned to treatment with DES (n=508) or commercially available BMSs (n=267). Baseline clinical, demographic, and lesion characteristics were similar between the study groups. Mean lesion length was 75.6±50.3 and 72.2±47.0 mm in the DES and BMS groups, respectively. The 12-month incidence of primary patency for DES treatment (83.2% [337 of 405]) was significantly greater than for BMS (74.3% [165 of 222]; P<0.01). Incidence of primary sustained clinical improvement was greater among patients treated with the DES than among those who received a BMS (83.0% versus 76.6%; P=0.045). The health-related quality of life dimensions of mobility and pain/discomfort improved for the majority of patients in both groups (for 66.4% and 53.6% of DES-treated and for 64.2% and 58.1% of BMS-treated patients, respectively) but did not differ significantly. At 12 months, no statistical difference was observed in all-cause mortality between patients treated with the DES or BMS (2.7% [13 of 474] versus 1.1% [3 of 263]; relative risk, 2.4 [95% CI, 0.69-8.36]; P=0.15).

CONCLUSIONS

By demonstrating superior 1-year primary patency, the results of the EMINENT randomized study support the benefit of using a polymer-based paclitaxel-eluting stent as a first-line stent-based intervention for patients with symptomatic peripheral artery disease attributable to femoropopliteal lesions.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02921230.

[Coverage of an infected Deep femoral arteria vascular graft bypass by pediculated chimeric antero- lateral thigh flap associated with a vastus lateral muscle]

Scarpa triangle defects with exposure of femoral bypass are challenging to treat. The authors present the case of a 46 years-old male with a groin defect of 10×18cm with an exposure on 5cm of an allograft of the deep femoral artery. Bypass was performed in emergency because of a limb ischemia with deep femoral artery thrombosis and aneurysm of the superficial femoral artery. The reconstructive surgery may propose a large musculo-cutaneous flap to fill the dead spaces surrounding the infected bypass, the flap should be vascularized by the deep femoral arteria, could not be the rectus abdominals flap because of the precedent abdominal incision. The homolateral pediculated ALT-flap with vastus lateral component appeared to be a good solution because of its versatility and the low morbidity of the donor site.

RISK FACTORS OF LONG-TERM INCISIONAL HERNIA AFTER OPEN SURGERY FOR ABDOMINAL AORTIC ANEURYSM: A BICENTRIC STUDY

INTRODUCTION

Conventional open surgery is still important beside endovascular surgery in the management of abdominal aortic aneurysms, with less reinterventions in the long-term follow-up. Incisional hernias are the major complication open surgery in the mid- and long term. The occurrence of this late complication could be due to the choice of the incision, median or transverse. The objectives of our retrospective and bicentric study were to characterize the long-term risk factors for incisional hernias after open surgery for abdominal aortic aneurysms, in particular by comparing the two types of laparotomy, and to determine the prevalence of the operated and not operated incisional hernias.

MATERIALS AND METHODS

Between January 2009 and December 2011, all the patients having elective open surgery for abdominal aortic aneurysm (AAA) by midline laparotomy at the University hospital of Besancon or by transversal laparotomy at the University Hospital of Strasbourg were included retrospectively. The demographic data, the time of diagnosis of the incisional hernia and the parietal reinterventions were collected during a 5-year postoperative follow-up. A univariate and multivariate Cox model was used for the statistical analysis to determine the long-term risk factors for the appearance of an incisional hernia.

RESULTS

During the study period, 223 patients presenting with AAA were included, 112 of them were operated by a midline laparotomy and 111 by a transverse laparotomy. The mean age of the patients was 69 ± 8,4years and 208 (93.3%) were men. The 5-year prevalence of incisional hernias was 14.3% (32), and 20 of these hernias (9%) had to be operated. Eighteen hernias (16.1%) occurred after a midline laparotomy and 14 (12.6%) after a transverse incision (P = 0.30). In univariate analysis, obstructive chronic pulmonary disease was the only significant risk factor for incisional hernia (P = 0.01) and an age over 65 years appeared to protect against this risk (P = 0.049). These results were confirmed by multivariate analysis, which showed that obstructive chronic pulmonary disease was an independent risk factor for incisional hernia (HR = 2.35, 95% CI 1.16-4.75), and that an age over 65 years was a protective factor (HR = 0.49 95% IC 0.00-0.99).

CONCLUSION

The type of laparotomy did not modify the rate of incisional hernias. We showed that only 9% of the patients had to be operated to treat an incisional hernia during the first five years after surgery for AAA in our bicentric study. Chronic obstructive pulmonary disease was the only independent risk factor for the occurrence of an incisional hernia.

Arterial Embolization of Polycystic Kidneys for Heterotopic Transplantation

INTRODUCTION

The purpose of this study was to evaluate the efficacy of polycystic kidney embolization, performed to reduce kidney volume before heterotopic kidney transplantation, as this technique could be an alternative to pretransplant nephrectomy.

MATERIALS AND METHODS

All patients who underwent pretransplant embolization of polycystic kidneys were included in a prospective register from June 2014 to February 2020. All patients underwent computed tomography (CT) scan with volumetric reconstruction (OsiriX, Bernex, Switzerland) before embolization and were then followed up at 3 and 6 months after embolization. Primary outcome was percentage of kidney volume reduction. Secondary outcomes were 30 day mortality and morbidity.

RESULTS

Thirty-one embolizations performed on 29 patients (medium age = 55.6; 62.1% male) were included between June 2014 and February 2020. All patients were under dialysis before embolization (9 peritoneal dialysis and 20 hemodialysis). Technical success was observed in 96.8% of cases. Mean procedural time was 65 minutes (range = 35-106 minutes) and mean length of in-hospital stay was 3.8 days (range = 3-6 days). A volume reduction allowing a kidney transplant was obtained for 28 patients (96.5%). The mean volume reduction was 39.9% (range = 6.01-68.2). The main observed complication was postembolization pain in 10 cases (32.2%). One patient needed complementary nephrectomy due to insufficient volume reduction. Twenty-three patients (79.3%) received renal transplant during follow-up with a mean delay of 19.5 month (range = 4-54).

CONCLUSION

Polycystic kidney embolization is an effective and safe minimally invasive technique. It can be proposed as the first-choice technique for kidney transplant recipients as an alternative to pretransplantation nephrectomy.

Vascular grafts collagen coating resorption and healing process in humans

Background

The objective of the present study was to evaluate the bioresorption rate of collagen coating (CC) sealed on textile vascular grafts (VGs) and their healing in humans using histologic analysis of explanted VGs.

Methods

A total of 27 polyester textile VGs had been removed during surgery from 2012 to 2020. The segments underwent histologic assessment. The CC bioresorption rate was assessed using morphometric analysis to determine the internal and external capsule thickness, inflammatory reaction degree, presence of neovessels, and endothelial cell layer.

Results

A total of 27 VGs were explanted from 25 patients because of infection (n = 5; 18.5%), thrombosis (n = 7; 25.9%), stenosis (n = 2; 7.4%), rupture (n = 4; 14.8%), aneurysmal degeneration (n = 3; 11.1%), revascularization (n = 4; 14.8%), or another cause (n = 2; 7.4%), with a median implantation duration of 291 days (interquartile range [IQR], 48-911 days). VGs with remaining CC (n = 7; 26%) had been explanted earlier than had those without (n = 20; 74%; 1 day [IQR, 1-45 days] vs 516 days [IQR, 79-2018 days]; P = .001). After 1 year, no remaining CC was detected on the analyzed VG sections. VGs implanted for <90 days had had a greater CC maximal thickness (63.90 μm [IQR, 0-83.25 μm] vs 0 μm [IQR, 0-0 μm]; P = .006) and a greater CC surface coverage (180° [IQR, 0°-360°] vs 0° [IQR, 0°-0°]; P = .002) than those implanted for >90 days. VGs implanted for >90 days had a greater external capsule thickness (889.2 μm [IQR, 39.6-1317 μm] vs 0 μm [IQR, 0-0 μm]; P = .002), a higher number of inflammatory mononuclear cells and giant cells (168 cells [IQR, 110-310 cells] vs 0 cells [IQR, 0-94 cells]; P < .0001) and a higher number of neovessels (4 [IQR, 0-5] vs 0 [IQR, 0-0]; P = .001) than those implanted for <90 days.

Conclusions

CC had a slow bioresorption rate in humans. Complete healing was never achieved, with no endothelial coverage observed. This finding implies that CC might not help graft healing.

The objective of the present study was to evaluate the bioresorption rate of collagen coating (CC) sealed on explanted textile vascular grafts (VGs) and their healing in humans using histologic analyses. We found that CC had a slow bioresorption rate in humans. Complete healing was never achieved, and no endothelial coverage was observed. Therefore, we question their use in daily practice because the faster healing potential of CC VGs has been an argument advanced by manufacturers for their use. Knowledge of the mechanisms of graft healing is necessary to understand the success and failure of the current bypass grafts.

X-Ray Exposure Time in Dedicated Academic Simulation Programs Is Realistic To Patient Procedures

Objective

To ascertain whether simulated endovascular procedures are comparable to real life operating room (OR) procedures, particularly with regard to irradiation time.

Methods

This was a retrospective study comparing simulation with clinical data. Fluoroscopy time and overall operation time were compared between simulated abdominal aortic endovascular repair (EVAR) and iliac procedures that were performed, respectively, from 2016 to 2019 and from 2015 to 2019, and clinical EVAR and iliac procedures performed in the OR between January 2018 and November 2021.

Results

Within the defined periods, 171 simulated procedures (91 EVAR, 80 iliac) and 199 clinical procedures (111 EVAR, 88 iliac) were performed. For both EVAR and iliac procedures, median total procedure time was much longer during real surgery (p < .001). However, median total fluoroscopy time remained the same, whether the procedure was real surgery or performed on the simulator, for iliac procedures (8.47 minutes in the OR, 8.35 minutes on the simulator, p = .61) and for EVAR procedures (14.80 minutes in the OR, 15.00 minutes on the simulator p = .474).

Conclusion

Simulated endovascular procedures are comparable with real life OR procedures, particularly with regard to irradiation time when integrated in a dedicated curriculum.

•

Simulation is a necessary tool for trainee education in vascular surgery.

•

Simulation training must reflect real situations in the operating room.

•

Xray exposure must be as low as possible.

•

Radiation safety must be taught in simulation.

•

Xray exposure time in academic simulation programs was realistic to real life.

Computed-tomography-based predictive scores of surgical complications to help decision-making in enrolling obese patients in kidney transplantation list

This study aimed at developing scores predicting surgical complications in obese transplant recipients, based on preoperative computed tomography (CT) parameters. All consecutive patients with a body mass index (BMI) ≥ 30 kg/m² who underwent kidney transplantation between 2012 and 2019 were included. The preoperative CT parameters were assessed: total fatty surface (TFS), subcutaneous fatty surface (SFS), iliac vessel to skin distance (VSD), and abdominal perimeter (AP). Per- and postoperative complications (vascular, urinary, parietal, and digestive complications) within 30 days were listed. Predictive models of surgical complications were generated based on the results of the logistic regression. Among the 163 patients included, 53 (32.5%) experienced surgical complications. The AP was a risk factor for complications in multivariate analysis (OR: 1.050; 95% CI: 1.016-1.087; p = 0.03). Two predictive models of complications were created based on the statistical analysis: a one-variable model based on AP (sensitivity 86.8%, specificity 41.8%, area under the curve (AUC) 65.3, with a cutoff value of 107 cm) and a five-variable model based on BMI, TFS, SFS, VSD, and AP (sensitivity 73.6%, specificity 57.3%, AUC 66.2). These models, based on patient morphometric measurements, could allow predicting the occurrence of surgical complications in obese candidates for kidney transplantation.

Robotic Surgery For in situ Renal Artery Aneurysm Repair: Technical Note and Literature Review About a Mini- Invasive Alternative

CASE REPORT

Classical surgical options for renal artery aneurysm (RAA) are usually restricted to endovascular surgery or open repair, either using an in-situ or ex-situ approach. A 45-year-old woman presenting with a 20-mm complex RAA with hilum location, not suitable for endovascular repair renal was treated with a mini-invasive robotic approach. This approach allowed an in-situ reconstruction in a complete mini-invasive manner with the Da Vinci Xi robot (Intuitive Surgical, Sunnyvale, CA). The robotic system was used for both surgical exposure and aneurysmectomy with patch closure. Clamping time was 38 minutes (warm ischemia), total operative time was 210 minutes.

LIITERATURE REVIEW

A comprehensive literature review was performed concerning the studies reporting a robotic approach for RAA. Main outcomes of interest were surgical technique, total operative time, clamping time, blood loss and postoperative renal function. Seven studies were identified, reporting a total of 20 RAAs. Most of the RAA were treated by aneurysmoraphy (n=9). Median total operative time varied between 228 and 300 min (range: 155 - 360 minutes), median clamping time varied between 26 and 44 minutes (range: 10 - 82 minutes). Median blood loss was comprised between100 and 150 mL (range: 25 - 650 mL). No alteration of renal function in the early post-operative period was reported.

CONCLUSION

RAA in-situ repair with a robotic approach is feasible and safe and should be considered as an alternative to open surgical repair when endovascular technique cannot be an option.

Radiation-induced lower-limb arteriopathy: report of 4 cases and systematic literature review

INTRODUCTION

Radiation-induced arteriopathy (RIA) is a rare complication but may become more common due to the increased use of radiotherapy and the prolonged survival of patients. There is still a lack of evidence concerning treatment options. The aim of this study is to review reported cases of lower-limb RIA in order to provide guidelines for management.

EVIDENCE ACQUISITION

We reported 4 cases treated for lower limb RIA and performed a systematic literature review without time limitation in the Medline database using the MeSh tems "iliac artery/radiation effects" OR "femoral artery/radiation effects." Main outcomes of interest were radiation dose, time before symptoms, symptoms, involved vessels, treatment and outcome.

EVIDENCE SYNTHESIS

Twenty-five studies were included, reporting a total of 43 patients. Median time between irradiation and symptoms was 12 years (range: 9 days-49 years), with a median irradiation dose of 40Gy. Clinical presentation was claudication in 18 patients (52%), critical limb threatening ischemia (CLTI) in 4 patients (11%), acute limb ischemia (ALI) in 3 patients (9%) and hemorrhage in 6 patients (17%), the remaining 4 patients were asymptomatic (11%). Vessels involved were iliac arteries in 65% of the cases, femoropopliteal arteries in 28% of cases and concomitant supra and infrainguinal vessels in 7% of the cases. Claudication was mostly treated by open surgery (62%). Treatment of CLTI included primary amputation (50%), open surgery (25%) or endovascular surgery (25%). ALI was treated medically (33%), by open surgery (33%) or in situ thrombolysis (33%). Hemorrhagic cases or pulsatile masses were mostly treated by open surgery (66%). Follow-up was reported in 26 patients (67%), with mean follow-up of 12 months (range: 2 weeks - 5 years). During follow-up, 16% of these patients presented a recurrence of symptoms, and 8% required a reintervention.

CONCLUSIONS

There seems to be no evidence for open versus endovascular treatment, but close and long-term follow-up is needed in these patients due to the possible late presentation and recurrence of symptoms after treatment.

Clinical trial outcomes and thoracic aortic morphometry after one year with the Valiant Navion stent graft system

AUTHORS' NOTE

On February 17, 2021, Medtronic Incorporated issued a global voluntary recall of the Valiant Navion Thoracic Stent Graft System (the device under study in the Valiant Evo Global Clinical Program that is the subject of this publication), and instructed physicians to immediately cease use of the Valiant Navion system and return any unused product. Medtronic initiated the recall in response to three clinical trial subjects recently observed with stent fractures, two of whom have confirmed type IIIb endoleaks. The data collection, analysis, and manuscript submission occurred before the notice of this recall, and, specifically, the 100 procedures reviewed for this series were free of events at 1 year related to the reason for this device recall. The authors of this article and the manufacturer were unaware of the recently detected adverse events at the time of the preparation of the manuscript, and the 1-year trial results, and imaging-based analyses described are unchanged. Management of thoracic aortic aneurysms continues to be a challenging problem and outcomes are dependent on patient anatomy. The present publication focuses on the importance of achieving proximal and distal seals and the consideration of the temporal changes of the aortic morphology as a part of the TEVAR planning process. The authors believe there is still scientific merit in disclosing this information, despite the current nonavailability of the Valiant Navion system.

OBJECTIVE

The Valiant Navion stent graft system (Medtronic Inc, Santa Rosa, Calif) is a third-generation device with improved conformability. We have reported the 1-year clinical trial outcomes, with a focus on an imaging-based analysis of the aortic morphology. We assessed the effects of graft implantation on the native anatomy and the effects of the 1-year changes in thoracic aorta morphology on the original seal zones of the stent graft.

METHODS

A total of 100 subjects were enrolled in a prospective single-arm clinical trial investigating the Valiant Navion stent graft system. An independent core laboratory (Syntactx, New York, NY) assessed the anatomic characteristics and performance outcomes.

RESULTS

Through 1 year of follow-up, the freedom from all-cause mortality, aneurysm-related mortality, and secondary procedures was 89.8%, 97.0%, and 94.8% respectively. Of the 100 patients, 5 had undergone a total of six secondary procedures, and 9 patients had developed an endoleak (type Ia and Ib in 1, type Ia in 1, type Ib in 3, and type II in 4 patients) within the first year. After 1 year, 2 of 76 patients (2.6%) had had an increase in their maximum aneurysm diameter of ≥5 mm, 62 (81.6%) had had stable sacs, and 12 (15.8%) had experienced sac shrinkage. Although no deployment failures had occurred, 36 of the 100 proximal (36%) and 31 of the 100 distal (31%) attachment zones were considered short according to our definitions. The stent graft had conformed to the native anatomy at implantation, because the preprocedural thoracic aorta tortuosity (1.45 ± 0.02) had not significantly changed at 1 month after implantation (1.46 ± 0.02). Despite a natural increase in thoracic tortuosity after 1 year (1.49 ± 0.02), wall apposition had been maintained over time, as evidenced by the low endoleak rates. Aortic elongation and dilation had occurred at the proximal end of the graft by an average of 1.2 mm and 1.6 mm, respectively. Aortic remodeling was more pronounced at the distal end, with an average increase of 4.2 mm in length and 2.8 mm in diameter.

CONCLUSIONS

The included patients had had positive 1-year outcomes with high freedom from mortality, endoleak development, and secondary procedures. Aortic elongation and dilation were more prevalent at the distal end, emphasizing the importance of distal attachment zone consideration as part of preoperative planning. Because aortic remodeling can be expected to continue over time, additional follow-up and imaging analysis in the trial will be necessary to assess the aortic morphology and its effects on stent graft performance.

Current status on vascular substitutes

In the last decades, the main evolution in the field of vascular surgery was correlated to the development and introduction of vascular substitutes. Currently, two types of synthetic vascular substitutes have been widely adopted: polyethylene terephthalate and expanded polytetrafluoroethylene. Ideally, they should demonstrate a behavior as close as possible as that of human arteries in terms of mechanical and biological properties. However, no vascular substitute has been found to compare with the patency rates of gold-standard autologous conduits, and major drawbacks of current vascular substitutes remain both thrombogenicity and infectability.

Compliance of Textile Vascular Prostheses Is a Fleeting Reality

OBJECTIVE

Compliance is considered to be a major property influencing the long term performances of synthetic vascular substitutes that could play a role in anastomotic false aneurysm and intimal hyperplasia stenosis onset. Over the last decades, manufacturers have tried to develop substitutes that mechanically mimic arterial properties and avoid a compliance mismatch at the anastomoses in particular. However, data are missing about how initial compliance properties could change with time. The goal of this study was to evaluate how the compliance of vascular grafts evolves under cyclic loading conditions in vitro.

METHODS

The compliance of three different models of commercially available textile polyethylene terephthalate (PET) grafts was evaluated. Tests were performed with and without their original coating. Compliance was assessed with a specific device dedicated to measure the deformations undergone by a graft under cyclic pressure loading conditions, using image analysis software. In each experiment, image analysis was performed under 60 and 140 mmHg pressure loading conditions at loading start (H0) and after three, six, and 24 h (H3, H6, H24) loading time. Average radial, longitudinal, and volumetric compliance was calculated from the obtained images.

RESULTS

Twenty-four samples were tested. Results demonstrate that all values decreased significantly within only a few hours. On average, the loss of compliance after 3 h of cyclic loading ranged on average from 35% for longitudinal compliance to 39% for radial compliance and 37% (p < .050) for volume compliance. After 24 h, the loss of radial, longitudinal and volume compliance was respectively 63 ± 3%, 60.5 ± 2% and 61 ± 7%.

CONCLUSION

In this in vitro model, PET graft compliance has already decreased significantly within 3 h. The rapid loss of compliance identified in this experimental study helps explain the mismatch mentioned in clinical observations.

Computed Tomography-Aortography Versus Color-Duplex Ultrasound for Surveillance of Endovascular Abdominal Aortic Aneurysm Repair

Background

Color-duplex ultrasonography (DUS) could be an alternative to computed tomography-aortography (CTA) in the lifelong surveillance of patients after endovascular aneurysm repair (EVAR), but there is currently no level 1 evidence. The aim of this study was to assess the diagnostic accuracy of DUS as an alternative to CTA for the follow-up of post-EVAR patients.

Methods

Between December 16, 2010, and June 12, 2015, we conducted a prospective, blinded, diagnostic-accuracy study, in 15 French university hospitals where EVAR was commonly performed. Participants were followed up using both DUS and CTA in a mutually blinded setup until the end of the study or until any major aneurysm-related morphological abnormality requiring reintervention or an amendment to the follow-up policy was revealed by CTA. Database was locked on October 2, 2017. Our main outcome measures were sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratios of DUS against reference standard CTA. CIs are binomial 95% CI.

Results

This study recruited prospectively 659 post-EVAR patients of whom 539 (82%) were eligible for further analysis. Following the baseline inclusion visit, 940 additional follow-up visits were performed in the 539 patients. Major aneurysm-related morphological abnormalities were revealed by CTA in 103 patients (17.2/100 person-years [95% CI, 13.9–20.5]). DUS accurately identified 40 patients where a major aneurysm-related morphological abnormality was present (sensitivity, 39% [95% CI, 29–48]) and 403 of 436 patients with negative CTA (specificity, 92% [95% CI, 90–95]). The negative predictive value and positive predictive value of DUS were 92% (95% CI, 90–95) and 39% (95% CI, 27–50), respectively. The positive likelihood ratio was 4.87 (95% CI, 2.9–9.6). DUS sensitivity reached 73% (95% CI, 51–96) in patients requiring an effective reintervention.

Conclusions

DUS had an overall low sensitivity in the follow-up of patients after EVAR, but its performance improved meaningfully when the subset of patients requiring effective reinterventions was considered.

Registration

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01230203.

Usefulness of Platelet-to-Lymphocyte Ratio as a Marker of Sarcopenia for Critical Limb Threatening Ischemia

BACKGROUND

Sarcopenia is a factor of poor prognosis for patients with critical limb threatening ischemia (CLTI), but its diagnosis requires imaging measurements and is time consuming. We investigated whether preoperative platelet-to-lymphocyte ratio (PLR) could be an easy and rapid marker of sarcopenia.

METHODS

Patients treated for CLTI between January 2019 and July 2019 were included in this single-center retrospective study. Sarcopenia was defined by a psoas muscle index (PMI) <5.5 cm²/m² in men, and <4.0 cm²/m² in women. PLR was calculated for all patients based on their systematic preoperative blood analysis. The diagnostic power of PLR was analyzed through a receiver operating characteristic (ROC) curve. Early outcomes of sarcopenic patients in terms of 30-day mortality and 30-day morbidity were retrieved.

RESULTS

Sixty-four patients were included in the study: 48 nonsarcopenic patients (mean PMI 7.34 cm²/m²; interquartile range [IQR] 6.58-8.01) and 16 sarcopenic patients (mean PMI 4.30 cm²/m²; IQR 3.45-5.17). No difference was found between both groups regarding patient demographics, clinical characteristics, cardiovascular risk factors, comorbidities, or revascularization modalities. PLR was significantly higher in the sarcopenic group (mean 332.1; IQR 158.2-320.7) compared with the nonsarcopenic group (mean 204.6; IQR 133.8-265.6) (P = 0.02). A PLR value ≥292.5 was shown to be a diagnostic marker for sarcopenia based on the ROC curve (sensitivity 31.3%, specificity 91.7%). Thirty-day mortality was 12.5% in the sarcopenic group and 2.1% in the nonsarcopenic group (P = 0.15); 30-day morbidity was 56.3% in the sarcopenic group and 10.4% in the nonsarcopenic group (P < 0.001).

CONCLUSIONS

PLR might help identifying a subgroup of CTLI patients associated with poor prognosis but does not seem appropriate to be used as a marker of sarcopenia given its low sensitivity.

Management of upper extremity aneurysms: a systematic review

INTRODUCTION

The aim of this paper is to provide recommendations for diagnosis and management of arterial or venous aneurysms of the upper extremity.

EVIDENCE ACQUISITION

A systematic review of the Medline and Cockrane databases was performed from 1988 to 2019 by a combined strategy of MeSh terms.

EVIDENCE SYNTHESIS

One-hundred-forty-four publications were identified: 111 addressing arterial aneurysms and 33 addressing venous aneurysms. A total of 162 cases of arterial aneurysms, mostly brachial aneurysms (34.0% of cases) and 40 cases of venous aneurysms, mostly located in the forearm (60.0% of cases) were reported. For both types of aneurysms, most common presentation was the perception of a mass (56.3% for arterial one and 87.5% for venous one), but thromboembolic complication (46.7%), paresthesia (16.5%) or rupture (6.4%) could be observed in the setting of arterial aneurysms, while arm swelling (27.5%), neurological symptoms (12.5%), pulmonary embolism (10.0%) or rupture (2.5%) could occur in the setting of venous aneurysms. DUS was performed as first imaging modality for both settings, followed but CTA and MRA, especially in arterial aneurysms, to evaluate distal emboli and surrounding vasculature. Surgical treatment was mostly based on excision of the aneurysms with revascularization for arterial aneurysms (77.2%) and resection without reconstruction for the venous one (85.0%). Complications occurred in 10.5% of the cases of arterial aneurysms, none occurred after venous aneurysm resection.

CONCLUSIONS

Prompt diagnosis and appropriate preoperative imaging are mandatory in order to offer the best treatment modality. Open resection with revascularization seems to be the treatment of choice for arterial aneurysms, although endovascular procedures became more popular. Venous aneurysms require excision without revascularization.

Posterior Circumflex Humeral Artery Aneurysm: Case Report and Systematic Literature Review

Posterior circumflex humeral artery (PCHA) aneurysm is a rare condition. It mostly affects young professional sports player and might be career threatening. This is the report of the case of a 28 year old volleyball player presenting with symptoms of right digital ischaemia caused by a PCHA aneurysm. Surgical treatment by resection of the aneurysm without revascularisation was performed. The post-operative course was uneventful and the patient returned to professional competition one month after surgery. A literature review is also presented in an attempt to provide recommendations for PCHA aneurysm diagnosis and management.

Total robotic iliac aneurysm repair with preservation of the internal iliac artery using sutureless vascular anastomosis

Objective

Internal iliac artery (IIA) preservation is associated with improved outcomes after both open and endovascular aortoiliac aneurysm repair. Total robotic laparoscopic repair of aortoiliac aneurysms has been reported in the past, but not in combination with sutureless anastomosis applied to the IIAs. The objective of this study was to demonstrate the feasibility of the total robotic laparoscopic technique including a method of deploying the Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) using robotic instruments.

Methods

Between June 2015 and December 2016, four patients underwent total robotic laparoscopic repair of isolated common iliac artery (CIA) aneurysms. Two patients had unilateral aneurysms and two had bilateral aneurysms. Unilateral CIA aneurysms were treated with a graft from the proximal CIA to the proximal external iliac artery, and bilateral CIA aneurysms were treated with a bifurcated graft between the distal aorta and both proximal external iliac arteries. The nitinol reinforced section of the GHVG was then inserted and deployed into the corresponding IIA, and the nonreinforced segment was sewn in an end-to-side fashion to the iliac graft.

Results

The median age of patients was 55.5 years (range, 48-64 years); median body mass index was 24.9 kg/m² (range, 23-26.4 kg/m²). All four cases were technically successful. Operative times were 325 and 332 minutes for unilateral cases and 491 and 385 minutes for bilateral cases. For the entire series, median proximal clamping time was 143 minutes (range, 110-163 minutes), and the median time to deploy the GHVG was 15 minutes (range, 8-27 minutes). The median estimated blood loss was 1800 mL (range, 800-2100 mL). Intraoperative cell salvage was used in all cases. No intraoperative or postoperative complications occurred. No patient required blood transfusion. All patients tolerated a regular diet on postoperative day 2 and were discharged on postoperative day 4. Patients returned to work and full physical activity within 6 weeks (range, 2-6 weeks). At 6-month follow-up, computed tomography angiography demonstrated 100% patency of iliac artery grafts as well as of the GHVGs.

Conclusions

Total robotic laparoscopic CIA aneurysm repair is feasible in both unilateral and bilateral cases in carefully selected patients. The GHVG can be successfully deployed using robotic technique for IIA preservation during total robotic CIA aneurysm repair.

A Popliteal Cyst Responsible for Acute Lower Limb Ischemia

We report the case of a 68-year-old man complaining of sudden intermittent claudication of the left limb. The patient was rapidly diagnosed with duplex ultrasound (DUS), computed tomography angiography, and magnetic resonance angiography as having a popliteal cyst (PC) compressing the popliteal artery, responsible for intermittent claudication. The patient underwent DUS-guided PC aspiration allowing symptoms resolution. However, he presented 3 recurrent ischemic syndromes from brutal claudication to more severe ischemia in a 3-month period, with increasing severity of the symptoms, treated with 3 DUS-guided PC aspirations. An extensive work-up excluded an atherosclerotic etiology. Consequently, due to increasing severity and quick recurrence of the symptoms and given the underlying knee osteoarthritis, the patient underwent radical treatment and got a total knee prosthetic replacement. One year later, follow-up was uneventful.

Endovascular Treatment for Venous Diseases: Where are the Venous Stents?

There is a growing need for dedicated endovascular devices to treat pathologies affecting the venous system. However, because of a lack of research into venous diseases and treatments, the optimal design, material, and mechanical properties of venous stents remain unknown. Development of the ideal venous stent should be based on a thorough understanding of the underlying venous pathology. There are multiple venous diseases that differ from each other depending on their location (iliocaval, superior vena cava), mechanism (thrombotic versus nonthrombotic lesions), and chronicity. Thus, it is likely that stent material, design, and features should differ according to each underlying disease. From a mechanical point of view, the success of a venous stent hinges on its ability to resist crushing (which requires high global and local radial rigidity) and to match with the compliant implant environment (which requires high flexibility). Device oversizing, textile coverage, and drug coating are additional features that should be considered in the context of venous diseases rather than directly translated from the arterial world. This review examines the unique forces affecting venous stents, the problems with using arterial devices to treat venous pathologies, preliminary results of a study comparing crush resistance of commercially available laser-cut stents with a novel braided stent design, and its applicability to venous interventions.

N-Acetyl Cysteine Restores Limb Function, Improves Mitochondrial Respiration, and Reduces Oxidative Stress in a Murine Model of Critical Limb Ischaemia

OBJECTIVE/BACKGROUND

The aim of this study was to investigate whether antioxidant therapy might decrease oxidative stress related deleterious effects in the setting of critical limb ischaemia (CLI).

METHODS

Twenty Swiss mice were submitted to sequential right femoral and iliac ligatures; the left limb served as control. The mice were assigned to two groups: in the first group (no-treatment group, n = 10) no treatment was administered; in the second group (N-acetyl cysteine [NAC] group, n = 10) NAC was administered by dissolution in drinking water for 4 weeks, starting on day 7, when CLI was effective. Clinical and functional scores were assessed by two blinded investigators. Mice were killed on day 40 and mitochondrial respiratory chain complex activities, calcium retention capacity, oxidative stress, and histological analysis were analysed.

RESULTS

Ischaemic muscles in the no-treatment group showed significantly impaired mitochondrial respiration and calcium retention capacity, with increased production of reactive oxygen species; but no statistical difference was noticed when comparing ischaemic muscles in the NAC group (n = 10) to contralateral muscles (n = 10) and to control muscles in the no-treatment group (n = 10). Ischaemic muscles in the no-treatment group exhibited myopathic features such as wider range in fibre size, rounded shape, centrally located nuclei, and smaller cross sectional areas, but none of these features were observed in contralateral muscles or in NAC-group muscles (ischaemic or controls).

CONCLUSION

Targeting inhibition of oxidative stress may be a potential therapeutic strategy for muscle protection in CLI and might be considered as potential adjunctive therapy to revascularisation procedures.

Open and Endovascular Repair of Popliteal Artery Aneurysms

BACKGROUND

The purpose of this study was to report midterm outcomes of open repair (OR) or endovascular repair (ER) of popliteal artery aneurysms (PAAs) and assess if outcomes of patients have changed in the endovascular era.

METHODS

This monocentric and retrospective study included all consecutive patients treated for PAA between January 2004 and December 2016. Before 2010, all patients underwent OR, but ER was available since 2010, and the choice between OR or ER was made on the basis of clinical presentation and preoperative morphological assessment. Survival, primary patency, primary-assisted patency, secondary patency, and limb salvage rates were assessed regarding the surgical way of treatment (OR or ER) or regarding the period of time (before 2010 or since 2010).

RESULTS

A total of 153 PAA were treated in 126 patients (103 limbs in OR and 50 limbs in ER). Mean follow-up was 3.8 years. Five-year survival was 97.7% for OR and 88.7% for ER. Five-year primary patency was 77.8% and 29.5% for OR and ER, respectively, primary-assisted patency 85.0% and 49.7%, respectively, and secondary patency 92.8% and 79.6%, respectively. Five-year limb salvage was 89.5% for OR and 87.9% for ER. No outcome difference was observed between patients who underwent surgery before or after ER was available.

CONCLUSIONS

Results of OR and ER in the setting of PAA are satisfactory. Outcomes of patients did not change in the endovascular era.

Late Peroneal Neuropathy after Open Surgical Treatment of Popliteal Artery Aneurysm

We report the case of a 71-year-old man complaining of swollen left limb and progressively worsening pain. He underwent surgery 12 years ago for popliteal artery aneurysm with proximal and distal ligation and venous bypass grafting. The patient was diagnosed as having left peroneal neuropathy caused by a 10.5 cm expanded aneurysmal sac compressing the peroneal nerve in the popliteal fossa. The patient underwent open repair with opening of the aneurysmal sac, removal of the thrombus, and sewing of the left genicular artery responsible for back-bleeding. Postoperative range of motion exercises and physical therapy allowed resolving foot drop 1 year after surgery.