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

Comparison of endovascular revascularization and bypass surgery for severe chronic lower limb ischemia: A prospective multicenter cohort study with propensity score matching

Objective: The aim of this study was to compare the results of lower limb bypass grafts with those of endovascular treatment in patients with severe chronic lower limb ischemia (SCI). Methods: This prospective, non-randomized, multicenter cohort study involved 520 patients with SCI. In this series, 239 patients underwent lower limb bypass surgery and 281 patients underwent endovascular treatment. The primary endpoint was 3-year amputation-free survival, the secondary endpoint was the percentage of ischemic wound healing at 90 days. The hemodynamic criteria associated with the severity of the wounds were analyzed by the WIfI classification and the extent of arterial lesions by the GLASS classification. We completed the study with a multidimensional analysis according to the Cox model and then by matching the groups by propensity score. Results: On the raw data, before pairing, the 3-year survival without amputation was not significantly different between the Bypass group (70 ± 3%) and the Endovascular group (67 ± 3%) (Kaplan-Meier Logrank: P = 32). The Cox model regression study found 5 variables independently associated with a risk of death and/or major amputation. After matching the two groups by propensity score, the 3-year amputation-free survival was found to be significantly higher in the Bypass group compared to the Endovascular group (75 ± 3% vs. 59 ± 4%, Logrank: P < 001). In addition, the healing rate was significantly higher in the Bypass group compared to the Endovascular group (Logrank: P < 001) with at 3 months 56 ± 6% complete healing in the Bypass group compared to 21 ± 5% in the Endovascular group. Finally, an interaction analysis by logistic regression, with the explanatory variable death/amputation, identified the WIfI score 2/3 (severity of ischemia and trophic disorder), the GLASS 3 score (Extensive arterial lesions), diabetes and severe chronic renal failure as more favorable factors for bypass revascularization. The presence of LVEF < 40% being more favorable for endovascular treatment. Conclusions: This prospective multicenter non-randomized study showed that patients treated with bypass surgery had more severe lesions than those treated with an endovascular technique. Matching groups by propensity score demonstrated the superiority of bypass revascularization for the primary outcome. Logistic regression interaction analysis suggested that the choice of revascularization technique should be tailored to the lesion profile (WIfI, GLASS) and the cardiovascular status of the patients.Objectif: Le but de cette étude était de comparer les résultats des pontages des membres inférieurs avec ceux du traitement endovasculaire chez les patients ayant une ischémie chronique sévère des membres inférieurs (ICS). Méthodes: Cette étude de cohorte multicentrique prospective non randomisée a porté sur 520 patients ayant une ICS. Dans cette série, 239 patients ont eu un pontage des membres inférieurs et 281 patients un traitement endovasculaire. Le critère de jugement principal était la survie à 3 ans sans amputation, le critère secondaire était le pourcentage de cicatrisation des plaies ischémiques à 90 jours. Les critères hémodynamiques, associés à la gravité des plaies ont été analysés par la classification WIfI et l’étendue des lésions artérielles par la classification GLASS. Nous avons complété l’étude par une analyse multidimensionnelle selon le modèle de Cox puis par l'appariement des groupes par score de propension. Résultats: Sur les données brutes, avant appariement, la survie à 3 ans sans amputation n’était pas significativement différente entre le groupe Pontage (70 ± 3 %) et le Groupe Endovasculaire (67 ± 3 %; Kaplan-Meier Logrank : p=.32). L’étude par régression selon le modèle de Cox a mis en évidence 5 variables indépendamment associées à un risque de décès et/ou d'amputation majeure. Après appariement des deux groupes par score de propension, la survie sans amputation à 3 ans était apparue significativement supérieure dans le groupe Pontage par rapport au groupe Endovasculaire (75 ± 3 % vs 59 ± 4 %, Logrank : p<.001). Par ailleurs le taux de cicatrisation était significativement supérieur dans le groupe Pontage par rapport au groupe Endovasculaire (Logrank : p<.001) avec à 3 mois 56 ± 6 % de cicatrisation complète dans le groupe Pontage contre 21 ± 5 % dans le groupe Endovasculaire. Enfin une analyse d'interaction par régression logistique, avec la variable explicative décès/amputation, avait identifié le score WIfI 2/3 (gravité de l'ischémie et trouble trophique), le score GLASS 3 (Lésions artérielles étendues), le diabète et l'insuffisance rénale chronique sévère comme des facteurs plus favorables à la revascularisation par pontage. La présence d'une FEVG < 40 % étant plus favorable au traitement endovasculaire. Conclusions: Cette étude prospective multicentrique non randomisée a montré que les patients traités par pontage avaient des lésions plus sévères que ceux traités par une technique endovasculaire. L'appariement des groupes par score de propension avait mis en évidence la supériorité de la revascularisation par pontage pour le critère de jugement principal. L'analyse d'interaction par régression logistique suggérait que le choix de la technique de revascularisation devait être adaptée au profil lésionnel (WIfI, GLASS) et à l’état cardiovasculaire des patients

Acute elbow dislocation with arterial rupture. Analysis of nine cases

SummaryElbow dislocations are the most frequently encountered dislocations after shoulder dislocations. In their vast majority these injuries involve only the joint and carry a good prognosis. Close anatomic proximity to the joint of neurovascular structures put them at risk of concomitant injury but this occurrence remains, actually very rare. The objective of this study is to retrospectively analyze the results of nine cases of elbow dislocations with brachial artery complications and to propose coherent therapeutic guidelines derived from this experience.Materials and methodsFrom 1999 to 2004, 357 elbow dislocations were treated by the traumatology team at the Purpan University Hospital and 340 at the Rangueil University Hospital in Toulouse, France. These two teaching institutions combined their series, contributing to seven dislocations associated with a brachial artery partial rupture, resulting in ischemia. Between 2001 and 2006 at the Le Mans Regional Hospital Center, 138 dislocations of the elbow were treated, and included two cases involving rupture of the brachial artery. In all these institutions’ emergency departments, elbow dislocations were mainly treated on an outpatient basis: closed reduction under ultra short-acting products general anesthesia, with stability evaluation followed by cast immobilization. In the rare instances of ischemia, the artery was repaired in concert with the vascular surgery team. All the nine cases had a similar treatment protocol and were submitted to an identical outcome evaluation method. The patients were all males with a mean age of 37.3 years (range, 18–58 years). The combined injury occurred at sports in two cases, because of a fall in three cases and as a result of a traffic accident in four cases. Ischemia was complete in three cases (no radial or ulnar pulse and devascularized hand). In the six other cases, the clinical presentation was subacute. An arteriogram was obtained in five cases after reduction of the dislocation, confirming the brachial axis disruption. Median and/or ulnar nerve injury was suspected in six patients. Only five elbows remained stable after reduction allowing plaster cast immobilization. In the other cases, dislocation recurrence or consequential residual varus/valgus laxity required external fixation or a cross-pinning fixation. An autologous vein, brachial artery bypass was performed in eight cases and an end-to-end anastomosis was carried out in one case. Revascularization was reestablished between 4 and 19h after injury (mean 10.5h).ResultsAll the patients were seen at a minimum of 2 years’ follow-up (mean of 4.3 years). On the basis of Mayo Clinic score, the results were considered excellent in three cases, good in four cases, and poor in two cases. No patients complained of elbow instability. The X-rays showed a reduced elbow in all cases and heterotopic ossifications in three cases. No degenerative lesion was observed at the longest follow-up.DiscussionThe incidence of a combined vascular injury with dislocation remains difficult to establish because the literature reports sporadic short series of clinical cases. The prevalence of this association is estimated to be between 0.3 and 1.7% in hospitals. The vascular lesion risk is probably related to the displacement extent and this later as a consequence of the injury intensity. This context calls for a diagnostic warning signal of possibly associated vascular involvement. Assessment of arterial vascularization should be systematic and mandatory with any osteoarticular injury. The slightest vascular status clinical doubt after reducing any dislocation presses for vascular patency work-up: echo-Doppler, angio-scan, arteriography. The multi-parametric nature of these combined injuries explain why their sometimes disappointing outcome remains dependent on the ability to deal with contradictory healing concerns: skin condition, capsular, and ligaments damages, type of revascularization procedure used, joint stability after closed reduction. This last parameter, being a substantial determinant for the period of immobilization, appears crucial to the final functional outcome, particularly in terms of range of motion loss or residual flexion contracture.Level of evidenceLevel IV. Therapeutic retrospective study

Amplatzer Plug to Occlude the Internal Iliac Artery During Endovascular Aortic Aneurysm Repair: A Large Multicenter Study

International audienc

A Gesture-Based Interface for Remote Surgery

International audienceThere has been a great deal of research activity in computer- and robot-assisted surgeries in recent years. Some of the advances have included robotic hip surgery, image-guided endoscopic surgery, and the use of intra-operative MRI to assist in neurosurgery. However, most of the work in the literature assumes that all of the expert surgeons are physically present close to the location of a surgery. A new direction that is now worth investigating is assisting in performing surgeries remotely. As a first step in this direction, this chapter presents a system that can detect movement of hands and fingers, and thereby detect gestures, which can be used to control a catheter remotely. Our development is aimed at performing remote endovascular surgery by controlling the movement of a catheter through blood vessels. Our hand movement detection is facilitated by sensors, like LEAP, which can track the position of fingertips and the palm. In order to make the system robust to occlusions, we have improved the implementation by optimally integrating the input from two different sensors. Following this step, we identify high-level gestures, like push and turn, to enable remote catheter movements. To simulate a realistic environment we have fabricated a flexible endovascular mold, and also a phantom of the abdominal region with the endovascular mold integrated inside. A mechanical device that can remotely control a catheter based on movement primitives extracted from gestures has been built. Experimental results are shown demonstrating the accuracy of the system