Apport de l'assistance par ordinateur lors de la pose d'endoprothèse aortique

The development of endovascular aortic procedures is growing. These mini-invasive techniques allow a reduction of surgical trauma, usually important in conventional open surgery. The technical limitations of endovascular repair are pushed to special aortic localizations which were in the past decade indication for open repair. Success and efficiency of such procedures are based on the development and the implementation of decision-making tools. This work aims to improve endovascular procedures thanks to a better utilization of pre and intraoperative imaging. This approach is in the line with the framework of computer-assisted surgery whose concepts are applied to vascular surgery. The optimization of endograft deployment is considered in three steps. The first part is dedicated to preoperative imaging analysis and shows the limits of the current sizing tools. The accuracy of a new measurement criterion is assessed (outer curvature length). The second part deals with intraoperative imaging and shows the contribution of augmented reality in endovascular aortic repair. In the last part, image guided surgery on soft tissues is addressed, especially the arterial deformations occurring during endovascular procedures which disprove rigid registration in fusion imaging. The use of finite element simulation to deal with this issue is presented. We report an original approach based on a predictive model of deformations using finite element simulation with geometrical and anatomo-mechanical patient specific parameters extracted from the preoperative CT-scan.Les techniques endovasculaires, particulièrement pour l’aorte, sont en plein essor en chirurgie vasculaire. Ces techniques mini-invasives permettent de diminuer l’agression chirurgicale habituellement importante lors de la chirurgie conventionnelle. Les limites techniques sont repoussées à certaines localisations de l’aorte qui étaient il y a encore peu de temps inaccessibles aux endoprothèses. Le succès et l’efficience de ces interventions reposent en partie sur l'élaboration et la mise en œuvre de nouveaux outils d'aide à la décision. Ce travail entend contribuer à l’amélioration des procédures interventionnelles aortiques grâce à une meilleure exploitation de l’imagerie pré et peropératoire. Cette démarche s’inscrit dans le cadre plus général des Gestes Médico-Chirurgicaux Assistés par Ordinateur, dont les concepts sont revisités pour les transposer au domaine de la chirurgie endovasculaire. Trois axes sont développés afin de sécuriser et optimiser la pose d'endoprothèse. Le premier est focalisé sur l’analyse préopératoire du scanner (sizing) et montre les limites des outils de mesure actuels et évalue la précision d’un nouveau critère de mesure des longueurs de l’aorte (courbure externe). Le deuxième axe se positionne sur le versant peropératoire et montre la contribution de la réalité augmentée dans la pose d’une endoprothèse aortique. Le troisième axe s’intéresse au problème plus général des interventions sur les tissus mous et particulièrement aux déformations artérielles qui surviennent au cours des procédures interventionnelles qui mettent en défaut le recalage rigide lors de la fusion d’images. Nous présentons une approche originale basée sur un modèle numérique de prédiction des déformations qui utilise la simulation par éléments finis en y intégrant des paramètres géométriques et anatomo-mécaniques spécifique-patient extraits du scanner préopératoire

Bare metal stent versus paclitaxel eluting stent for intermediate length femoropopliteal arterial lesions (BATTLE trial): study protocol for a randomized controlled trial

BACKGROUND: Currently, endovascular treatment is indicated to treat femoropopliteal lesions ≤15 cm. However, the Achilles’ heel of femoropopliteal endovascular repair remains restenosis. Paclitaxel eluting stents have shown promising results to prevent restenosis in femoropopliteal lesions compared to percutaneous transluminal angioplasty. A recently released prospective registry using a newer generation of self-expandable nitinol stents (Misago®; Terumo Corp., Tokyo, Japan) supports primary bare metal stenting as a first-line treatment for femoropopliteal lesions. To date, no studies have been designed to compare bare metal stents to paclitaxel eluting stents for the treatment of femoropoliteal lesions. The BATTLE trial was designed to compare paclitaxel eluting stents (Zilver® PTX®) and a last generation bare self-expandable nitinol stents (Misago® RX, Terumo Corp., Tokyo, Japan) in the treatment of intermediate length femoropopliteal lesions (≤14 cm). METHODS/DESIGN: A prospective, randomized (1:1), controlled, multicentric and international study has been designed. One hundred and eighty-six patients fulfilling the inclusion criteria will be randomized to one of the two assessments of endovascular repair to treat de novo femoropopliteal lesions ≤14 cm in symptomatic patients (Rutherford 2 to 5): bare stent group and paclitaxel eluting stent group. The primary endpoint is freedom from in-stent restenosis at 1 year defined by a peak systolic velocity index >2.4 (restenosis of >50%) at the target lesion and assessed by duplex scan. Our main objective is to demonstrate the clinical superiority of primary stenting using Zilver® PTX® stent system versus bare metal self-expandable stenting in the treatment of femoropopliteal lesions in patients with symptomatic peripheral arterial disease. DISCUSSION: This is the first randomized and controlled study to compare the efficacy of bare metal stents and paclitaxel eluting stents for the treatment of femoropopliteal lesions. It may clarify the indication of stent choice for femoropopliteal lesions of intermediate length. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02004951. 3 December 2013

Lower Rate of Restenosis and Reinterventions With Covered vs Bare Metal Stents Following Innominate Artery Stenting

PURPOSE: To determine any difference between bare metal stents (BMS) and balloon-expandable covered stents in the treatment of innominate artery atheromatous lesions. MATERIALS AND METHODS: A multicenter retrospective study involving 13 university hospitals in France collected 93 patients (mean age 63.2±11.1 years; 57 men) treated over a 10-year period. All patients had systolic blood pressure asymmetry >15 mm Hg and were either asymptomatic (39, 42%) or had carotid (20, 22%), vertebrobasilar (24, 26%), and/or brachial (20, 22%) symptoms. Innominate artery stenosis ranged from 50% to 70% in 4 (4%) symptomatic cases and between 70% and 90% in 52 (56%) cases; 28 (30%) lesions were preocclusive and 8 (9%) were occluded. One (1%) severely symptomatic patient had a <50% stenosis. Demographic characteristics, operative indications, and procedure details were compared between the covered (36, 39%) and BMS (57, 61%) groups. Multivariate analysis was performed to determine relative risks of restenosis and reinterventions [reported with 95% confidence intervals (CI)]. RESULTS: The endovascular procedures were performed mainly via retrograde carotid access (75, 81%). Perioperative strokes occurred in 4 (4.3%) patients. During the mean 34.5±31.2-month follow-up, 30 (32%) restenoses were detected and 13 (20%) reinterventions were performed. Relative risks were 6.9 (95% CI 2.2 to 22.2, p=0.001) for restenosis and 14.6 (95% CI 1.8 to 120.8, p=0.004) for reinterventions between BMS and covered stents. The severity of the treated lesions had no influence on the results. CONCLUSION: Patients treated with BMS for innominate artery stenosis have more frequent restenoses and reinterventions than patients treated with covered stents

Persistent left superior vena cava: Review of the literature, clinical implications, and relevance of alterations in thoracic central venous anatomy as pertaining to the general principles of central venous access device placement and venography in cancer patients

Persistent left superior vena cava (PLSVC) represents the most common congenital venous anomaly of the thoracic systemic venous return, occurring in 0.3% to 0.5% of individuals in the general population, and in up to 12% of individuals with other documented congential heart abnormalities. In this regard, there is very little in the literature that specifically addresses the potential importance of the incidental finding of PLSVC to surgeons, interventional radiologists, and other physicians actively involved in central venous access device placement in cancer patients. In the current review, we have attempted to comprehensively evaluate the available literature regarding PLSVC. Additionally, we have discussed the clinical implications and relevance of such congenital aberrancies, as well as of treatment-induced or disease-induced alterations in the anatomy of the thoracic central venous system, as they pertain to the general principles of successful placement of central venous access devices in cancer patients. Specifically regarding PLSVC, it is critical to recognize its presence during attempted central venous access device placement and to fully characterize the pattern of cardiac venous return (i.e., to the right atrium or to the left atrium) in any patient suspected of PLSVC prior to initiation of use of their central venous access device

Computer aided surgery in endovascular aortic procedures

Les techniques endovasculaires, particulièrement pour l’aorte, sont en plein essor en chirurgie vasculaire. Ces techniques mini-invasives permettent de diminuer l’agression chirurgicale habituellement importante lors de la chirurgie conventionnelle. Les limites techniques sont repoussées à certaines localisations de l’aorte qui étaient il y a encore peu de temps inaccessibles aux endoprothèses. Le succès et l’efficience de ces interventions reposent en partie sur l'élaboration et la mise en œuvre de nouveaux outils d'aide à la décision. Ce travail entend contribuer à l’amélioration des procédures interventionnelles aortiques grâce à une meilleure exploitation de l’imagerie pré et peropératoire. Cette démarche s’inscrit dans le cadre plus général des Gestes Médico-Chirurgicaux Assistés par Ordinateur, dont les concepts sont revisités pour les transposer au domaine de la chirurgie endovasculaire. Trois axes sont développés afin de sécuriser et optimiser la pose d'endoprothèse. Le premier est focalisé sur l’analyse préopératoire du scanner (sizing) et montre les limites des outils de mesure actuels et évalue la précision d’un nouveau critère de mesure des longueurs de l’aorte (courbure externe). Le deuxième axe se positionne sur le versant peropératoire et montre la contribution de la réalité augmentée dans la pose d’une endoprothèse aortique. Le troisième axe s’intéresse au problème plus général des interventions sur les tissus mous et particulièrement aux déformations artérielles qui surviennent au cours des procédures interventionnelles qui mettent en défaut le recalage rigide lors de la fusion d’images. Nous présentons une approche originale basée sur un modèle numérique de prédiction des déformations qui utilise la simulation par éléments finis en y intégrant des paramètres géométriques et anatomo-mécaniques spécifique-patient extraits du scanner préopératoire.The development of endovascular aortic procedures is growing. These mini-invasive techniques allow a reduction of surgical trauma, usually important in conventional open surgery. The technical limitations of endovascular repair are pushed to special aortic localizations which were in the past decade indication for open repair. Success and efficiency of such procedures are based on the development and the implementation of decision-making tools. This work aims to improve endovascular procedures thanks to a better utilization of pre and intraoperative imaging. This approach is in the line with the framework of computer-assisted surgery whose concepts are applied to vascular surgery. The optimization of endograft deployment is considered in three steps. The first part is dedicated to preoperative imaging analysis and shows the limits of the current sizing tools. The accuracy of a new measurement criterion is assessed (outer curvature length). The second part deals with intraoperative imaging and shows the contribution of augmented reality in endovascular aortic repair. In the last part, image guided surgery on soft tissues is addressed, especially the arterial deformations occurring during endovascular procedures which disprove rigid registration in fusion imaging. The use of finite element simulation to deal with this issue is presented. We report an original approach based on a predictive model of deformations using finite element simulation with geometrical and anatomo-mechanical patient specific parameters extracted from the preoperative CT-scan

Facteurs prédictifs préopératoires de régression du sac anévrysmal après traitement endovasculaire des anévrysmes de l'aorte abdominale

But: la régression du sac anévrysmale après traitement endovasculaire (EVAR) est un marqueur fiable de succès à long terme. Le but de cette étude était d'identifier les facteurs prédictifs de régression du sac selon les normes internationales de description anatomique des AAA. Méthodes: sur 199 patients opérés d'un AAA par voie endovasculaire entre 2000 et 2009, 164 est un suivi scannographique et échographique complet ont été inclus dans cette étude rétrospective. Pour être inclus, tous les angioscanners devaient être analysables avec un logiciel permettant d'effectuer des mesures tridimensionnelles (Endosize® , Rennes, France). Chaque paramètre anatomique a été catégorisé selon 4 grades de sévérité conformément aux reporting standard de la société internationale de chirurgie vasculaire. A partir de ces grades, un score de gravité anatomique a été calculé au niveau du collet, de l'AAA et des artères iliaques. Les facteurs cliniques et démographiques ont également été étudiés. Les patients présentant une régression>=5mm de leur AAA au cours du suivi appartenaient au groupe A, les autres au groupe B. Résultats: les taux de régression était de 40,2% (groupe A, n=66). L'âge moyen dans le groupe A était de 71.4+- 8.9 ans et de 76.3+-8.3 ans dans le groupe B (P=5 mm were assigned to group A, and the others were assigned to group B. Results: aneurysmal regression occured in 66 (40.2%) patients (group A). The mean age was 71.4+-8.9 years in group A, and 76.3+-8.3 in group B. Univariate analyses showed sllmaller severity scores at the aortic neck (p=0.05) and the iliac arteries (p=0.002) in group A. In group A, calcifications and thrombus were less significant at the aortic neck (p=0.003 and p=0.02) and at the iliac arteries (p=0.001 et p=0.02), and inferior mesenteric artery patency was less frequent (68.2% vs 82.7%, p=0.04). Two multivariate analyses were carried out, of which one considered the scores, and the other was based on the variables included in the scores. In the first, the patients of group A were younger (p=0.002) and aortic neck calcifications were less significant (p=0.007). In the second, the patients of group Awere younger (p<0.001) and the aortic neck scores were smaller (p=0.04). There was no difference between the two groups, in terms of the implanted endoprosthesis, nor in the follow-up (46.4+-24 months in group A, and 47.2+-22 months in group B, p=0.35). Conclusion: in this study, the young age of the patients and their aortic neck quality, in particular the absence of neck calcification, appear to have been the main factors affecting aneurysm shrinkage, such that they represent a target population for the improvement of EVAR resultsRENNES1-BU Santé (352382103) / SudocSudocFranceF