[Is endovascular treatment of acute thoracic aortic disease possible in centers where extracorporal circulation is not available?]

OBJECTIVE

To determine whether access to extra-corporal circulation (ECC) is necessary to treat acute descending thoracic aorta disease.

METHOD

From January 2004 to May 2006, 16 patients underwent endovascular stent-graft repair of the descending thoracic aorta, among them 13 (81%) were treated in an emergency setting (nine men, mean age: 75.4 years, range 30-94 years). The indication was traumatic aortic rupture (n=3, 23%), complicated acute type B dissection (n=4; 31%), symptomatic or ruptured thoracic aortic aneurysm (n=4; 31%), aorto-esophageal fistula (n=1; 7,5%) and aortic intramural haematoma (n=1; 7,5%). Computed tomography showed hemomediastin and/or hemothorax in five patients (38%). Transesophageal echocardiography and angiography were performed in two (15%) and one patients respectively. Cerebrospinal fluid drainage was performed for two patients (15%).

RESULTS

Endovascular repair was successfully completed in 92.3% of cases. The 30-day mortality was 7.5% (n=1). There was one case (7.5%) of delayed paraplegia. Follow-up ranged between two and 24 months (mean 10.2), no rupture occurred. Three type I endoleaks were detected and only two were treated. Two none related additional mortalities were observed. None of these patients has needed ECC.

CONCLUSION

The unavailability of ECC does not seem to be a compromising factor in the management of thoracic aorta disease, however a good experience in endovascular techniques is required.

Efficacy of Hemobahn® in the Treatment of Superficial Femoral Artery Lesions in Patients with Acute or Critical Ischemia: A Comparative Study with Claudicants

PURPOSE

To assess the results of covered stents in the treatment of superficial femoral artery (SFA) occlusive disease.

METHOD

From July 2000 till June 2003, 32 patients (34 limbs) were scheduled for procedures including Hemobahn deployment in the SFA. Indication for treatment was claudication (group I, N=15 patients and 16 limbs, 31.2% occlusions) or critical and acute ischemia (group II, N=17 patients and 18 limbs, 61.1% occlusions). TASC D SFA lesions were excluded. No limb artery was patent pre-operatively in 19% and 89% of limbs in groups I and II, respectively (p=0.00001).

RESULTS

Outflow procedures were performed simultaneously in one limb in group I and 12 in group II (p=0.0003). The technical, hemodynamic and clinical success rates were 100, 100 and 94.1%, respectively. Mean follow-up was 18.1 months. Primary patency rates at 12 months were 81.3+/-10.6% in group I and 88.6+/-9.0% in group II (p=0.547). At 12 months, the secondary patency and limb salvage rates were, respectively, 87.5+/-8.9 and 100% in group I and 87.5+/-8.93 and 94.45+/-6.71% in group II.

CONCLUSION

Treatment of SFA occlusive lesions (excluding TASC D lesions) with the Hemobahn covered stent yielded good results for both claudicants with good outflow and patients with critical or acute ischemia with bad outflow, if concomitant outflow-improving procedures were performed.

Comparison Between Duplex Scanning and Angiographic Findings in the Evaluation of Functional Iliac Obstruction in Top Endurance Athletes

OBJECTIVE

Review of a 10 year-experience, to evaluate the efficacy of pre-operative investigations in the detection of external iliac artery (EIA) endofibrosis in top endurance athletes.

DESIGN

Retrospective study.

MATERIALS

From September 1995 to March 2004, 13 highly-trained athletes (all men, mean age 32.3 years) underwent surgery for disease involving 14 lower limbs (11 left, one right, one bilateral).

METHODS

We compared ultrasound scan (US) and digital subtraction angiography (DSA) data, at rest and at hip flexion with intra-operative findings for all 14 lower limbs. We analyzed the presence of stenosis in the external and common iliac arteries, the presence of psoas muscle arteries and the presence of excessive EIA length.

RESULTS

In the affected limbs, before treatment, the mean ankle brachial index (ABI) at rest was 0.98 compared with 0.56 after exercise, p=0.0001. The sensitivities of the US vs DSA examination in the detection of external and common iliac artery stenosis were, respectively, 84.6 and 53.8% vs 53.8 and 12.5%. The muscle psoas artery was detected by DSA with a sensitivity of 57.1 and 100% specificity. For the detection of excessive EIA length, the sensitivity of US was 85.7% with 57.1% specificity.

CONCLUSIONS

A fall of ABI after exercise proves the presence of a significant stenosis in symptomatic athletes. Color coded duplex ultrasonography is recommended for non-invasive imaging of suspected endofibrotic stenosis in young athletes, since it detects reliably both stenosis and elongation of iliacal arteries.

Subintimal Angioplasty: Feasible and Durable

OBJECTIVE

To assess prospectively the feasibility and durability of subintimal angioplasty (SA) clinically and by duplex scans every 3 months.

PATIENTS AND METHODS

Within a period of 54 months, we selected 96 patients with 100 occlusions (mean length: 11.5 cm) of femoro-popliteal or tibial arteries, for SA.

RESULTS

The technical success rate was 88% and seven out of 12 failures were treated by conventional surgery. Five below-the-knee amputations were performed despite a patent recanalization. The following complications occurred: arterial perforation (6), arterial thrombosis (4), extensions beyond the planned re-entry site (5), and arterial dissection (2). Primary, assisted-primary and secondary patency rates were 61, 68 and 74%, respectively at 24 months. The 24 month-limb salvage and survival rates were 78 and 85%, respectively. Duplex imaging demonstrated 10 restenosis (five symptomatic >70%, five asymptomatic 30-70%), seven occlusions (five asymptomatic, two symptomatic treated by a bypass) and one asymptomatic dilatation.

CONCLUSION

In a selected group of patients SA is feasible with a high initial technical success rate. SA is a good alternative in patients who are poor candidates for bypass surgery.

[Development and repair of vessels from bone marrow stem cells in the adult: from biology to clinical practice]

In addition to its role in hematopoiesis, bone marrow appears to be a reservoir of stem cells that can differentiate into components of vessel wall. Upon stimulation by factors such as tissue ischemia, bone marrow stem cells can enter into circulating blood, and incorporate into areas of vascular development. Animal models suggest that bone marrow is a cellular source for tissue repair and/or regeneration. Data from humans, and clinical trials using bone marrow stem cells for the treatment of chronic ischemia in limbs and myocardium, support the view that stem cells may represent a new tool for the treatment of ischemia.