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Les méthodes existantes de réparation endo-vasculaire aortique sont présentées. Neuf modèles synthétiques réalistes sont proposés, comportant des niveaux de sténose différents, et des conditions aux limites adaptées. Les simulations effectuées permettent de calculer débits, pressions et contraintes pariétales. Ces résultats pourront venir en aide au médecin afin de mieux appréhender la méthode optimale d'intervention.

Background Common femoral artery (CFA) stenting appears as a promising alternative treatment to the open surgery for de novo CFA stenosis. The stenting of lesions just located at the CFA is simple, whereas stenting of CFA bifurcation lesions is more complex, and outcomes are still matter of debate. The aim of this study was to describe and to compare clinical outcomes of techniques used to treat simple over complex lesions for the stenting of CFA lesions. Materials/Methods From the French randomized controlled trial, TECCO, a total of 54 patients underwent stenting intervention and were enrolled in this study. Patients were excluded if they had CFA thrombosis, restenosis, and nonatheromatous lesions. Patients were classified by simple and complex lesions based on the type of lesion. The primary end point was the primary sustained clinical improvement. Results Eighteen patients were included in the simple lesion group, and 36 patients, in the complex lesion group. Baseline characteristics of patients were comparable between the 2 groups. The technical success was 100% in the simple lesion group and 91.7% in the complex lesion group. There was no significant difference between the 2 groups, regarding the primary sustained clinical improvement. The primary patency rates at 24 months for simple and complex lesion groups were 86.3% and 79%, respectively (P = 0.66). Freedom from target lesion revascularization was of 93.3% and 82% in the simple and complex lesion group, respectively (P = 0.34). Conclusions The stenting technique for CFA bifurcation lesions is a safe and effective technique. More trials with a large number of patients are needed to define the optimal stenting technique.

Aberrant subclavian artery (ASCA) occurs rarely but is one of the most frequent anatomical variations of the supra-aortic trunks. No consensus has been established on its best treatment. The goal of this study was to report the outcomes of ASCA treated by the hybrid approach.This non-interventional retrospective multicentre analysis included patients treated for ASCA by the hybrid approach in 12 French university hospitals between 2007 and 2019. The hybrid approach was defined as an endovascular procedure combined with open surgery or a hybrid stent graft. Patients were divided in 4 groups (from less to more complex treatment). The primary end point was 30-day mortality. The secondary end points were 30-day complications and late mortality.This study included 43 patients. The mean age was 65 (SD, standard deviation: 16) years. Symptoms were found in 33 patients. Subclavian revascularization combined with aberrant subclavian artery occlusion was undertaken in 13 patients. Unilateral and bilateral subclavian revascularization combined with a thoracic aortic stent graft was undertaken in 11 and 6 patients, respectively. Total aortic arch repair combined with a thoracic aortic stent graft was undertaken in 13 patients. Thirty-day mortality was 2.3% with a technical success rate of 95.3%. The 30-day major postoperative complication rate was 16.3%: 4 strokes, 2 tamponades, 1 acute respiratory distress syndrome. Mean follow-up was 56.3 (SD: 44.7) months. The late mortality was 18.6%.The ASCA hybrid approach is feasible, safe and effective with low early mortality. Morbidity is rather high. However, it increases with the complexity of the hybrid approach, which should be kept as simple as possible if the anatomical morphology allows.

Purpose: Carotid artery stenting (CAS) appears as a promising alternative treatment to carotid endarterectomy for radiation therapy (RT)-induced carotid stenosis. However, this is based on a poor level of evidence studies (small sample size, primarily single institution reports, few long-term data). The purpose of this study was to report the long-term outcomes of a multicentric series of CAS for RT-induced stenosis. Methods: All CAS for RT-induced stenosis performed in 11 French academic institutions from 2005 to 2017 were collected in this retrospective study. Patient demographics, clinical risk factors, elapsed time from RT, clinical presentation and imaging parameters of carotid stenosis were preoperatively gathered. Long-term outcomes were determined by clinical follow-up and duplex ultrasound. The primary endpoint was the occurrence of cerebrovascular events during follow-up. Secondary endpoints included perioperative morbidity and mortality rate, long-term mortality rate, primary patency, and target lesion revascularization. Results: One hundred and twenty-one CAS procedures were performed in 112 patients. The mean interval between irradiation and CAS was 15 ± 12 years. In 31.4% of cases, the lesion was symptomatic. Mean follow-up was 42.5 ± 32.6 months (range 1–141 months). The mortality rate at 5 years was 23%. The neurologic event-free survival and the in-stent restenosis rates at 5 years were 87.8% and 38.9%, respectively. Diabetes mellitus (p=0.02) and single postoperative antiplatelet therapy (p=0.001) were found to be significant predictors of in-stent restenosis. Freedom from target lesion revascularization was 91.9% at 5 years. Conclusion: This study showed that CAS is an effective option for RT-induced stenosis in patients not favorable to carotid endarterectomy. The CAS was associated with a low rate of neurological events and reinterventions at long-term follow-up.

Background Although autogenous venous grafts are preferable for below-the-knee bypass surgery in patients with critical limb ischemia, some 20% of patients will have no suitable vein for grafting, compelling a resort to artificial graft materials. Retrospective subgroup analyses within published studies comparing heparin-bonded polytetrafluoroethylene (PTFE) with crude PFTE graft in below-the-knee bypass suggest that heparin-bonded graft offers superior long-term patency rates, but this has not been prospectively verified in patients with critical limb ischemia. Methods A single-blind randomized controlled trial in 20 French centers has been designed. Patients assessed as having no suitable autologous vein for bypass grafting for critical lower limb ischemia will be randomized to receive either a heparin-bonded PTFE graft or a crude PTFE graft. A literature review suggested expected 1-year patency rates of 53% for the crude ePTFE arm and 74% for the heparin-bonded PTFE arm. On analyzing 1-year patency rate as a binary variable, for a significance level α = 0.05 and a randomization ratio of 1:1, a total of 176 patients (88 in each arm) will be required to obtain approximately 80% power to reject the null hypothesis. Assuming 10% dropout at 1 year and 20% mortality, 228 patients will be randomized (114 patients in each arm). Results The primary outcome variable will be patency at 1 year assessed by duplex ultrasound color-flow scan. Any intervention to open up or prevent a graft occlusion before 1 year will be classified as loss of patency. Technical success, deaths, complications, major adverse cardiovascular and limb events, length of hospitalization, and quality of life will also be recorded and analyzed as secondary outcome variables. Cost-utility and cost-effectiveness analyses based on standard tariffs in the French health insurance system will be performed. Conclusions The REPLACE trial is the first randomized controlled trial designed to determine if heparin-bonded PTFE graft is superior to crude PTFE graft in below-the-knee bypass surgery for critical limb ischemia.

Background The purpose of this study was to report our experience of treatment of aortic aneurysms using combination of renal and visceral arteries bypasses and fenestrated/branched stent graft in various complex anatomical situations. Methods Between November 2005 and March 2017, 10 patients underwent a hybrid strategy combining bypasses for renal and/or visceral arteries and custom-made fenestrated/branched stent grafts. Two patients had abdominal aortic aneurysm (1 juxtarenal and 1 suprarenal), and 8 patients had thoracoabdominal aortic aneurysm (1 type I, 2 type II including one dissection, 2 type III, 1 type IV, and 2 type V). In total, 37 renal and visceral arteries were targeted, of which 23 were treated using fenestrated or branched stent graft and 14 were treated by bypass (11 to renal artery and 3 to celiac trunk). Results Technical success was 100%, and no patient died during a mean follow-up of 24.3 ± 21 months. Six patients had 7 postoperative complications after bypass surgery, and 3 patients had 3 complications after fenestrated or branched endovascular aneurysm repair (FEVAR/BEVAR) procedure. Seven reinterventions were performed in 3 patients. No occlusion of target vessels occurred. Renal function was stable during follow-up in all patients except one who developed end-stage renal failure requiring permanent dialysis. On the last follow-up computed tomography scan, aneurysm diameter decreased for 6 patients, was stable for 3 patients, and increased for one patient, in which persistent type II endoleak was observed. Aneurysm exclusion was complete in the remaining 9 patients. Conclusions Combination of FEVAR/BEVAR procedures with renal and/or visceral artery bypass in patients with complex aortic aneurysms is feasible with acceptable results. Morbidity associated with bypass surgery has to be carefully balanced with the risk of catheterization difficulties in the setting of adverse anatomical features of the visceral/renal arteries or the aorta.

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.

Objective A crucial step in designing fenestrated stent grafts for treatment of complex aortic abdominal aneurysms is the accurate positioning of the fenestrations. The deployment of a fenestrated stent graft prototype in a patient-specific rigid aortic model can be used for design verification in vitro, but is time and human resources consuming. Numerical simulation (NS) of fenestrated stent graft deployment using the finite element analysis has recently been developed; the aim of this study was to compare the accuracy of fenestration positioning by NS and in vitro. Methods All consecutive cases of complex aortic abdominal aneurysm treated with the Fenestrated Anaconda (Terumo Aortic) in six European centers were included in a prospective, observational study. To compare fenestration positioning, the distance from the center of the fenestration to the proximal end of the stent graft (L) and the angular distance from the 0° position (C) were measured and compared between in vitro testing (L1, C1) and NS (L2, C2). The primary hypothesis was that ΔL (|L2 – L1|) and ΔC (|C2 – C1|) would be 2.5 or less mm in more than 80% of the cases. The duration of both processes was also compared. Results Between May 2018 and January 2019, 50 patients with complex aortic abdominal aneurysms received a fenestrated stent graft with a total of 176 fenestrations. The ΔL and ΔC was 2.5 mm or less for 173 (98%) and 174 (99%) fenestrations, respectively. The NS process duration was significantly shorter than the in vitro (2.1 days [range, 1.0-5.2 days] vs 20.6 days [range, 9-82 days]; P Conclusions Positioning of fenestrations using NS is as accurate as in vitro and could significantly decrease delivery time of fenestrated stent grafts.

Background Kidney recipients are increasingly older with arterial disease and extended arterial calcifications. In a kidney transplantation population, the prognosis value of aortic and iliac calcifications remains poorly explored. We aimed to assess the impact of pretransplantation aortoiliac vascular calcifications on patients, grafts survival, and cardiovascular events. Methods This retrospective study included kidney transplantation patients from 2006 to 2012 for whom we had available presurgery abdominal computed tomography results (n = 100). We designed a score to quantify aortoiliac calcifications. Primary end points were patient and graft survival. Secondary end points were renal function and cardiovascular morbidity. Predictive performances of calcification score were assessed using area under receiver-operating characteristic curves. Patients were classified in quartiles depending on global calcium score value. Results The cumulated rate of death and graft loss was 13% with no significant differences for survival between quartiles. No significant difference was observed in renal function (P = 0.4). Seventeen cardiovascular events were registered with a significant correlation between calcium score elevation and need of cardiovascular surgery during the follow-up (P = 0.01). Global calcium score had a predictive value of 74.5% (95% confidence interval 0.62–0.87) with 71% sensitivity and 73% specificity. Conclusions Aortoiliac calcifications do not decrease patient and graft survival. High calcium score predict cardiovascular events and procedures during the follow-up.

With a focus on renal function, the goal of this multicentre study was to assess peri-operative complications and late mortality of open surgical repair (OSR) of juxtarenal abdominal aortic aneurysms (JRAAA).From February 2005 to December 2015, 315 consecutive patients undergoing elective OSR of a JRAAA in five French academic centres were evaluated retrospectively. The definition of JRAAA was an aortic aneurysm extending up to but not involving the renal arteries, i.e., a short neck10 mm. End points included post-operative death; acute kidney injury (AKI) defined by the RIFLE (Risk, Injury, Failure, Loss of function, End stage renal disease) criteria; and long term follow-up with freedom from chronic renal decline (CRD) and any graft related complications. Factors predictive of renal insufficiency were determined by multivariable analysis.Of 315 patients, 292 (92.6%) were men (mean age 68 ± 8 years), and 73 (23.2%) had baseline chronic kidney disease (CKD) with an estimated glomerular filtration rate of60 mL/min/1.73 mThis multicentre study suggests that in fit patients, open JRAAA repair can be performed with acceptable operative risk with durable results in terms of both graft integrity and preservation of renal function.

Background Preoperative decolonization is recommended in Staphylococcus aureus nasal carriers scheduled for cardiac surgery. We aimed to evaluate the effectiveness of and compliance with mupirocin use in nasal S. aureus carriers in a real-life setting. Methods Prospective study including consecutive patients scheduled for cardiac surgery screened for S. aureus nasal carriage at preoperative consultation. Carriers were prescribed mupirocin nasal ointment, chlorhexidine shower and mouthwash. Effectiveness of decolonization was evaluated with a postoperative nasal sample. Compliance was evaluated objectively by determination of nasal mupirocin concentration using UPLC-MS/MS and self-reported by questionnaire. Results Over 10 months, 361 patients were included, 286 had preoperative screening, 75 (26.2%) were S. aureus nasal carriers and 19 of them (25.3%) failed to be effectively decolonized. No resistance to mupirocin was documented. Preoperative and postoperative strains were identical in all cases. Declared good compliance was associated with decolonization success (OR = 24; 95% CI 4–143, P Conclusions In real life, decolonization is not always effective, hence there is a persisting risk of S. aureus endogenous infection. Mupirocin concentration measurement may help to understand compliance issues and failures in decolonization.

Objective In this paper, we present an endoscopic expandable sizer conceived to allow thoracoscopic aortic valve replacement with a sutureless prosthesis using a dynamic sizing of the aortic annulus. Methods Ten aortic torsos were prepared using a five-trocar thoracoscopic setting. Once the aortotomy was performed and the aortic valve leaflets removed, the technical feasibility of the endoscopic sizing (introduction into the trocar, expansion into the aortic annulus, determination of the valve size, and retraction) with the device was assessed. In case of successful thoracoscopic sizing, endoscopic implantation of a sutureless valve (five LivaNova Perceval prosthesis and five Medtronic 3f Enable bioprosthesis) was performed. Before ascending aorta closure, we assessed the appropriate sealing of the bioprosthesis in the native annulus with camera visualization and a nerve hook inspection. Results All the 10 endoscopic sizings were technically feasible. The scheduled aortic sutureless valve implantations were successfully performed. In all cases, fitting and placement of the sutureless bio-prosthesis in the flaccid heart was satisfactory, with no paraprosthetic leakage detectable by the nerve hook. Conclusions The use of the endoscopic expandable sizer is technically possible. In this early-stage test in the flaccid heart, selection of the valve size was satisfactory during thoracoscopic sutureless aortic bioprosthesis implantation. Further laboratory evaluation with fluid dynamics (aortic root pressurization) will be performed before a clinical study is started.

Objective During endovascular repair of abdominal aortic aneurysms (EVAR), in the absence of a distal iliac landing zone, the Amplatzer plug is increasingly being used to replace other internal iliac artery (IIA) embolization techniques. This study aimed at assessing the technical success, complication occurrence, and durability of the Amplatzer plug for IIA embolization. Method From January 1, 2007 to December 31, 2013, all consecutive patients who underwent internal iliac embolization with an Amplatzer plug during EVAR were included in the study. There were 169 patients, (160 men, 9 women, mean 75 ± 9 years), treated by unilateral (158 cases, 93%) or bilateral (11 cases, 7%) embolization of the IIA, performed either separately prior to (65 cases, 38.5%) or during EVAR (104 cases, 61.5%). Follow up CT scan and/or US scan were performed 1 month after treatment and yearly thereafter. The inclusions were done retrospectively but the series was continuous and consecutive. Data were collected and analyzed using acquisition REDCap software. Results The technical success rate was 97.6%. Failures were device migration ( n = 1), navigation failure ( n = 2), and release outside the target zone ( n = 1). On average, 1.43 plugs were required to achieve the embolization. The average amount of contrast agent for the embolization procedure was 111 ± 51 mL and the radiation dose was 127,777 ± 89,528 mGy/cm 2 . The total fluoroscopy time was 854 ± 538 seconds. No re-canalization of the IIA trunk was observed during follow up. Complications were buttock claudication ( n = 41, 24.3%), which resolved in 24 cases (58.5%, 24/41) at the first follow up, and intestinal ischemia requiring limited bowel resection in two cases. Conclusion This multicenter study is the largest published to date. It demonstrates the efficacy and reliability of the Amplatzer plug to embolize the IIA during EVAR, with few side effects.

We present a technique of mitral valve surgery performed in a patient with severe pectus excavatum and previous Bentall surgery. Neither redo sternotomy nor conventional right minithoracotomy were thought to provide adequate surgical access to the mitral valve. We therefore opted for a combined procedure comprising sternal reconstruction and right minithoracotomy mitral valve replacement. The mitral valve was replaced and the sternum reconstructed according to the Ravitch technique.

Recently, sutureless aortic bioprostheses have been increasingly adopted to facilitate minimally invasive aortic valve replacement. We aimed at evaluating the impact of the transition from conventional bioprostheses to the routine use of the 3f Enable prosthesis (Medtronic ATS Medical, Minneapolis, MN) for aortic valve replacement through ministernotomy.Between November 2009 and November 2012, 83 consecutive minimally invasive aortic valve replacement procedures were performed in our institution by the same surgeon through an upper T-shaped ministernotomy. The earliest 42 patients (group A) received a conventional bioprosthesis, and the later 41 patients (group B) received the sutureless 3f Enable valve. Aortic clamping and cardiopulmonary bypass times, early outcomes, and valve hemodynamics were compared.There was no statistical intergroup difference in baseline characteristics. In-hospital mortality was 1% (a single nonvalve-related death). Average aortic clamping times in group A and group B were, respectively, 85 ± 17 and 47 ± 11 minutes (p0.0001); the cardiopulmonary bypass time was 108 ± 21 and 69 ± 15 minutes, respectively (p0.0001). There were three paravalvular leakages in group A (grade I) and four in group B (two grade I, and two grade II); three pacemaker implantations occurred in group B (p = 0.07); mean transvalvular gradient at discharge was 16.9 ± 9.1 mm Hg in group A and 11.4 ± 4.3 mm Hg in group B (p = 0.0007). During follow-up (average 25.5 ± 12.9 months), one structural valve deterioration was registered in group A, and was treated with a valve-in-valve procedure.In our initial experience, the sutureless 3f Enable technology significantly reduced the clamping and cardiopulmonary bypass times, as well as the mean transvalvular gradient in aortic valve replacement through ministernotomy.

Background A sutureless aortic valve can be inserted through a right anterior minithoracotomy (RAMT) with consistent decreased cross-clamping time and ease of insertion. We report the experience of RAMT implantation of the 3f Enable (Medtronic, Inc, Minneapolis, Minn) self-expanding sutureless bioprosthesis, performed in 2 European cardiac surgery centers. Method From September 2012 to April 2014, a total of 71 patients with severe aortic stenosis were selected to receive an aortic valve replacement via RAMT using the sutureless valve. Hemodynamic parameters and clinical outcome were assessed at discharge and up to 16 months postoperatively. Results All the patients received the prosthesis with success. One conversion to median sternotomy was necessary, owing to severe pleural adhesions. Overall in-hospital mortality was 2.8%. Mean cardiopulmonary bypass and cross-clamping time were, respectively, 91 ± 29 minutes and 66 ± 19 minutes. Reclamping was necessary in 4 cases (5.6%). Early incidences of grade I or lower paravalvular leakages and pacemaker implantation were, respectively, 4.2% and 5.6%. No paravalvular leakage greater than grade I was registered. The mean follow-up time was 8.1 months; the mean transvalvular gradient was, at discharge and at 6-12 months, respectively, 10.7 ± 4.3 mm Hg and 9.6 ± 3.1 mm Hg. The degree of regurgitation remained stable in all cases. Freedom from all-cause and valve-related mortality was 97% and 99%, respectively, at 1 year. Conclusions Aortic valve replacement via RAMT with the 3f Enable valve is a reproducible procedure, as it provides satisfactory hemodynamics, and a low valve-related complication rate. Greater experience is needed to compare the performance of the 3f Enable valve with that of other sutureless valves implanted via the same RAMT procedure.

Background - Transcatheter aortic valve replacement (TAVR) is standard therapy for patients with severe aortic stenosis who are at high surgical risk. However, national data regarding procedural characteristics and clinical outcomes over time are limited. Objectives - The aim of this study was to assess nationwide performance trends and clinical outcomes of TAVR during a 6-year period. Methods - TAVRs performed in 48 centers across France between January 2013 and December 2015 were prospectively included in the FRANCE TAVI (French Transcatheter Aortic Valve Implantation) registry. Findings were further compared with those reported from the FRANCE 2 (French Aortic National CoreValve and Edwards 2) registry, which captured all TAVRs performed from January 2010 to January 2012 across 34 centers. Results - A total of 12,804 patients from FRANCE TAVI and 4,165 patients from FRANCE 2 were included in this analysis. The median age of patients was 84.6 years, and 49.7% were men. FRANCE TAVI participants were older but at lower surgical risk (median logistic European System for Cardiac Operative Risk Evaluation [EuroSCORE]: 15.0% vs. 18.4%; p < 0.001). More than 80% of patients in FRANCE TAVI underwent transfemoral TAVR. Transesophageal echocardiography guidance decreased from 60.7% to 32.3% of cases, whereas more recent procedures were increasingly performed in hybrid operating rooms (15.8% vs. 35.7%). Rates of Valve Academic Research Consortium-defined device success increased from 95.3% in FRANCE 2 to 96.8% in FRANCE TAVI (p < 0.001). In-hospital and 30-day mortality rates were 4.4% and 5.4%, respectively, in FRANCE TAVI compared with 8.2% and 10.1%, respectively, in FRANCE 2 (p

Objectifs Le traitement de l’arteriopathie obliterante des membres inferieurs (AOMI) par technique endovasculaire en ambulatoire (HA) est une alternative a l’hospitalisation conventionnelle (HC). Nous rapportons dans ce travail les resultats cliniques en termes de securite et d’efficacite a 30 jours de la comparaison de ces deux prises en charge. Materiels AMBUVASC est une etude prospective, multicentrique controlee et randomisee. Les principaux criteres d’inclusion etaient l’egibilite a l’hospitalisation ambulatoire, l’ischemie d’effort, l’utilisation d’un introducteur de 5 a 7 French inclus, une ponction femorale retrograde. Les ponctions femorales retrogrades, radiales et humerales etaient exclues. Un systeme de fermeture arterielle etait utilise systematiquement dans le groupe HA et selon l’operateur dans le groupe HC. Le critere principal etait le ratio cout-utilite incremental. Les criteres secondaires etaient le deces, les complications ; les reinterventions et d’efficacite (rutherford, IPS). Resultats Cent-soixante patients etaient randomises (80 par groupe). Dans le bras HA, 4 patients changeaient de bras (refus de l’ambulatoire ; contre-indication de l’anesthesiste). En intention de traiter modifiee, 76 etaient analyses dans le bras HA et 77 dans le bras HC. Cent pour cent des patients etaient ASA 1, 2 ou 3 stable ; 95 % des patients etaient claudicants. Un stenting etait realise dans 96 % des cas dans le groupe HA et 86 % des cas dans le groupe HC (p = 0,03). Le succes technique etait de 96 % dans le groupe HA et de 99 % dans le groupe HC (p = 0,37). Quatre-vingt-neuf pour cent des patients en ambulatoire sortaient le soir meme. A 30 jours, on notait un deces dans le groupe HA non lie a l’AOMI. A 30 jours, 3 et 1 reinterventions etaient respectivement realisees dans les groupes HA et HC. Trois reinterventions etaient realisees en raison de complications au niveau de l’artere traitee et 1 complication en raison d’une thrombose au point de ponction. Aucune reintervention pour hemorragie n’etait realisee. Le taux de complications etait similaire entre le bras HA et HC (20 % vs 18 %, p = 0,81). Il n’y avait pas de difference entre les 2 groupes en termes d’amelioration clinique (p = 0,39) et hemodynamique (p = 0,84). Conclusion Le traitement de l’arteriopathie obliterante des membres inferieurs par technique endovasculaire en ambulatoire est sur et efficace.

Objectives With a focus on renal function, the goal of this multicentre study was to assess peri-operative complications and late mortality of open surgical repair (OSR) of juxtarenal abdominal aortic aneurysms (JRAAA). Methods From February 2005 to December 2015, 315 consecutive patients undergoing elective OSR of a JRAAA in five French academic centres were evaluated retrospectively. The definition of JRAAA was an aortic aneurysm extending up to but not involving the renal arteries, i.e., a short neck Results Of 315 patients, 292 (92.6%) were men (mean age 68 ± 8 years), and 73 (23.2%) had baseline chronic kidney disease (CKD) with an estimated glomerular filtration rate of Conclusions This multicentre study suggests that in fit patients, open JRAAA repair can be performed with acceptable operative risk with durable results in terms of both graft integrity and preservation of renal function.

We report the case of a 61-year-old man who underwent a Bentall procedure with a BioValsalva conduit for an acute type A aortic dissection. Two years later the patient presented at our institution with severe aortic regurgitation caused by the rupture of one cusp of the bioprosthesis (Elan valve) included in the conduit. A transcatheter valve-in-valve option was discussed by the heart team but was dismissed in favor of a sutureless 3f Enable valve implantation into the failing bioprosthesis after leaflet removal. This strategy simplified the surgical procedure and provided excellent postoperative hemodynamics at follow-up.

International audience; In this study, bulge inflation tests were used to characterize the failure response of 15 layers of human ascending thoracic aortic aneurysms (ATAA). Full field displacement data were collected during each of the mechanical tests using a digital image stereo-correlation (DIS-C) system. Using the collected displacement data, the local stress fields at burst were derived and the thickness evolution was estimated during the inflation tests. It was shown that rupture of the ATAA does not systematically occur at the location of maximum stress, but in a weakened zone of the tissue where the measured fields show strain localization and localized thinning of the wall. Our results are the first to show the existence of weakened zones in the aneurysmal tissue when rupture is imminent. An understanding these local rupture mechanics is necessary to improve clinical assessments of aneurysm rupture risk. Further studies must be performed to determine if these weakened zones can be detected in vivo using non-invasive techniques.

Objective The objective of this study was to evaluate the early and long-term outcome of cryopreserved arterial allografts (CAAs) used for in situ reconstruction of abdominal aortic native or secondary graft infection and to identify predictors of mortality. Methods We retrospectively included 71 patients (mean age, 65.2 years [range, 41-84 years]; men, 91.5%) treated for abdominal aortic native or secondary graft infection (65 prosthetic graft infections; 16 of them had secondary aortoenteric fistula, 2 venous graft infections, and 4 mycotic aneurysms) by in situ reconstruction with CAA in the university hospitals of Clermont-Ferrand and Saint-Etienne from 2000 to 2016. The cryopreservation protocol was identical in both centers (−140°C). Early ( 30 days) mortality and morbidity, reinfection, and CAA patency were assessed. Computed tomography was performed in all survivors. Survival was analyzed with the Kaplan-Meier method. Univariate analyses were performed with the log-rank test and multivariate analysis with the Cox regression model. Results Mean follow-up was 45 months (0-196 months). Early postoperative mortality rate was 16.9% (11/71). Early postoperative CAA-related mortality rate was 2.8% (2/71); both patients died of proximal anastomotic rupture on postoperative days 4 and 15. Early CAA-related reintervention rate was 5.6% (4/71); all had an anastomotic rupture, and two were lethal. Early postoperative reintervention rate was 15.5% (11/71). Intraoperative bacteriologic samples were positive in 56.3%, and 31% had a sole microorganism. Escherichia coli was more frequently identified in the secondary aortoenteric fistula and Staphylococcus epidermidis in the infected prosthesis. Late CAA-related mortality rate was 2.8%: septic shock at 2 months in one patient and proximal anastomosis rupture at 1 year in one patient. Survival at 1 year, 3 years, and 5 years was 75%, 64%, and 54%, respectively. Multivariate analysis identified type 1 diabetes (hazard ratio, 2.49; 95% confidence interval, 1.05-5.88; P = .04) and American Society of Anesthesiologists class 4 (hazard ratio, 2.65; 95% confidence interval, 1.07-6.53; P = .035) as predictors of mortality after in situ CAA reconstruction. Reinfection rate was 4% (3/71). Late CAA-related reintervention rate was 12.7% (9/71): proximal anastomotic rupture in one, CAA branch stenosis/thrombosis in five, ureteral-CAA branch fistula in one, and distal anastomosis false aneurysm in two. Primary patency at 1 year, 3 years, and 5 years was 100%, 93%, and 93%, respectively. Assisted primary patency at 1 year, 3 years, and 5 years was 100%, 96%, and 96%, respectively. No aneurysm or dilation was observed. Conclusions The prognosis of native or secondary aortic graft infections is poor. Aortic in situ reconstruction with CAA offers acceptable early and late results. Patients with type 1 diabetes and American Society of Anesthesiologists class 4 are at higher risk of mortality.

The TECCO (Traitement des Lésions Athéromateuses de l'Artère Fémorale Commune par Technique Endovasculaire Versus Chirurgie Ouverte [Endovascular Versus Open Repair of the Common Femoral Artery]) trial is a randomized comparison of safety and efficacy of stenting versus open surgery for de novo common femoral artery (CFA) stenosis.Surgery for CFA lesions is considered effective and durable. Despite the widespread use of endovascular repair for infrainguinal disease, the value of this procedure for such lesions is uncertain.From February 23, 2011, to September 5, 2013, a total of 117 patients with de novo atherosclerotic lesions of the CFA were randomly assigned to undergo surgery (n = 61) or stenting (n = 56). The main exclusion criteria were asymptomatic disease, restenosis, and thrombosis of the CFA. The primary outcome was the morbidity and mortality rate within 30 days. This includes any general complications or local complications that caused or prolonged hospitalization and/or re-intervention, lymphorrhea of more than 3 days, and post-operative paresthesia that required drugs. The median duration of follow-up was 2 years (interquartile range [IQR]: 19.8 to 24.9 years).Primary outcome events occurred in 16 of 61 patients (26%) in the surgery group and 7 of 56 patients (12.5%) in the stenting group (odds ratio: 2.5; 95% confidence interval: 0.9 to 6.6; p = 0.05). The mean duration of hospitalization was significantly lower in the stenting group (3.2 ± 2.9 days vs. 6.3 ± 3 days; p 0.0001). At 24 months, the sustained clinical improvement, the primary patency rate, and the target lesion and extremity revascularization rates were not different in the 2 groups.In patients with de novo atherosclerotic lesions of the CFA, the perioperative morbidity and mortality rate was significantly lower among patients who underwent endovascular therapy by stenting compared with surgery, whereas clinical, morphological, and hemodynamic outcomes were comparable at mid-term. (Traitement des Lésions Athéromateuses de l'Artère Fémorale Commune par Technique Endovasculaire Versus Chirurgie Ouverte [Endovascular Versus Open Repair of the Common Femoral Artery] [TECCO]; NCT01353651).

International audience; OBJECTIVE/BACKGROUND:The goal of the present study was to assess the aging phenomena on second-generation textile endoprostheses (EPs) through explant analysis and to establish a preliminary classification of observed defects and material damages.METHODS:From January 2011 to June 2016 110 second- and recent-generation EPs were collected as a part of a European collaborative retrieval program. The analysis focused on the first 41 consecutive commercial EPs collected between 2011 and 2014 and made from polyethylene terephthalate. Explants were submitted to a standardized evaluation protocol, which included data recording, eye-naked evaluation, cleaning of organic remnants, and structural analysis under numerical optical microscopy. Observations were reported using a classification based on 15 features evaluating the fabric, the stitches between the fabric and the stents, and the stents. The total surface area of the holes within the fabric was measured.RESULTS:EPs were implanted for thoracic and abdominal procedures in 12 and 29 cases, respectively. The mean ± SD duration of implantation was 34 ± 26 months (range 2 days-8 years). Sixty-four percent of the samples demonstrated at least one defect caused by compression damage potentially related to the insertion of the EP within the delivery system, which promoted holes and tears. Ninety-five percent of all EPs demonstrated at least one type of abrasion on the stitches. The degradation of the stitches and the number of ruptures increased with duration of implantation. Stent degradation was rare and consisted of corrosion and rupture. Cumulated holed surface area increased with time and was measured up to 13.5 mm2.CONCLUSION:Various aging-related phenomena on commercial textile EPs were identified and classified. Main damaging mechanisms were related to compression and abrasion leading to tears and holes in the fabric and rupture of stitches.

This study describes the long-term results of renal autotransplantation for renovascular hypertension performed in children who are now 21 years of age or older.Sixteen children (4 boys, 12 girls) with a mean age of 11.2 years at the time of the procedure underwent ex-vivo surgery at the university hospital of Saint-Etienne between 1992 and 2008. Acetylsalicylic acid was used for antiplatelet therapy in the postoperative period, without routine anticoagulation. The mean follow-up period was 15 years. The clinical course of these patients was retrospectively reviewed in adulthood and the results analyzed.The children were treated with a mean of 2.37 drugs per patient, and the mean preoperative blood pressure of the entire patient population was 151/89 mmHg. Mean preoperative creatinine clearance was 80 ml/min/1.73 mThis study shows that renal autotransplantation has good and stable long-term results and is an effective conservative strategy for treating renovascular hypertension in children, thus avoiding nephrectomy.

International audience; Secondary interventions after endovascular repair of abdominal aortic aneurysms are frequent because stent-graft (SG) related complications may occur (mainly endoleak and SG thrombosis). Complications have been related to insufficient SG flexibility, especially when devices are deployed in tortuous arteries. Little is known on the relationship between SG design and flexibility. Therefore, the aim of this study was to simulate numerically the bending of two manufactured SGs (Aorfix--Lombard Medical (A) and Zenith--Cook Medical Europe (Z)) using finite element analysis (FEA). Global SG behavior was studied by assessing stent spacing variation and cross-section deformation. Four criteria were defined to compare flexibility of SGs: maximal luminal reduction rate, torque required for bending, maximal membrane strains in graft and maximal Von Mises stress in stents. For angulation greater than 60°, values of these four criteria were lower with A-SG, compared to Z-SG. In conclusion, A-SG was more flexible than Z-SG according to FEA. A-SG may decrease the incidence of complications in the setting of tortuous aorto-iliac aneurysms. Our numerical model could be used to assess flexibility of further manufactured as well as newly designed SGs.

Purpose The study aimed to examine the association between incidentally discovered mesenteric artery stenosis, renal artery stenosis (RAS) and coronary artery disease in patients undergoing coronary angiography. Materials and methods We performed a prospective analysis of consecutive patients undergoing routine cardiac catheterisation. Abdominal aortograms in lateral and antero-posterior view were obtained to assess arterial stenosis of the coeliac axis, superior mesenteric artery and renal arteries. Significant arterial stenosis was defined as a narrowing of at least 50% compared with the normal artery. Demographic data and cardiovascular risk factors were analysed. Results The prevalence of visceral artery stenosis (VAS) was 63/450 (14%) including 48/450 (10.6%) cases of coeliac axis stenosis and 15/450 (3.3%) cases of superior mesenteric artery stenosis. Female sex (p = 0.01), older age (p = 0.03) and the presence of coronary artery disease (p = 0.05) were significant predictors for the presence of VAS in univariate analysis. The determinants for VAS in multivariate analysis were female sex and three-vessel coronary artery disease, while two- and three-vessel coronary artery disease was significant for RAS. Conclusion Screening for VAS and RAS in female patients older than 60 years with more than two diseased coronary segments could have a high diagnostic value.

Contexte Afin de comparer les resultats du traitement endovasculaire (TE) des anevrysmes de l’aorte abdominale (AAA) chez les patients avec et sans anevrysme associe de l’artere iliaque commune (AAIC) se prolongeant sur la bifurcation iliaque. Methodes Analyse retrospective de 157 patients qui ont beneficie d’un TE pour AAA entre 1999 et 2007. Le groupe 1 etait constitue de 133 patients sans et avec un AAIC avec collet distal (classification A, B, C, ou D). Le groupe 2 etait constitue de 24 patients avec un AAIC associe se prolongeant a la bifurcation iliaque (type E). Les endoprotheses etaient les suivantes : Powerlink (Endologix, Irvine, CA) dans 42, Zenith (Cook, Bjaeverskov, Danemark) dans 55, et Talent (Medtronic, Sunnyvale, CA) dans 60 patients. Quarante patientseu des endoprotheses aorto-uni-iliaques. Resultats Il n’a ete observe aucune difference de mortalite globale et de l’incidence de rupture des AAA. la survie a 5 ans sans complications associees a l’AAA etait de 72 ± 5% et de 41 ± 14% dans les groupes 1 et 2, respectivement ( p = 0,006). La survie sans secondaire etait de 84 ± 5% et de 55 ± 12% dans les groupes 1 et 2, respectivement ( p = 0,0008). L’incidence des fuites de type 1 et des thromboses d’endoprothese etait de 17 et 8 % dans le groupe 2, et de 3,8 et 0,8 % dans le groupe 1, respectivement ( p = 0,07 et p = 0,01, respectivement). Conclusion les complications liees a l’AAA et les interventions secondaires se produisent plus frequemment chez les patients presentant des AAA de type E. Les fuites de type 1 et les thromboses d’endoprotheses sont plus frequentes chez ces patients. Ces resultats justifient le developpement de technologies mieux adaptees pour le traitement de AAICs, telles que les endoprotheses branchees et flexibles.

Purpose: To evaluate the medium-term outcomes following aortic aneurysm repair utilizing fenestrated endografts performed in 13 French academic centers. Materials and Methods: A retrospective analysis of prospectively collected data. All patients had asymptomatic aneurysms involving or close to the visceral-bearing abdominal aorta and were judged to be at high-risk for open surgical repair. Fenestrated endografts were designed using computed tomography reconstructions performed on three-dimensional workstations. The procedures were conducted under fluoroscopic control by experienced endovascular teams. All patients were evaluated with computed tomography, duplex ultrasound, and plain film radiograph at discharge, 6, 12, 18, and 24 months, and annually thereafter. Results: Eighty patients (78 males) were treated over 44 months (May 2004–January 2008). Median age and aneurysm size were 78 years (range: 48–90 years) and 59 mm (range: 47–82 mm), respectively. A total of 237 visceral vessels were perfused through a fabric fenestration (median of 3 per patient). One early conversion to open surgery was required. Completion angiography showed that 234 of 237 (99%) target vessels were patent. Two patients (2.5%) died within 30 days of device implantation. Predischarge imaging identified 9 (11%) endoleaks: 3 type I, 5 type II, and 1 type III. The median duration of follow-up was 10 months (range: 1–38 months). No aneurysms ruptured or required open conversion during the follow-up period. Four of 78 (5%) died during follow-up (actuarial survival at 24 months 92%), none of these deaths were aneurysm related. Aneurysm sac size decreased by more than 5 mm in 33%, 53%, and 58% at 6, 12, and 18 months, respectively. One patient had sac enlargement within the first year, associated with a persistent type II endoleak. In-stent stenoses or occlusion affected 4 renal arteries. Secondary procedures were performed in 8 patients (10%) during follow-up, 5 to correct endoleaks and 3 to correct threatened visceral vessels. Conclusions: The use of endovascular prostheses with graft material incorporating the visceral arteries is safe in high risk patients with high risk aneurysms. In the medium-term it is effective in preventing rupture. However, meticulous follow-up to assess sac behavior and visceral ostia is critical to ensure optimal results.

International audience; BACKGROUND: Nowadays, most patients who undergo colorectal surgery are discharged early. An early predictor of septic complications could avoid readmissions and decrease morbidity. CRP could be a good predictor allowing a safe discharge. METHODS: A prospective, observational study was conducted from November 2007 to October 2008. All patients who underwent elective colorectal surgery were included. Clinical (temperature, pulse, abdominal tenderness, bowel movements) and laboratory data (C-reactive protein, leukocyte count) were recorded and evaluated as early predictors of septic complications (namely, anastomotic leaks). All detected leaks were considered fistulas, independently of their clinical significance. Clinical and inflammatory parameters were analyzed with univariate and multivariate techniques; logistic regression was performed and areas under the receiver operating characteristic curve were compared. RESULTS: A total of 133 patients were included. The overall incidence of anastomotic leaks was 15.5% and mortality was 4.5%. C-reactive protein at postoperative days 2 and 4 was a good predictor of anastomotic leak (areas under the curve were 0.715 and 0.845, respectively) and other postoperative septic complications (areas under the curve were 0.804 and 0.787), showing the highest accuracy among clinical and laboratory data. A cutoff of 125 mg/l in the level of C-reactive protein at postoperative day 4 yielded a sensitivity of 81.8% and a negative predictive value of 95.8% for the detection of anastomotic leakage. CONCLUSIONS: C-reactive protein is a simple way to ensure a safe discharge from hospital after elective colorectal surgery. Patients with CRP values >125 mg/l on the fourth postoperative day should not be discharged.

The aim of this study was to analyze the early and late results of iterative aortic surgery after bypass of infrarenal aorta. Results from Clermont-Ferrand and Saint-Etienne hospitals have been collected. Between January 1993 and December 2001, 61 patients (59 men and two women, mean age 65 years) underwent a partial or complete second aortic reconstruction through a direct approach. Three different indications that required redo surgery were detected. Twenty-three patients presented with an infection (37%), 17 with an occlusive pathology (28%), and 21 with an aneurysm (34%). Medical or endoluminal treatment could no longer be considered. Mean period of time for redo surgery was 101 months (range 1-294). Eighteen of the procedures were emergency surgeries. A polyester prosthesis was used in 45 cases, an arterial allograft in 15 cases, and autogenous venous material in one case. In 22 cases (36%) a visceral, renal, or infracrural revascularization was associated. Four patients died (6.5%): three with an infection and one with an occlusive pathology. Global morbidity rate was 64%. Twelve vascular surgical complications (19%) required redo surgery: seven limb ischemia, three hemorrhage, and two colic ischemia. The preoperative factors generating severe complications were a septic context, renal insufficiency, and American Society of Anesthesiologists grade 3 or 4. Follow-up concerned the 57 surviving patients with a 43-month mean period of time (range 4-105). Actuarial survival rate was 80.7% at 3 years and could be compared to that observed after infrarenal aortic first surgery. Primary and secondary global patency rates were, respectively, 66.4 +/- 6.7% and 94.6 +/- 3% at 3 years with no major amputation. In our series including 37% of septic patients and nearly 30% of patients operated on in emergency, aortic iterative surgery led to mortality and morbidity rates twice and four times as important as those resulting from infrarenal aortic initial surgery, respectively. In the long term, patient survival and limb salvage rates were quite similar to those obtained with de novo surgery.

Le but de cette etude a ete d'analyser les resultats precoces et tardifs de la chirurgie aortique iterative apres pontage prothetique de l'aorte sous-renale. Les observations des CHU de Clermont-Ferrand et Saint-Etienne ont ete regroupees. Entre Janvier 1993 et Decembre 2001, 61 patients (59 hommes, 2 femmes, âge moyen 65 ans) ont beneficie, par abord direct de l'aorte, du changement complet ou partiel d'une restauration aortique precedemment realisee. Trois indications imposant la reintervention ont ete distinguees : 23 patients presentaient une infection prothetique (37%), 17 une pathologie occlusive (28%), 21 une pathologie anevrysmale (34%). Les possibilites d'un traitement medical ou d'un traitement endoluminal avaient ete epuisees. Le delai moyen de reintervention a ete de 101 mois (1 a 294 mois). Dix-huit interventions ont eu lieu en urgence. Une prothese en Dacron a ete utilisee 45 fois, une allogreffe arterielle 15 fois et du materiel veineux autogene une fois. Dans 22 cas (36%) une revascularisation viscerale, renale, ou sous-crurale a ete associee. Quatre deces (6,5%) post-operatoires sont survenus : trois chez des patients presentant une infection prothetique et un une pathologie occlusive. Le taux global de morbidite a ete de 64%. Douze complications chirurgicales vasculaires (19%) ont necessite une reintervention : 7 ischemies de membre, 3 hemorragies, 2 ischemies coliques. Les facteurs preoperatoires favorisant la survenue d'une complication severe ont ete : le contexte septique, l'insuffisance renale, les patients classes ASA 3 ou 4. Le suivi a concerne les 57 patients survivants et a ete de 43 mois en moyenne (4 a 105). La survie actuarielle a ete de 80,7% a 3 ans et etait comparable a celle observee apres chirurgie aortique sous-renale de premiere intention. La permeabilite globale primaire et secondaire a 3 ans a ete respectivement de 66,4% ± 6,7 et de 94,6 ± 3. Aucune amputation majeure n'a ete observee. Dans notre serie qui comporte 37% de patients septiques et pres de 30% de patients operes en urgence, la chirurgie iterative aortique a entraine respectivement une mortalite et une morbidite 2 et 4 fois plus importante que la chirurgie aortique sous-renale de premiere intention. A long terme la survie des patients et le taux de conservation de membre sont comparables a ceux de la chirurgie de premiere intention.