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Percutaneous coronary interventions of saphenous vein grafts are associated with an increased risk of periprocedural complications; among these, the rupture of the vein graft is probably the less common and the most dangerous; it is even more exceptional when it occurs on a stented portion of the graft. We report the case of a 75-year-old man who presented during a balloon angioplasty of intent restenosis of a saphenous vein graft a spectacular graft rupture at the level of the previously stented site and who was ultimately successfully treated with a covered stent., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Acute coronary occlusion is the leading cause of out-of-hospital cardiac arrest, so patients are usually referred for immediate coronary angiography and angioplasty. We report here the observation of such a patient who previously underwent a coronary artery bypass intervention and who had a difficult arterial access. Moreover, the nature of the grafts was unknown (saphenous and/or mammary arteries). Multi-slice cardiac tomo-densitometry was performed rather than a conventional coronary angiography and it allowed the analysis of native arteries and grafts. There was no stenosis and angioplasty was unnecessary., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Purpose: Conventional balloon angioplasty of anastomotic stenosis following bypass surgery is insufficient at mid- and long-term. However, short-term results with cutting balloon angioplasty (CBA) are satisfactory. The purpose of this study is to determine the long-term results using this technique. Materials and methods. Between January 2002 and January 2006, all patients with anastomotic stenosis more than one month after bypass surgery, shorter than 2 cm and>50%, were referred without randomisation to CBA., Results: A total of 19 patients with mean age of 63.5 years (55-82 years), 14 males and 5 females, were included. Twenty stenoses (femoral n=15, popliteal n=4 and calf n=1) managed with CBA affected 17 infrainguinal and 2 suprainguinal bypasses. One patient had anastomotic stenoses at both extremities. The rate of technical success aws 100%. Mean follow-up was 32 months (12-42). Three deaths occurred during follow-up. One patient presented with restenosis at 3 months, successfully treated with repeat CBA. No thrombosis or infection was observed., Conclusion: The results with CBA appear persistent and compete favorably with results from surgical repair. A randomized trial would be necessary to confirm these results.

Revascularisation of the lower limbs with vein graft is frequent. Femoro-popliteal infrainguinal bypass have good permeability rates at five years. The weak point of autogenous vein bypass grafting is vein graft stenosis, which develops particularly in the first post-operative year. Stenoses are mostly in relation with myo-intimal hyperplasia and are often located at anastomoses. Serial arteriography and echographic studies have shown that the development of intrinsic graft stenosis is found in 20 to 30% of vein conduits in the lower extremity. On the basis of an abundance of clinical data, Duplex ultrasound surveillance of infrainguinal vein graft to detect and repair such lesions before graft occlusion is widely accepted and has shown in many retrospective studies to have a positive influence on lifetime of venous grafts. Critical stenosis (peak systolic velocity (PSV) > 300 cm/s and velocity ration (VR) > 4) should undergo surgical revision as it heralds occlusion of the vein graft in short delays. Intermediate stenosis (peak systolic velocity (PSV) 200-300 cm/s and velocity ratio (VR) 2-4 should be accurately followed as 50 to 70% progress to critical stenosis. Use of echo-doppler monitoring is supported by one randomised study which showed superiority of ultrasound surveillance over clinical surveillance, and by a well described relation between graft thrombosis and an increased amputation rate. In contrast, Duplex ultrasound surveillance for prosthetic grafts is not widely accepted primarily because of the occurrence of rare intrinsic lesions in prosthetic grafts, compared to in vein grafts. Vascular doctors are increasingly concerned with the costs of surveillance program and of surgical interventions. Recent economic appraisal have shown that cost associated with graft maintenance is significant, particularly in the first-year and demands consideration. However revision of a duplex-identified stenosis seems to be less costly than revision after graft thrombosis. Costs of limb amputation and the following expense of postamputation rehabilitation are very high and justify limb-salvage-related expense. The results of an ongoing randomised controlled trial (the Vein Graft Trial) comparing duplex ultrasound surveillance against clinical surveillance only will certainly bring more data on the benefits of echographic surveillance.

Objective: To examine the outcome of intracoronary stent placement by 'primary intention', guided by angiography alone, and without the use of postprocedural anticoagulation., Design: Prospective, observational study., Setting: Canadian university teaching hospital., Patients: Patients (n=559) undergoing urgent or elective percutaneous revascularization procedures (n=616) in whom a preprocedural decision to employ coronary stent placement was made. Emergency and bailout stent procedures were excluded., Intervention: Stents were delivered at high pressure (1616 to 1818 kPa) on balloons matched to the proximal reference segment diameter. Adequacy of stent deployment was judged by angiographic criteria alone. Postprocedural medication included acetylsalicylic acid and ticlopidine. Quantitative coronary angiographic analysis was independently performed. Acute procedural outcomes were prospectively collected. Patients were followed for one year., Results: All but one patient had a successful angiographic result. Periprocedural death (0.3%), Q wave myocardial infarction (MI) (0%), non-Q MI (1.6%) and stent thrombosis (0.6%) were uncommon events. At one year, 96% of patients were alive and free of MI, while 12% of patients required repeat target lesion revascularization., Conclusion: A primary intention strategy of intracoronary stenting, guided by angiography alone, is a safe and effective approach to percutaneous coronary revascularization.

The pinch off syndrome due to squeezing of the implanted catheter is a rare complication of permanent venous access devices (0.1 to 1% of the cases). The cause is a mechanical catheter's compression in the costo-clavicular space, when implanted too medially in the subclavian vein. In case of lack of venous reflux or injection difficulties, sometimes complicated by local pain, a radiological control must be obtained to demonstrate signs of compression or beginning of fracture. Significant damage to the system is shown be extravasation of radioopaque contrast medium. The suspicion of catheter damage justifies early replacement of the system to avoid right heart or pulmonary artery embolism. The electron microscopic scanning tends to prove that the catheter's rupture is caused by a fatigue process.

Forty five Carbon-lined (CL) and 45 Standard (ST) 4 mm internal diameter polytetrafluoroethylene (PTFE) grafts were implanted as aortic interpositions in 90 New Zealand rabbits. In a pilot study of 20 animals, 10 CL and 10 ST grafts were used to develop microsurgical techniques, then 60 grafts were placed in 60 rabbits with lower morbidity. The 2-hour graft patency (Doppler study, Transonic flow probe and 8 mHZ) showed a better patency rate in the CL group (93% versus 80%). In 10 animals, platelet accumulation was investigated in vivo using scintigraphy after injection of autologous platelets labeled with Indium111. In vitro, radioactivity counting of the explanted midgrafts sections at 2 hours revealed a 6-fold higher activity in ST grafts (6.60 +/- 1.98 x 103 platelets/mm2 versus 0.82 +/- 0.25 x 103 platelets/mm2; p < 0.05). Light microscopy found platelet and fibrin deposition (PFD) in nearly all ST grafts, whereas PFD were found in only 13% of the CL grafts corresponding to those thrombosed grafts (chi2:61.117; p < 0.001). Carbon-lining decreases platelet accumulation on PTFE grafts and the rabbit aortic interposition appears to constitute a quantitative and reproducible model for investigation of antithrombotic drugs.

The aim of this study was to evaluate the early postoperative angiographic features of arterial coronary bypass grafts in 83 asymptomatic patients referred consecutively from the surgical unit. The patients aged 33 to 78 years (average 62 years) were operated between August 1989 and March 1992 and received only arterial coronary bypass grafts: 209 arteries bypassed (121 internal mammary including 10 sequential grafts, 46 radial, 36 epigastric including 4 sequential grafts and 6 gastroepiploic arterial grafts), an average of 2.4 bypass grafts per patient. Selective angiography of the arterial grafts was performed systematically between the 7th and 15th postoperative days in patients with uncomplicated recoveries. The native coronary arterial network was opacified only when a graft was "non-functional": haemodynamic (> 70%) stenosis or occlusion. 3.8% of pediculated mammary grafts were occluded. On the other hand, 16.6% of free internal mammary grafts were occluded. None of the radial artery grafts were occluded, but 8% were stenotic. Finally, 30% of epigastric and 50% of the gastroepiploic grafts were occluded. These results confirm the good function of in situ mammary artery grafts by suggest that systematic multiple arterial grafts should be used with caution. Radial artery grafts give very encouraging results which require long-term evaluation. Early postoperative evaluation of coronary arterial grafts provides important information and should be considered a routine procedure.

Ultrasound techniques and radionuclide studies are very often used to assess vascularization of renal transplants. Although, in acute tubular necrosis or acute rejection, it is difficult to choose between these two techniques, in 3 recent cases of renal artery thrombosis, we conclude that color coded Doppler is preferable to nuclear medicine or duplex system to diagnose this form of thrombosis.

One hundred and fifty patients who underwent revascularisation of the left anterior descending artery (LAD) by the left internal mammary artery (LIMA) between 1981 and 1983 were recalled for control coronary angiography one year after surgery. One hundred patients gave consent. The patency rate in these 100 patients was 90 per cent. The presumed causes of the 10 thromboses observed were: for LAD (5 cases), technical problems (3 cases), competitive flow (2 cases). Ten per cent of the patent LIMA grafts were abnormal: moderate stenosis of the anastomosis (5 cases), small LIMA (3 cases), stenosis of the middle segment of the LIMA (1 case). In addition, we observed 7 cases of competitive flows: 3 cases with a LAD which was not sufficiently stenotic, 4 cases with a large saphenous diagonal bypass graft. If a diagonal artery bypass is necessary, it is better to revascularize by either a latero-lateral anastomosis with the LIMA or by using the right IMA. Ninety per cent of the patent grafts were quite satisfactory ar 1 year: regular, supple, and perfectly congruent with the bypassed artery which was injected massively. As a number of North American teams have shown, this good patency rate seems to be maintained at long term, which is not the case with saphenous vein bypass grafts.