Inferior Mesenteric Artery Stenting as a Novel Treatment for Chronic Mesenteric Ischemia in Patients with an Occluded Superior Mesenteric Artery and Celiac Trunk

IntroductionChronic mesenteric ischemia (CMI) is a challenging problem, with revascularization the mainstay of treatment. Management of CMI is especially challenging in the patient with superior mesenteric artery (SMA) and celiac artery (CA) occlusions.ReportWe report a case series of four patients with chronic mesenteric ischemia who were not candidates for CA or SMA revascularization who were successfully treated with inferior mesenteric artery (IMA) angioplasty and stent placement to improve collateral circulation and palliate symptoms.DiscussionTo our knowledge, this is the largest case series to date reporting the use of an IMA stent to improve collateral circulation in patients with CMI

Percutaneous coil embolization of postcatheterization arterial femoral pseudoaneurysms

AbstractStudy Design: This study was a prospective monocentric study to assess the safety and effectiveness of percutaneous embolization with coils of postcatheterization femoral pseudoaneurysm (PCFP). Patients and Methods: Seventeen PCFPs of 32-mm mean diameter in 16 patients were embolized while anticoagulant or antiplatelet therapy was maintained. Ultrasound scan-guided compression repair failed at least one time in 13 cases and was contraindicated in the four remaining cases. With ultrasound-Doppler scan guidance, the PCFPs were percutaneously punctured with a 16-gauge intravenous catheter. An angiogram was performed through the catheter to ensure its location within the sac. Stainless steel spring coils with synthetic fibers were introduced within the PCFP with fluoroscopic control. Successful thrombosis was checked with ultrasound-Doppler scan and was repeated at days 1, 30, and 180 when possible. Results: All PCFPs of 32-mm mean diameter were successfully treated with two to nine coils. After embolization, gentle additional compression was necessary for complete occlusion, with a mean duration of 6.3 minutes (range, 0 to 15 minutes), except in one case with treatment with abciximab in which it was 45 minutes. All procedures were uneventful and painless. The mean follow-up period was 9.5 months (range, 1 to 21 months). Two recurrences (11.7%) were observed, and one was successfully treated with a second embolization. Conclusion: Percutaneous embolization with coils appears to be a safe and effective method for treatment of PCFP. It may be performed in patients undergoing anticoagulant or antiplatelet therapy and must be attempted when ultrasound scan-guided compression repair has failed or is contraindicated. (J Vasc Surg 2002;36:127-31.

Ponowne zabiegi u chorych leczonych z powodu tętniaka aorty brzusznej stentgraftami wewnątrznaczyniowymi - wskazania, czynniki ryzyka i rokowanie

Background. The aim of this study was evaluation of secondary interventions defined as procedures performed to close endoleak, or to improve limb patency after endovascular AAA repair and to assess their predictive factors and prognosis. Material and methods. Patient’s data and follow-up events of all patients who underwent endovascular repair of AAA between January 1995 and November 2001 in our institution were prospectively collected and stored in our database. Patients were divided into two groups according to the presence or absence of secondary reintervention during follow-up. Age, sex, type of AAA, AAA diameter, comorbidities, type of graft and period of treatment were compared using a univariate analysis. Prognosis was assessed by comparison of life table analysis. Interventional success defined as the lack of AAA conversion or rupture were also compared in both groups. Results. Two hundred and six patients were included in the study. During follow-up, thirty-two patients (16%) required 47 secondary interventions. Respectively 22 and 10 patients were treated with endovascular methods to close various type of endoleaks or were operated on to restore limb blood flow. The only significant predictive factor of secondary reintervention was the type of grafts: early generation 29/101(28.7%) versus the latest generation 3/102 (2.9%). The survival rate was not statistically different in both groups. The interventional success was significantly different 27/32 (84.4%) versus 173/174 (99.4%) Conclusions. Secondary reinterventions which mainly with early generation grafts improved outcome of endovascular AAA repair in 15% of the cases. However no death could be attributed to these reinterventions or to conversions.Wstęp. Celem pracy była ocena powikłań powodujących konieczność wykonania dodatkowych zabiegów likwidujących przeciek lub udrożniających stentgraft u chorych poddanych wewnątrznaczyniowemu leczeniu tętniaków aorty brzusznej (TAB) oraz zbadanie wpływu analizowanych powikłań na odległe wyniki terapii. Materiał i metody. W okresie od stycznia 1995 do listopada 2001 r. na Oddziale Chirurgii Naczyń Hospital Henri Mondor w Creteil metodą wewnątrznaczyniową, stosując stentgrafty aortalne, zoperowano 205 chorych z TAB. W celu przeprowadzenia badania chorych podzielono na dwie grupy: grupę pierwszą stanowili pacjenci wymagający przeprowadzenia ponownych zabiegów, drugą - chorzy niewymagający ponownych zabiegów. Wiek, płeć, rodzaj, wymiary tętniaka, obciążenia, rodzaj stentgraftu i okres obserwacji porównano, stosując odpowiednie analizy statystyczne. Wykonano analizę przeżycia chorych, uwzględniając odległe wyniki leczenia. W obu grupach porównano powodzenie zabiegu zdefiniowane jako brak konwersji do metody otwartej lub pęknięcie TAB. Wyniki. W badaniu uczestniczyło 206 chorych. Podczas obserwacji 32 chorych (16%) wymagało 47 ponownych zabiegów. W celu zlikwidowania przecieku leczono 22 chorych, natomiast 10 chorych poddano terapii z powodu niedrożności stentgraftu z wykorzystaniem technik wewnątrznaczyniowych lub metodą otwartą. Jedynym istotnym statystycznie czynnikiem związanym z liczbą ponownych zabiegów był rodzaj stentgraftu: starsza generacja 29/101 (28,7%), nowsza generacja 3/102 (2,9%). Czas przeżycia w obu grupach nie różnił się w sposób istotny statystycznie. Wyniki w poszczególnych grupach były następujące: 27/32 (84,4%) w pierwszej grupie, 173/174 (99,4%) w drugiej grupie. Wnioski. Ponowne zabiegi spowodowały poprawę wyników w 15% przypadków, obserwowano je głównie w grupie chorych z starszymi typami stentgraftów. Wśród osób poddanych ponownym zabiegom i konwersjom do metody otwartej nie zanotowano przypadków śmiertelnych

Surgical and regional treatments for colorectal cancer metastases in older patients: A systematic review and meta-analysis

Objective The present study explored the existing literature to describe the outcomes of surgical and regional treatments for colorectal cancer metastases (mCRC) in older patients. Methods A literature search was conducted in PubMed, EMBASE, Cochrane and ClinicalTrials.gov for studies published since 2000 that investigated the short- and long-term outcomes of regional treatments (surgical or non-surgical) for mCRC in patients aged >= 65 years. Pooled data analyses were conducted by calculating the risk ratio (RR), mean differences (MD) and hazard ratio (HR) between older and younger patients or between two different approaches in older patients. Results After screening 266 articles, 29 were included in this review. These studies reported the outcomes of surgery (n = 19) and non-surgical local ablation treatments (n = 3) for CRC metastases in older vs. younger patients or compared the outcomes of different interventions in older patients (n = 7). When comparing older vs. younger patients undergoing liver surgery for mCRC, pooled data analysis showed higher postoperative mortality [RR = 2.53 (95%CI: 2.00-3.21)] and shorter overall survival [HR = 1.17 (95%CI: 1.07-1.18)] in older patients, whereas no differences in operative outcomes, postoperative complications and diseasefree survival were found. When comparing laparoscopy vs. open surgery for liver resection in older mCRC patients, laparoscopy was associated with fewer postoperative complications [RR = 0.27 (95%CI: 0.10-0.73)]. Conclusion Liver resection for mCRC should not be disregarded a priori in older patients, who show similar operative and postoperative outcomes as younger patients. However, clinicians should consider that they are at increased risk of postoperative mortality and have a worse overall survival, which may reflect comorbidities and frailty

Status Update and Interim Results from the Asymptomatic Carotid Surgery Trial-2 (ACST-2)

Objectives: ACST-2 is currently the largest trial ever conducted to compare carotid artery stenting (CAS) with carotid endarterectomy (CEA) in patients with severe asymptomatic carotid stenosis requiring revascularization. Methods: Patients are entered into ACST-2 when revascularization is felt to be clearly indicated, when CEA and CAS are both possible, but where there is substantial uncertainty as to which is most appropriate. Trial surgeons and interventionalists are expected to use their usual techniques and CE-approved devices. We report baseline characteristics and blinded combined interim results for 30-day mortality and major morbidity for 986 patients in the ongoing trial up to September 2012. Results: A total of 986 patients (687 men, 299 women), mean age 68.7 years (SD ± 8.1) were randomized equally to CEA or CAS. Most (96%) had ipsilateral stenosis of 70-99% (median 80%) with contralateral stenoses of 50-99% in 30% and contralateral occlusion in 8%. Patients were on appropriate medical treatment. For 691 patients undergoing intervention with at least 1-month follow-up and Rankin scoring at 6 months for any stroke, the overall serious cardiovascular event rate of periprocedural (within 30 days) disabling stroke, fatal myocardial infarction, and death at 30 days was 1.0%. Conclusions: Early ACST-2 results suggest contemporary carotid intervention for asymptomatic stenosis has a low risk of serious morbidity and mortality, on par with other recent trials. The trial continues to recruit, to monitor periprocedural events and all types of stroke, aiming to randomize up to 5,000 patients to determine any differential outcomes between interventions. Clinical trial: ISRCTN21144362. © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved

Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding: UK Medical Research Council and Health Technology Assessment Programme

Traitement par embolisation des endofuites de type II (suivi et efficacité)

Objectifs. Evaluation de la faisabilité et de l efficacité de l embolisation intra artérielle dans le traitement des endofuites de type II survenant après la pose d endoprothèse aortique. Matériel et méthode. Etude rétrospective monocentrique de 1996 à 2006. La faisabilité et l efficacité ont été évaluées respectivement par les taux de succès technique et clinique. Résultats. 58 cas d endofuites de type II ont été détectés chez 550 patients parmi lesquels vingt huit patients (48.3 %) ont été traités par l embolisation par voie intra artérielle. Le taux de succès technique de l embolisation était de 83%. Le taux de succès clinique était de 40.7% après le premier geste et de 51.8% après une deuxième embolisation. Aucune complication majeure ni rupture d anévrysme n est survenue au cours ou au décours de l embolisation. Conclusion. En cas de décision d intervention, l embolisation est un traitement sûr et efficace qui permet d éviter le recours à la chirurgie dans plus de la moitié des cas.Purpose. Evaluation of the feasibility and efficacy of intra arterial embolisation in the treatment of type II endoleaks complicating endovascular aneurysm repair (EVAR). Materials and methods. Retrospective study of cases performed between 1996 and 2006 in a single institution. feasibility and efficacy were measured by technical and clinical success rate respectively. Results. A total of 58 type II endoleak have been detected in 550 patients treated by EVAR. Among these 58 cases of type II endoleaks, 28 patients (48.3%) have been treated by intra arterial embolisation. Technical success rate was 83%. Clinical success rate was 40.7% after the first embolisation and 51.8% if a second embolisation was done. No major complication or aneurysm rupture has occurred during or after the procedure Conclusion. Intra arterial embolisation is a reliable and effective treatment for type II endoleaks which should be treated. It lets to avoid the surgical treatment in more than half of cases.PARIS13-BU Serge Lebovici (930082101) / SudocSudocFranceF