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International audience; Background: Intravascular lithotripsy (IVL) is a promising new technology for disrupting de-novo calcified coronary lesions (DNL) before percutaneous coronary intervention (PCI). We assessed 12-month outcomes of IVL in patients undergoing PCI for DNL or intra stent restenosis (ISR) lesions related to device underexpansion.Methods: Prospective analysis of patients in the multicentre all-comers French Shock Initiative IVL registry. The primary safety endpoints in this analysis were in-hospital and 12-month major adverse cardiovascular events (MACE: cardiac death, myocardial infarction or target vessel revascularization). The primary effectiveness endpoint was procedural success, defined as

BackgroundThe best recanalization strategy for mechanical thrombectomy (MT) remains unknown as no randomized controlled trial has simultaneously evaluated first-line stent retriever (SR) versus contact aspiration (CA) versus the combined approach (SR+CA).ObjectiveTo compare the efficacy and safety profiles of SR, CA, and SR+CA in patients with acute ischemic stroke (AIS) treated by MT.MethodsWe analyzed data of the Endovascular Treatment in Ischemic Stroke (ETIS) Registry, a prospective, multicenter, observational study of patients with AIS treated by MT. Patients with M1 and intracranial internal carotid artery (ICA) occlusions between January 2015 and March 2020 in 15 comprehensive stroke centers were included. We assessed the association of first-line strategy with favorable outcomes at 3 months (modified Rankin Scale score 0–2), successful recanalization rates (modified Thrombolysis In Cerebral Infarction (mTICI) 2b/3), and safety outcomes.ResultsWe included 2643 patients, 406 treated with SR, 1126 with CA, and 1111 with SR+CA. CA or SR+CA achieved more successful recanalization than SR for M1 occlusions (aOR=2.09, (95% CI 1.39 to 3.13) and aOR=1.69 (95% CI 1.12 to 2.53), respectively). For intracranial ICA, SR+CA achieved more recanalization than SR (aOR=2.52 (95% CI 1.32 to 4.81)), no differences were observed between CA and SR+CA. SR+CA was associated with lower odds of favorable outcomes compared with SR (aOR=0.63 (95% CI 0.44 to 0.90)) and CA (aOR=0.71 (95% CI 0.55 to 0.92)), higher odds of mortality at 3 months (aOR=1.56 (95% CI 1.22 to 2.0)) compared with CA, and higher odds of symptomatic intracranial hemorrhage (aOR=1.59 (95% CI 1.1 to 2.3)) compared with CA.ConclusionsDespite high recanalization rates, our results question the safety of the combined approach, which was associated with disability and mortality. Randomized controlled trials are needed to evaluate the efficacy and safety of these techniques.

International audience; Background: Intravascular ultrasound (IVUS)-guided PCI improves the prognosis of left main stem (LMS) PCI and is currently recommended by international guidelines. Although OCT resolution is greater than that of IVUS, this tool is not yet recommended in LMS angioplasty due to the absence of data.Aims: This pilot study aimed to analyse the feasibility, safety and impact of OCT-guided LMS PCI.Methods: This prospective, multicentre trial investigated whether patients might benefit from OCT-guided PCI for mid/distal LMS according to a pre-specified protocol. The primary endpoint was procedural success defined as follows: residual angiographic stenosis

Background and Purpose: The efficacy of endovascular therapy in patients with acute ischemic stroke due to tandem occlusion is comparable to that for isolated intracranial occlusion in the anterior circulation. However, the optimal management of acute cervical internal carotid artery lesions is unknown, especially in the setting of carotid dissection, but emergency carotid artery stenting (CAS) is frequently considered. We investigated the safety and efficacy of emergency CAS for carotid dissection in patients with acute stroke with tandem occlusion in current clinical practice. Methods: We retrospectively analyzed a prospectively maintained database composed of 2 merged multicenter international observational real-world registries (Endovascular Treatment in Ischemic Stroke and Thrombectomy in Tandem Lesion). Data from endovascular therapy performed in the treatment of tandem occlusions related to acute cervical carotid dissection between January 2012 and January 2019 at 24 comprehensive stroke centers were analyzed. Results: The study assessed 136 patients with tandem occlusion due to dissection, including 65 (47.8%) treated with emergency CAS and 71 (52.2%) without. The overall rates of favorable outcome (90-day modified Rankin Scale score, 0–2) and successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b–3) were 58.0% (n=76 [95% CI, 49.6%–66.5%]) and 77.9% (n=106 [95% CI, 71.0%–85.0%]), respectively. In subgroup analyses, the rate of successful reperfusion (89.2% versus 67.6%; adjusted odds ratio, 2.24 [95% CI, 1.33–3.77]) was higher after CAS, whereas the 90-day favorable outcome (54.3% versus 61.4%; adjusted odds ratio, 0.84 [95% CI, 0.58–1.22]), symptomatic intracerebral hemorrhage (sICH; 10.8% versus 5.6%; adjusted odds ratio, 1.59 [95% CI, 0.79–3.17]), and 90-day mortality (8.0% versus 5.8%; adjusted odds ratio, 1.00 [95% CI, 0.48–2.09]) did not differ. In sensitivity analyses of patients with successful intracranial reperfusion, CAS was not associated with an improved clinical outcome. Conclusions: Emergency stenting of the dissected cervical carotid artery during endovascular therapy for tandem occlusions seems safe, whatever the quality of the intracranial reperfusion.

Systems of care have been challenged to control progression of the COVID-19 pandemic. Whether this has been associated with delayed reperfusion and worse outcomes in French patients with ST-segment elevation myocardial infarction (STEMI) is unknown.Aim: To compare the rate of STEMI admissions, treatment delays, and outcomes between the first peak of the COVID-19 pandemic in France and the equivalent period in 2019.Methods: In this nationwide French survey, data from consecutive STEMI patients from 65 centres referred for urgent revascularization between 1 March and 31 May 2020, and between 1 March and 31 May 2019, were analysed. The primary outcome was a composite of in-hospital death or non-fatal mechanical complications of acute myocardial infarction.Results: A total of 6306 patients were included. During the pandemic peak, a 13.9±6.6% (P=0.003) decrease in STEMI admissions per week was observed. Delays between symptom onset and percutaneous coronary intervention were longer in 2020 versus 2019 (270 [interquartile range 150-705] vs 245 [140-646]min; P=0.013), driven by the increase in time from symptom onset to first medical contact (121 [60-360] vs 150 [62-420]min; P=0.002). During 2020, a greater number of mechanical complications was observed (0.9% vs 1.7%; P=0.029) leading to a significant difference in the primary outcome (112 patients [5.6%] in 2019 vs 129 [7.6%] in 2020; P=0.018). No significant difference was observed in rates of orotracheal intubation, in-hospital cardiac arrest, ventricular arrhythmias and cardiogenic shock.Conclusions: During the first peak of the COVID-19 pandemic in France, there was a decrease in STEMI admissions, associated with longer ischaemic time, exclusively driven by an increase in patient-related delays and an increase in mechanical complications. These findings suggest the need to encourage the population to seek medical help in case of symptoms., Contexte. Les systèmes de santé à travers le monde ont été fortement mis à l’épreuve afin de contrôler la progression de l’épidémie de la COVID-19. L’éventualité que la réorganisation des soins ait pu influencer les délais de reperfusion ou le devenir des patients présentant des syndromes coronaires aigus avec sus-décalage du segment ST (SCA ST +) n’a pas été explorée en France.Objectif. Comparer le taux d’admissions pour SCA ST+, les délais de traitement et enfin le devenir de ces patients entre la première vague épidémique de la COVID-19 et pendant la période similaire en 2019.Méthodes. Dans ce registre national multicentrique, les patients avec SCA ST+ provenant de 65 centres français admis en urgence pour revascularisation entre le 1e mars et le 31 mai 2020 et entre le 1e mars et le 31 mai 2019 ont été analysés. Le critère de jugement principal était un critère composite regroupant la mortalité intrahospitalière toute cause confondue et les complications mécaniques en lien avec l’infarctus.Résultats. Un total de 6 306 patients ont été inclus. Pendant le pic de la pandémie une réduction de 13,9 ± 6,6 % (P = 0,003) des admissions pour SCA ST+ a été observée par semaine. Les délais entre l’apparition des symptômes et l’angioplastie percutanée était significativement augmentés 270 (150−705) versus 245 (140−646) minutes (P = 0,013). Cette augmentation était exclusivement liée à une augmentation du temps entre l’apparition des symptômes et le premier contact médical 121 (60−360) en 2019 versus 150 (62−420) minutes en 2020 (P = 0,002). Durant cette période a été constaté un plus grand nombre de complications mécaniques (0,9 % vs 1,7 % (P = 0,029) conduisant à une augmentation significative de notre critère de jugement principal 112 patients (5,6) en 2019 vs 129 (7,6 %) en 2020 (P = 0,018).Conclusions. Pendant le premier pic de la pandémie il a été constaté : une diminution du taux de SCA ST + associé à un temps d’ischémie prolongé, poussé par l’augmentation du temps entre l’apparition des symptômes et le premier contact médical et enfin un plus grand nombre de complications mécaniques. Ces observations suggèrent la nécessité d’encourager la population à consulter au moindre symptôme inquiétant.

BACKGROUND: Treatment management and outcomes of unruptured nonsaccular aneurysms are different compared with their saccular counterparts. PURPOSE: Our aim was to analyze the outcomes after flow diversion among nonsaccular unruptured lesions. DATA SOURCES: A systematic search of 3 data bases (2005–2019) was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. STUDY SELECTION: We included studies reporting flow diversion for nonsaccular unruptured aneurysms of the posterior and distal anterior circulations. Anterior circulation lesions were included if located distal to the petrocavernous and supraclinoid ICA (MCA, A1, anterior communicating artery, A2). Giant dolichoectatic holobasilar lesions were excluded because of their poor treatment outcomes. DATA ANALYSIS: Aneurysm occlusion and complication rates were calculated (random effects meta-analysis). DATA SYNTHESIS: We included 15 studies (213 aneurysms). The long-term adequate occlusion rate was 85.3% (137/168; 95% CI, 78.2%–92.4%; I(2) = 42.3%). Treatment-related complications were 17.4% (41/213; 95% CI, 12.45%–22.4%; I(2) = 0%). Overall, 15% (37/213; 95% CI, 10%–20%; I(2) = 0%) were ischemic events. Procedure-related morbidity was 8% (20/213; 95% CI, 5%–12%; I(2) = 0%). Fusiform or dissecting types had comparable adequate occlusion (116/146 = 83%; 95% CI, 74%–92%; I(2) = 48% versus 33/36 = 89%; 95% CI, 80%–98%; I(2) = 0%; P = .31) and complication rates (35/162 = 17%; 95% CI, 10%–25%; I(2) = 24% versus 11/51 = 19%; 95% CI, 10%–31%; I(2) = 0%; P = .72). Aneurysm size (>10 versus ≤10 mm) was independently associated with a higher rate of complications (OR = 6.6; 95% CI, 1.3–15; P = .02). The rate of ischemic events after discontinuation of the antiplatelet therapy was 5% (5/93; 95% CI, 2%–9%; I(2) = 0%). LIMITATIONS: Small and retrospective studies were available for this meta-analysis. CONCLUSIONS: Unruptured nonsaccular aneurysms located in the posterior and distal anterior circulations can be effectively treated with flow diversion. Nevertheless, treatment-related complications are not negligible, with about 15% ischemic events and 8% morbidity. Larger size (>10 mm) significantly increases the risk of procedure-related adverse events.

PurposeTo evaluate the occurrence and risk factors of acute in-stent thrombosis or stent occlusion in patients with tandem occlusions receiving intracranial mechanical thrombectomy and emergent extracranial internal carotid artery stenting with a dual layer carotid stent.MethodsMulticenter retrospective data collection and analysis of stroke databases of seven comprehensive stroke centers from three European countries.ResultsOverall, 160 patients (mean (SD) age 66 (12) years; 104 men (65%); median (IQR) baseline NIHSS 14 (9–18); IV lysis, n=97 (60.6%)) were treated for a cervical carotid artery occlusion or stenosis using a CASPER stent (MicroVention), and received mechanical thrombectomy for an intracranial occlusion between April 2014 and November 2018. During the procedure or within 72 hours, formation of thrombus and complete occlusion of the CASPER stent was observed in 33/160 (20.8%) and in 12/160 patients (7.5%), respectively. In 25/33 (75.8%) and in 9/12 patients (75%), respectively, this occurred during the procedure. No statistically significant difference was observed between patients with and without thrombus formation with regard to pre-existing long term medication with anticoagulants or intraprocedural administration of heparin, acetylsalicylic acid (ASA), or heparin and ASA. Favorable early neurological outcome was similar in patients with (n=15; 45.5%) and without (n=63; 49.6%) thrombus formation at the CASPER stent.ConclusionAcute thrombosis or occlusion of CASPER stents in thrombectomy patients receiving emergent extracranial internal carotid artery stenting for tandem occlusions were observed more often during the procedure than within 72 hours of follow-up, were less frequent then previously reported, and showed no impact on early neurological outcome.

BACKGROUND AND PURPOSE: Flow-diverting stents can be used to treat intracranial aneurysms that are not amenable to treatment with coils. We analyzed ophthalmic consequences due to coverage of the origin of the ophthalmic artery by flow-diverting stents for the treatment of internal carotid artery aneurysms. MATERIALS AND METHODS: From April 2009 to April 2013, the clinical and angiographic outcomes of all 28 patients treated for aneurysms with flow-diverting stents covering the origin of the ophthalmic artery were prospectively collected. The origin of the ophthalmic artery in relation to the target aneurysm was classified by using a 4-type classification. A complete ophthalmic examination was performed by a single ophthalmologist 48 hours before and 1 week after covering the ophthalmic artery. RESULTS: Ophthalmic artery patency was normal at the end of endovascular treatment in 24/28 cases (85.7%). With extensive ophthalmic examinations, 11 patients (39.3%) showed new ophthalmic complications. Patients with the ophthalmic artery originating from the aneurysm sac were at high risk for retinal emboli (4/5, 80%). Patients with the ophthalmic artery originating from the inner curve of the carotid siphon were at high risk for optic nerve ischemic atrophy (3/4, 75%). CONCLUSIONS: This prospective study shows that covering the ophthalmic artery with a flow-diverting stent is not without potential complications. Ophthalmic complications can occur but are often not diagnosed. The anatomic disposition of the ophthalmic artery in relation to the carotid siphon and aneurysm should be clearly understood because some configurations have a higher risk. When not required, covering of the ophthalmic artery by flow-diverting stents should be avoided.

International audience; BACKGROUND: Cardiac magnetic resonance can detect myocardial oedema using myocardial transverse relaxation time (T2)-weighted sequences but quantitative data are lacking in patients evaluated early after acute myocardial infarction. AIM: To assess the spatial distribution of T2 in patients with recent acute myocardial infarction. METHODS: Twenty-four consecutive patients (mean age 60+/-11 years) with acute myocardial infarction (anterior, n=12; inferior, n=12) were evaluated prospectively. T2 was determined using a series of breath-hold T2-weighted segmented half-Fourier turbo-spin echo sequences. No-reflow was defined as the association of early hypoenhancement and delayed enhancement in an akinetic region after a bolus injection of DOTA-Gd (0.2 mmol/kg). RESULTS: No-reflow was present in 13 (54%) patients and absent in 11 (46%) patients. Mean T2 was increased in the infarct region (84.9+/-23.7 ms) compared with in the remote myocardium (62.8+/-10.3 ms, p=0.0001) and in control subjects (55.7+/-4.6 ms, p

Background and Purpose— The management of unruptured intracranial aneurysms remains controversial and the results of endovascular treatment are not precisely known because no prospective data exist. The first prospective multicenter study (ATENA) was conducted in Canada and France to determine clinical outcome and risks of this treatment. Methods— Six hundred forty-nine patients harboring a total of 1100 aneurysms from 27 Canadian and French neurointerventional centers were prospectively and consecutively treated by endovascular coil embolization. Of these, 739 unruptured intracranial aneurysms were treated during 700 procedures. Aneurysms were selectively treated in the great majority of cases (98.4%) with coils alone (54.5%), the balloon remodeling technique (37.3%), or stenting (7.8%). Results— Endovascular treatment failed in 32 aneurysms (4.3%). Technical adverse events with or without clinical modification were encountered in 15.4% of patients and included thromboembolic complications (7.1% per procedure), intraoperative rupture (2.6% per procedure), and device-related problems (2.9% per procedure). Adverse events associated with transient or permanent neurological deficit or death were encountered in 5.4% of cases. The 1-month morbidity and mortality rates were 1.7% and 1.4%, respectively. Conclusions— Endovascular treatment of unruptured intracranial aneurysms is feasible in a high percentage of cases with low morbidity and mortality rates.

International audience; OBJECTIVES:To compare the volume of in-stent neointimal proliferation, assessed by intravascular ultrasound (IVUS), at 6-month follow-up after implantation of a coronary Carbofilm-coated stent (Tecnic Carbostent, Sorin Biomedica Cardio, Saluggia, Italy) versus a conventional 316 L stent (Rx Multi-Link Penta, Abbott Laboratories, Abbott Park, IL). BACKGROUND:Many trials suggest that stent characteristics and coating could be important determinants of restenosis. METHODS:From October 2004 to May 2005, 63 patients were randomized to Tecnic (T, n = 30) or Penta (P, n = 33). The primary end-point was in-stent volume of neointimal hyperplasia (NIH) measured by IVUS at 6 months. The secondary end-points included binary restenosis, minimal luminal diameter (MLD), target lesion revascularization, and major adverse cardiac events. RESULTS:There were no significant differences between T and P as to mean age, male gender, clinical status, complexity of the lesion, lesion length, reference vessel diameter before percutaneous coronary intervention (PCI), MLD pre-PCI, and stent-to-artery ratio. However, MLD poststenting was greater in P group than T group (2.81 +/- 0.45 mm vs. 2.49 +/- 0.33 mm, P < 0.002). At 6 months, angiographic late lumen loss (0.61 +/- 0.51 mm vs. 0.92 +/- 0.61 mm, P < 0.043), in-stent obstruction (25.86 +/- 16.48% vs. 38.33 +/- 19.56%, P = 0.021), and in-stent late loss volume (31.62 +/- 29.75 mm(3) vs. 57.28 +/- 37.16 mm(3), P = 0.016) were significantly lower in T group than in P group. CONCLUSION:Penta stent appears to offer a better deployment and a larger MLD post-PCI than Carbofilm-coated stent. However, a thicker NIH was observed on Penta stent at 6-month follow-up, when compared to Tecnic.

International audience; An 80% dysfunction rate at 2 years limits the use of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of complications of portal hypertension. The use of covered stents could improve shunt patency; however, long-term effect and safety remain unknown. Eighty patients randomized to be treated by TIPS either with a covered stent (Group 1) or an uncovered prosthesis (Group 2) were followed-up for 2 years. Doppler US was performed every 3 months. Angiography and portosystemic pressure gradient measurement were performed every 6 months or whenever dysfunction was suspected. Actuarial rates of primary patency in Groups 1 and 2 were 76% and 36% respectively (P=0.001). Clinical relapse occurred in four patients (10%) in Group 1 and 12 (29%) in Group 2 (P

OBJECT It was initially considered safe for flow-diverting stents to cover the ostia of branching vessels during endovascular procedures for the treatment of intracranial aneurysms. As more recent evidence suggests, however, their use is not always free of ischemic concerns in terms of covered arterial ostia. The authors sought to determine the frequency of silent and clinically evident diffusion-weighted imaging (DWI)–detected abnormalities related to stent placement as a means of elucidating potential clinical risks. METHODS This is a prospective single-center study on a series of patients with intracranial aneurysms that were treated with flow-diverting stents. All patients systematically underwent an MRI protocol that included DWI before treatment, between 24 and 48 hours postprocedure, and 3 months postembolization. Effectiveness of anticoagulation treatment was assessed for all patients. Lesions seen on DWI were correlated to the parent artery and the side-branch territories and were statistically analyzed in relation to their time of occurrence and clinical presentation. The authors compared the DWI findings in these patients to findings obtained in patients treated with a stent-assisted coiling technique during the same time period. RESULTS Over the course of 18 consecutive months, 38 consecutive patients (7 males and 31 females) with 49 intracranial aneurysms were treated using flow-diverting stents. Overall, 81.6% of the DWI spots found remained clinically silent during the follow-up period. Five ischemic clinical complications (13.2%) occurred in the postprocedural period. No statistically significant correlation could be established between DWI spots or aneurysm location and clinical complications or follow-up modified Rankin Scale score at 3 months. The complication rate was 7.8% (n = 3) at the 3-month follow-up, and mortality was 0%. Compared with stent-assisted coiling, use of flow-diverting stents showed a statistically significant correlation with silent DWI findings postintervention. CONCLUSIONS Lesions seen on DWI resulting from the procedure are far more common than anticipated, but the technique remains safe and effective, providing an interesting alternative for “difficult” aneurysms, regardless of location. Late-occurring DWI-detected lesions distal to side arterial branches imply a local pressure gradient drop, related to flow competition by collateral networks. Further research is needed to assess the extent and significance of these events.

Extension to the right heart chambers can cause valve obstruction, leading to cardiac insufficiency and death. Magnetic resonance and computed tomographic angiography are the most sensitive methods to diagnose this pathology and to enable planning of the most appropriate therapeutic strategy. Treatment consists in a total hysterectomy and bilateral salpingo-oophorectomy, along with removal of as much of the extrauterine tumor as possible. Recurrence can result from incomplete excision and may necessitate further surgical treatment. Because of the presence of estrogen receptors, antiestrogens such as tamoxifen may be given when the tumor is unresectable or to control for incomplete resection or recurrence of the tumor.

International audience; Consumptive coagulopathy is known to occur in patients with aneurysm, especially in the thoracic localization. Compared to open chest surgery, the endovascular treatment leaves in place a large thrombosed aneurysmal sac, which might induce and/or exacerbate the coagulopathy. Although exceptional, some recent reports have raised the potential disastrous issue related to this complication. We report the case of a 74-year-old patient treated for an asymptomatic thoracic aorta aneurysm by endoprosthesis who developed a fatal disseminated intravascular coagulopathy. This complication has been related to a type III endoleak associated with a preoperative hepatic insufficiency.

International audience; We investigated the ability of 16-slice computer tomography (CT) to discriminate any restenosis after left main coronary artery stenting in 29 consecutive patients. CT was able to detect all stents and analyze the lumen properly in 27 of 29 cases. With the exception of arrhythmic or heavily calcified segments, multislice CT provides a noninvasive alternative to conventional coronary angiography in the follow-up of left main angioplasty with stenting.

A 56-year-old woman presented with bearing down. She had received a renal allograft 3 years before admission, without any renal complaints after transplantation. There was no fever. The physical examination findings were unremarkable. Her blood pressure was 143/102 mm Hg with a pulse rate of 68 beats/min. Laboratory tests revealed a white blood cell count of 5 10/mm, hemoglobin was 12.8 g/dL, and the serum creatinine level was 1.3 mg/dL. A contrast-enhanced multislice helical computed tomography scan of the abdomen was performed. On the axial images (A), an ovoid mass with contrast filling at the arterial phase was seen in the right part of the pelvis (arrows). A selective iliac arteriogram (B) with three-dimensional reconstruction (C) confirmed the diagnosis of a large-necked pseudoaneurysm at the anastomotic site of the renal allograft artery. An uncovered, flexible, self-expanding endovascular stent was placed at the base of the pseudoaneurysm in the renal allograft and external iliac arteries. Superselective coil embolization of the pseudoaneurysm cavity was then performed through the stent meshes using the packing technique: detachable microcoils of various lengths and diameters (DCS, Standart or Soft Detach-18 Embolization Coil System, Cook, Bjaeverskov, Denmark) were deployed across the neck into the pseudoaneurysmal sac. A control angiography showed total exclusion of the pseudoaneurysm perfusion, with preserved patency of the renal allograft artery and unchanged delineation of the external iliac artery (D). The patient’s postprocedural course was uneventful, without flow into the aneurysm cavity by duplex ultrasound imaging.

International audience; AIMS: Primary percutaneous coronary intervention (PPCI) is the recommended treatment for patients with acute ST-segment elevation myocardial infarction (STEMI). Despite substantial evidence of its effectiveness, a 2007 study reported that only 40-45% of European STEMI patients were treated with PPCI, with large variations in treatment availability between countries. In 2008, the Stent for Life (SFL) initiative was launched by the European Association of Percutaneous Cardiovascular Interventions and EuroPCR in partnership with the European Society of Cardiology (ESC) Working Group on Acute Cardiac Care and country-specific national cardiac societies. The aim is to promote the prioritisation of percutaneous coronary intervention treatment towards those who will benefit most, namely STEMI patients. The following countries are currently participating: Bulgaria, Egypt, France, Greece, Italy, Portugal, Romania, Serbia, Spain and Turkey. METHODS AND RESULTS: Since SFL was launched, several activities have been initiated in the participating countries. Preliminary reports suggest that major increases have been seen in the numbers of PPCI performed, with some countries reporting very significant increases in PPCI use from 2008-2010. Improvements in STEMI mortality rates have also been observed. CONCLUSIONS: This report summarises the progress of the SFL initiative in the 10 target countries.

International audience; BACKGROUND: Migration is the most common complication of the fully covered metallic self-expanding esophageal stent (SEMS). This study aimed to determine the potential preventive effect of proximal fixation on the mucosa by clips for patients treated with fully covered SEMS. METHODS: In this study, 44 patients (25 males, 57%) were treated with fully covered SEMS including 22 patients with esophageal stricture (4 malignant obstructions, 6 anastomotic strictures, and 12 peptic strictures) and 22 patients with fistulas or perforations (10 anastomotic leaks, 4 perforations, and 8 postbariatric surgery fistulas). The Hanarostent (n = 25), Bonastent (n = 5), Niti-S (n = 12), and HV-stent (n = 2) with diameters of 18 to 22 mm and lengths of 80 to 170 mm were used. Two to four clips (mean, 2.35 ± 0.75 clips) were used consecutively in 23 patients to fix the upper flared end of the stent with the esophageal mucosal layer. Stent migration and its consequences were collected in the follow-up assessment with statistical analysis to compare the patients with and without clip placement. RESULTS: No complication with clip placement was observed, and the retrieval of the stent was not unsettled by the persistence of at least one clip (12 cases). Stent migration was noted in 15 patients (34%) but in only in 3 of the 23 patients with clips (13%). The number of patients treated to prevent one stent migration was 2.23. The predictive positive value of nonmigration after placement of the clip was 87%. In the multivariate analysis, the fixation with clips was the unique independent factor for the prevention of stent migration (odds ratio, 2.3; 95% confidence interval, 0.10-0.01; p = 0.03). CONCLUSIONS: Anchoring of the upper flare of the fully covered SEMS with the endoscopic clip is feasible and significantly reduces stent migration.

We read with interest the article by Jeanin van Hooft and colleagues, and congratulate them on their accomplishment, especially in an emergency setting. However, this trial raises ethical and oncological dilemmas that deserve comment. First, in 1996, the American Society of Clinical Oncology stated that overall survival and quality of life should be regarded as the main patient outcomes in clinical oncology. Quality of life is particularly important when survival is equivalent for diff erent treatments. Van Hooft and colleagues did not justify the omission of survival data in their trial. Second, the trial was stopped early because of safety concerns; there was a high perforation rate, six of 47 patients (12·8%), and low technical success rate (70%, 33 of 47 patients) in the stenting group. The investigators discussed the various reasons for these poor outcomes. However, those in favour of the use of stents could argue that better external validity of the data is needed; do 20 stent placements represent suffi cient surgical experience? What is the mean number of stents placed per month per endoscopist? The uncertainty principle, or equipoise, is a fundamental scientifi c and ethical principle for randomised clinical trials. From the results of existing trials it would seem that uncertainty regarding colonic stenting versus surgery no longer exists because, to our knowledge, three of the four previous randomised clinical trials in this discipline were stopped for safety reasons. In these three trials, the cumulative mortality rates were similar after stenting as a bridge to surgery and surgery alone (7·9% [eight of 105 patients] vs 5·7% [six of 105], respectively). Systematic reviews of stenting show a median clinical perforation rate of 4% (range 0–83%). This rate seems to be acceptable to most authors. However, if a surgeon reported such a rate of surgical perforation, he would almost certainly need to retrain. Cancer perforation can jeopardise the future of patients by changing a potentially curable disease into an incurable one. In addition to the clinical perforation, researchers have reported a high rate of silent perforation, which could compromise survival even if this risk has not yet been shown. Taking into account that stenting can lead to a high perforation rate (and the oncological consequences of that), along with the unknown oncological outcome after stenting, van Hooft and colleagues’ proposal of further randomised trials is troubling. Trials in such a setting would not respect the uncertainty principle. Before a new trial is undertaken, we should know the eff ect of stenting on survival and local recurrences, which could be achieved by establishment of a registry to include survival data for all patients receiving colonic stents. We suggest that colonic stenting as bridge to surgery should no longer be done routinely until such robust survival data are available.

International audience; BACKGROUND: Idiopathic tracheal stenosis (ITS) is a rare condition representing a difficult therapeutic challenge. Endoscopic management is a therapeutic option but long-term results are not established. The aim of this retrospective multicenter study was to analyze long-term outcome after endoscopic management of ITS. METHODS: Nine institutions involved in interventional bronchoscopy were contacted and asked to identify ITS endoscopically treated. A standard form was used to report the main characteristics and long-term outcome after endoscopic management. RESULTS: Twenty-three patients, 96% women, aged 45±16 years, were endoscopically treated for ITS. Time between first symptoms and diagnosis was 19±18 months. Bronchoscopy showed a weblike (61%) or complex (39%) stenosis, located in the upper part of the trachea, mainly in the cricoid area. Endoscopic treatment included mechanical dilation only (52%) or associated with laser or electrocoagulation (30%) and stent placement (18%). All procedures were efficient. The follow-up after endoscopic management was 41±34 months. The ITS recurrence occurred in 30% at 6 months, 59% at 2 years, and 87% at 5 years, with a delay of 14±16 months. The treatment of recurrence (n=13) included endoscopic management in 12 cases. CONCLUSIONS: Endoscopic management of ITS provides a safe and efficient therapeutic option but late recurrences are frequent and require long-term follow-up.

International audience; BACKGROUND: Early change in local intracoronary hemostasis following drug-eluting (DES) and bare metal stent (BMS) implantation has never been assessed in stable angina patients. METHODS: Markers of local platelet activation (soluble glycoprotein V [sGPV] and P-Selectin [CD62P]), coagulation activation (tissue factor [TF], prothrombin fragments 1 + 2 [F1 + 2] and activated factor VII [FVIIa]) and fibrinolysis markers (D-dimers [DD], fibrinogen [FIB], tissue plasminogen activator [t-PA], and plasminogen activator inhibitor type-1 complexes [PAI-1]) were determined in 20 patients with stable angina who underwent percutaneous coronary intervention (PCI). All patients were pretreated with clopidogrel, aspirin, and enoxaparin. Systematic balloon predilation was performed before DES (9 patients) and BMS (11 patients) implantation. All blood samples were drawn 10-20 mm distal to the lesion site. RESULTS: No significant changes in levels of platelet activation markers occurred during PCI. There was a transient significant increase in TF (14%; P = 0.004), in F1 + 2 (40%; P = 0.001), and FVIIa (31%; P = 0.007) following angioplasty. Similarly, a significant 43% increase was observed in DD levels following balloon predilation, associated with an increase of 46%, 60%, and 70% in FIB, t-PA and PAI-1 levels, respectively (all P < 0.0001). All these markers returned to baseline values after stent implantation. No difference was observed between DES and BMS. CONCLUSIONS: Early changes in local hemostasis activation following PCI, were related to balloon predilation. Neither DES nor BMS increased markers of platelet activation, coagulation, or fibrinolysis, under dual antiplatelet and anticoagulant pretreatment.

International audience; Exercise may induce platelet activation in spite of using antiplatelet treatment. We present a case where the initial acute coronary syndrome and the iterative stent thrombosis always occurred after intense and prolonged physical effort. For this patient the at rest response to platelet inhibition with antiplatelet treatments was assessed as adequate, but after exercise the patient developed platelet activation which could be the trigger of his stent thrombosis.

International audience; PURPOSE: To report our experience with endovascular stent-graft repair of descending thoracic aorta diseases in high risk patients. MATERIALS AND METHODS: Between 2000 and 2007, 49 high surgical risk patients (mean age: 64.6 years) underwent stent-graft placement, including 24 cases presenting acutely. Mean follow-up was 25.4 months. Etiologies included 15 aneurysms, 11 dissections, 10 penetrating ulcers, 9 false aneurysms, 2 ruptures of the aortic isthmus, 2 intramural hematomas. RESULTS: Access failure occurred in one patient. The overall mortality was 27.1% (n=13), nine related to the presenting pathology or treatment. Thirty-day mortality was 10.4% (n=5). Complications included vascular injury at the iliac or femoral artery access (10.2%), 1 case of flaccid paraplegia, 2 cases of transient paraparesis, 2 strokes, 2 stent migrations and 1 stent rupture. The rate of early endoleak was 39.6% while the rate of delayed endoleak was 14.6%. Seven patients (14.6%) required repeat endovascular interventions. Explantation was required in 2 cases. The latest available follow-up showed no lesion enlargement in 70.7% (n=29/41) of our patients. CONCLUSION: Descending thoracic aortic pathology can be treated using endografts in high risk patients, although significant morbidity and mortality remain. Because of the high rate of endoleaks, close follow-up is required.

International audience; PURPOSE: To report initial experience with endovascular stent-grafting in aortic intramural hematoma (IMH). MATERIALS AND METHODS: From 2000 to 2006, 15 patients (mean age, 67 years; range, 54-83 y) underwent endovascular treatment of aortic IMH. Thirteen patients were admitted for acute aortic syndrome and two for traumatic aortic injury. An endovascular procedure was performed as primary treatment for four patients (type A IMH, n = 3; type B IMH, n = 1) and as a second-line therapy in 11 patients because of unfavorable evolution (type A IMH, n = 1; type B IMH, n = 10). All stent-grafts were placed in the descending aorta, even for type A IMH. The mean follow-up was 21 months (range, 6-72 months). RESULTS: The primary success rate was 93%, with complete exclusion of the lesion (n = 14). Exclusion was partial for one patient with a type I endoleak (7%). The 30-day mortality rate was zero. IMH evolution was favorable in all cases, with decreased aortic wall thickening (n = 8) or complete regression (n = 7). Complications associated with endovascular repair were mainly related to aneurysm formation (20%). The late death rate was 7%. CONCLUSIONS: Endovascular stent-graft treatment can be performed in the management of complicated IMH, even in some cases of type A IMH, when an intimal lesion is located in the isthmus or descending aorta with contraindications to surgery. This procedure offers low morbidity and mortality rates, representing a feasible therapeutic option especially for elderly patients with comorbidities. Further studies are necessary to confirm these preliminary results.

International audience; AIMS: It is unclear whether primary aspiration can prevent distal embolisation and thereby improve myocardial perfusion in patients presenting with acute myocardial infarction (AMI) within 12 hours after onset. METHODS AND RESULTS: At 24 centres in Europe and India, 249 AMI patients were randomised to primary aspiration with the Export aspiration catheter (Medtronic Vascular, Santa Rosa, CA, U.S.A.) followed by stenting (N=120) or to conventional stenting without primary aspiration (N=129). There were no significant differences between the 2 groups in baseline characteristics or target lesion TIMI scores. Procedure time was 36.7 +/- 18.0 minutes for primary aspiration followed by stenting versus 34.5 +/- 21.5 minutes for conventional stenting (P=0.08). Debris was obtained by primary aspiration from 85.3% of the arteries. The use of a bailout technique was significantly lower for primary aspiration than for conventional stenting (5.8% vs. 14.7%, P=0.02). For the primary endpoint of the combined rate of myocardial blush grade 3 and/or ST-segment resolution >50% to assess myocardial perfusion, primary aspiration followed by stenting was superior to conventional stenting (85.0% vs. 71.9%, P=0.025). Immediately postprocedure, the rate of myocardial blush grade 3 was 35.8% for primary aspiration followed by stenting versus 25.4% for conventional stenting (P=0.094). At 60 minutes post procedure, the rate of ST-segment resolution >50% was 73.5% for primary aspiration followed by stenting versus 64.8% for conventional stenting (P=0.218). Primary aspiration was also associated with a significantly higher postprocedure corrected TIMI frame count than conventional stenting (20 +/- 14.9 vs. 22.8 +/- 14, P=0.02). At 30 days, there were no differences between the treatments in the rate of major adverse cardiac and cerebral events. CONCLUSIONS: Compared with conventional stenting, primary aspiration with the Export aspiration catheter followed by stenting improved myocardial reperfusion in AMI patients presenting with TIMI flow grade 0 to 1. Further study of primary aspiration involving larger numbers of patients is warranted to assess its effect on longer-term clinical outcome.

International audience

International audience; Usual imaging after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) consists of AAA diameter monitoring and endoleak detection. Among additional predictor parameters previously proposed to help clinicians in better identifying subgroups of AAA still at risk of rupture, AAA wall motion after EVAR has been studied, but its value was not clearly established. Tissue Doppler imaging (TDI) is an ultrasonographic modality which allows wall motion measurements along an arterial segment. The aim of the current study was to analyze AAA wall motion with TDI before and after EVAR and to describe its evolution in patients with more than 1 month of follow-up. Twenty-five consecutive patients undergoing EVAR between February 2005 and June 2007 gave informed consent to be prospectively investigated with the TDI system before EVAR and at each visit during follow-up. The mean (SD) follow-up was 13.7 (9.7) months. Maximum mean segmental dilation (MMSD), segmental compliance, dilation at maximum diameter, pressure strain elastic modulus (Ep), and stiffness were compared between three periods (before stenting, before discharge, and at last follow-up), and their relation with AAA diameter was analyzed. A significant decrease in AAA compliance was immediately observed after successful EVAR and remained stable during later follow-up. On the other hand, AAA diameter progressively decreased along time and was statistically lower at the last control compared to the initial value. MMSD, segmental compliance, and dilation at maximum diameter were positively related to AAA diameter. This means that the larger the AAA diameter after stenting, the higher the value for these parameters can be expected. On the contrary, percentage of AAA diameter decrease and percentage of MMSD decrease were not related after successful EVAR. There was no parallelism between loss in compliance and diameter decrease along time, and there is not a unique pattern of AAA diameter and compliance evolution after EVAR. Even if comparison between patients without and with endoleak was weak due to the small sample of the latter group (five patients with endoleak), compliance tended to be greater in case of endoleak. AAA wall motion after successful EVAR reflects complex interactions between all the components of the stented aneurysm which evolve over time, including true compliance of the aneurysm wall itself; intra-aneurysm sac pressure with possible different effects for peak, mean, and pulse pressures; remodeling of the thrombus; stiffness characteristics of the graft; and systemic pressure. Combining simultaneous MMSD records with actual intrasaccular pressure measurements in patients with and without endoleak would improve our understanding of the clinical pulsatility mechanism within AAA after EVAR.

International audience; BACKGROUND AND PURPOSE: Since publication of previous meta-analyses comparing endovascular and surgical treatment of patients with carotid artery stenosis, two further large-scale trials have been conducted, almost doubling the number of patients available for analysis. Therefore, it is justified to update these meta-analyses. METHODS: Relevant trials were identified by a search of the literature using an electronic database. Trials with a nonrandomized patient allocation were not included. We focused on events within 30 days after intervention and made two sets of analysis: one with all trials and one with large trials exclusively including symptomatic patients. RESULTS: Only Endartérectomie Versus Angioplastie chez les patients ayant une Sténose carotide Symptomatique Serrée (EVA3S) and Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy (SPACE) were identified to be included in the updated meta-analysis. In total, 2985 patients were included in eight trials of which 89% were symptomatic. In contrast to previous analyses, this meta-analysis found a significant difference between the odds ratios of any stroke or death within 30 days after treatment with a disadvantage of endovascular treatment when analysing all trials (odds ratio [OR], 1.38; 95% confidence interval [CI] 1.04-1.83; P = .024). Significant heterogeneity was found for this analysis (P = .03). The increase of the odds of suffering from disabling stroke or death in the endovascular compared with the surgical group was not significant in the analysis of all trials (OR, 1.37; 95% CI, 0.92-2.04; P = .12); no heterogeneity was found for this analysis (P = .27). In the analysis of the large trials with symptomatic patients, the OR for the endpoint any stroke or death was 1.29 (95% CI 0.94-1.76; P = .11); with a hint for heterogeneity (P = .10). For the endpoint disabling stroke or death, the OR was 1.33 (95% CI 0.89-1.93; P =.17) without any heterogeneity (P = .58). CONCLUSION: The expressiveness of this meta-analysis is limited by the heterogeneity of some tests. The main result is that surgical treatment still remains the gold standard for treatment of patients with symptomatic carotid artery stenosis, who do not have an increased surgical risk. Carotid artery stenting is neither safer than nor as safe as carotid endarterectomy in large clinical trials when short-term stroke and death rates are taken into account. Further recruitment into ongoing randomized trials is strongly recommended.

International audience; A 60-year-old man presented an oesophageal transmural necrosis fistulised in the trachea following curative photodynamic therapy (PDT) for a superficial recurrence of an oesophageal carcinoma, initially treated by radiochemotherapy. Two stents, a tracheal and an oesophageal one, were placed. Eight months later the patient is in complete remission with only mild swallowing problems. This complication, although unusual, has already been described by other teams with the association of radiochemotherapy and PDT. The present case study suggests that illumination dose should be lowered in this indication.

Background: Although carotid angioplasty and stenting (CAS) is widely used to treat carotid stenosis, recent studies point to the inferiority of the procedure compared with carotid endarterectomy. Methods: We present 50 consecutive cases of CAS treated in our unit. Endarterectomy was contraindicated in these patients due to high operative risk. All the patients underwent a diffusion-weighted MRI (DWI) before and after the procedure and had a neurological assessment in a stroke unit. Results: No deaths were recorded until 30 days after the procedure. Six patients [12%, confidence interval at 95% (CI95) = 3.7–20.2] had a positive DWI MRI after the procedure but only 2 (4%, CI95 = 0–9.43) had a worse neurological status. Conclusion: This study shows that CAS is feasible with a low morbid-mortality rate in patients with a high surgical risk. DWI is highly sensitive to detect neurological complications after the procedure.

To describe the imaging work-up and management of type III endoleaks detected after covered stent-graft treatment of descending thoracic aortic aneurysms.Retrospective study of circumstances surrounding the diagnosis, management and outcome type III endoleaks occuring in 3 of 18 patients following covered stent-graft treatment of descending thoracic aortic aneurysms between April 1998 and July 2005. The endoleaks were detected at a mean follow-up of 22 months (19-24 months) after stent-graft placement.The type III endoleaks were detected on scheduled follow-up CT examinations in asymptomatic patients. Endovascular management was proposed at a mean interval time of 4.4 months (1 week - 11 months) after diagnosis of the endoleak, and was successful in all 3 cases. One patient died 1 month after endovascular repeai of the leak, 1 patient required surgical management at 14 months for new recurrence, and 1 patient had a favorable outcome at 2 months.Follow-up of patients after covered stent-graft treatment of descending thoracic aortic aneurysms is required. Prompt endovascular repair of delayed complications may be possible, but surgical management may become necessary.

International audience; OBJECTIVE: The self-expanding metallic stent (SEMS) is widely used in the palliative treatment of stenosing esophageal cancer. Multidetector computed tomography (MDCT) allows volumetric investigation including virtual endoscopy. The aim of this study was to determine the feasibility of MDCT follow-up of esophageal SEMS and to describe the imaging patterns encountered as well as correlating them with fibroscopic evaluation. MATERIAL AND METHODS: Thirteen consecutive patients (10 M, mean age 64 years) with esophageal SEMS as a palliative treatment underwent MDCT for recurrent dysphagia (n =7), chest pain and fever (n = 1) or follow-up without symptoms (n = 5). Patency and esophageal wall patterns were studied and compared with diagnosis by fibroscopy. RESULTS: No metallic artefact related to the SEMS was observed. At the SEMS level, MDCT revealed a tissular lump (n = 1), a thin recurrent layer of tissue (n = 1), extrinsic compression (n = 1), fluid stasis (n =7) and intussusception of the gastric wall into the SEMS (n =4). The esophageal wall was analyzed by MDCT (peripheral thickening around the stent (n = 8), tumor overgrowth under or above the SEMS level (n = 8)) and showed tracheal compression (n = 3). At the level of the SEMS, fibroscopy showed tumor recurrence (n = 2), a thin recurrent layer of tissue (n = 1), a distorted SEMS (n = 1) and a tumor overgrowth under or above the SEMS level (n = 6). In comparison with fibroscopy, MDCT satisfactorily diagnosed the SEMS patency in 92% of cases and the esophageal wall in 73%. CONCLUSIONS: Morphology, patency of the SEMS and analysis of the esophageal wall can be performed by MDCT with a good degree of accuracy as compared to fibroscopy. In such patients in palliative care, a non-invasive investigation is worth promoting as a first-line procedure.

International audience; INTRODUCTION: Stenting is accepted in managing patients with inoperable obstruction of the upper airways. The choice of the type as well as the dimensions of stents are crucial as it impacts on the success of the procedure and potential complications which must be diagnosed non-invasively. STATE OF THE ART: The goal of this review is to present our multidisciplinary experience using multidetector CT as a minimally invasive technique for detecting airway obstructions, for evaluating preoperatively local anatomic conditions useful to determinate the type and size of metallic stents to be used, and following non-invasively the stent in order to detect various complications. CONCLUSIONS: MDCT acquisition should use thin slices as multiplanar reformations and 3D reconstructions play an essential complementary role to axial images in pre- and post-stent placement settings.

International audience; BACKGROUND: Double stenting of oesophagus and airways may be required in palliative treatment of patients with locally advanced oesophageal cancer. AIM: To assess feasibility, efficacy and complications occurring in patients with locally advanced oesophageal cancer receiving both oesophagus and airways stenting. METHODS: In one single centre between 1997 and 2005, among 180 patients with locally advanced oesophageal cancer treated by the palliative placement of a self-expanding metal stent, patients requiring double stenting of oesophagus and airways were identified. Clinical efficacy, complications and survival were retrospectively collected. RESULTS: Fifteen patients (8.3% of 180) required a double stenting at follow-up. Symptomatic efficacy of oesophagus and airways stenting was 86.7% for dysphagia and 100% for dyspnoea. Median survival after the second stent insertion was 99 days. Life-threatening early complications occurred in three patients after double stenting (20%), including two deaths following oesophageal perforation and massive haemoptysis, respectively. Procedure-related mortality was 13.3%. CONCLUSIONS: Double stenting of oesophagus and airways is feasible in patients with locally advanced oesophageal cancer, with a relevant clinical efficacy. However, early major complications including procedure-related death may occur in as many as 20% of patients. This treatment should be reserved to very selected patients with severe symptoms and end-stage disease.

BACKGROUND: Incidence of perioperative in-stent thrombosis associated with myocardial infarction in patients undergoing major lung resection within 3 months of coronary stenting. METHODS: Retrospective multi-institutional trial including all patients undergoing major lung resection (lobectomy or pneumonectomy) within 3 months of coronary stenting with non-drug-eluting stents between 1999 and 2004. RESULTS: There were 32 patients (29 men and 3 women), with age ranging from 46 to 82 years. One, two or four coronary stents were deployed in 72%, 22% and 6% of the patients, respectively. The time intervals between stenting and lung surgery were

International audience; We report the initial experience of two cardiovascular surgery centers in the treatment of descending thoracic aorta lesions with covered stent grafts in high-surgical risk patients. From April 1999 to November 2004, 54 patients, mean age 64 years (range 16-83), were treated by stent graft for a lesion of the descending aorta (degenerative aneurysms n = 22, aortic dissections n = 12, chronic post traumatic aneurysms n = 5, anastomotic false aneurysms n = 2, penetrating ulcers n = 4, intramural hematomas n = 5, traumatic rupture n = 4), with 42.6% treated on an emergency basis. Three devices were used: Talent (n = 49), Excluder (n = 4), and Zenith (n = 1). In three patients, combined surgery of the proximal aorta was performed. Prior bypass of the left supra-aortic arteries was performed in four patients. The follow-up was clinical and radiological (plain chest film and computed tomographic scan) at 1, 3, 6, 12, 18, and 24 months and yearly thereafter. The stent graft was successfully deployed in all cases. Two early deaths related to the stent graft (one migration and aortic rupture and one stroke) and one related to adult respiratory distress syndrome occurred. Morbidity was 16.6% (iliac access damage n = 4, groin reintervention n = 3, transient ischemic attack n = 1, tamponade n = 1). The follow-up was 100% complete (mean 22.8 months, range 3-51). Fifteen primary endoleaks (type I n = 6, type II n = 8, type III n = 1) and one secondary endoleak were reported. They were treated by additional stent graft (n = 7) and elective surgical conversion (n = 1). Six endoleaks resolved spontaneously at 6 months, and two are being monitored. Twelve endoleaks (75%) occurred in patients treated for degenerative aneurysms. Freedom from secondary reintervention was 81.3% at 3 years. Two transient paraparesias were observed at 3 and 18 months. Of the 13 deaths observed during the follow-up, only one was related to the stent graft. Actuarial survival at 12 and 24 months was 90.0% and 75.4%, respectively. Mortality results are encouraging in this specific cohort of high-surgical risk patients. A new kind of morbidity is observed, related to endoleaks, whose necessary management could hinder the durability of the technique.

International audience; BACKGROUND: Carotid stenting is less invasive than endarterectomy, but it is unclear whether it is as safe in patients with symptomatic carotid-artery stenosis. METHODS: We conducted a multicenter, randomized, noninferiority trial to compare stenting with endarterectomy in patients with a symptomatic carotid stenosis of at least 60%. The primary end point was the incidence of any stroke or death within 30 days after treatment. RESULTS: The trial was stopped prematurely after the inclusion of 527 patients for reasons of both safety and futility. The 30-day incidence of any stroke or death was 3.9% after endarterectomy (95% confidence interval [CI], 2.0 to 7.2) and 9.6% after stenting (95% CI, 6.4 to 14.0); the relative risk of any stroke or death after stenting as compared with endarterectomy was 2.5 (95% CI, 1.2 to 5.1). The 30-day incidence of disabling stroke or death was 1.5% after endarterectomy (95% CI, 0.5 to 4.2) and 3.4% after stenting (95% CI, 1.7 to 6.7); the relative risk was 2.2 (95% CI, 0.7 to 7.2). At 6 months, the incidence of any stroke or death was 6.1% after endarterectomy and 11.7% after stenting (P=0.02). There were more major local complications after stenting and more systemic complications (mainly pulmonary) after endarterectomy, but the differences were not significant. Cranial-nerve injury was more common after endarterectomy than after stenting. CONCLUSIONS: In this study of patients with symptomatic carotid stenosis of 60% or more, the rates of death and stroke at 1 and 6 months were lower with endarterectomy than with stenting. (ClinicalTrials.gov number, NCT00190398 [ClinicalTrials.gov].).

International audience; Autostatic ureteral stents have been commonly used in urology for more than 20 years. Encrustation is a frequent and well described phenomenon that sometimes makes stent removal difficult. The main predisposing factors are: duration of stenting, history or concomitant stone disease, urinary tract infection or bacterial colonization, pregnancy and chemotherapy. Treatment depends on the degree of encrustation, especially when it involves the proximal loop. Extracorporeal lithotripsy alone or combined with endoscopic treatment is very effective, but open surgery may sometimes be necessary. The authors report a case in which drainage was exceptionally prolonged as the stent was removed after a period of 10 years. Stent removal required 3 operations, including one open procedure. The steps of treatment are described and the aetiologies of encrustation and the therapeutic strategy are discussed.

International audience; We report two cases of percutaneous transhepatic stenting of the portal vein to treat stenosis and occlusion disclosed 5 and 18 months, respectively, after orthotopic liver transplantation in two adult patients. If long-term patency is satisfactory, this technique should allow long-term management of portal vein stenosis and occlusion without the use of thrombolysis.

International audience; The purpose of this study was to assess the ability of 16-slice computed tomography (CT) to detect in-stent restenosis of proximal coronary arteries. From November 2002 to April 2004, 134 consecutive patients with proximal stents (3.25 +/- 0.47 mm) were prospectively studied. Multidetector CT (MDCT) was performed 24 h (baseline) and 6 months after angioplasty and analysed by two radiologists blinded to the results of the coronary angiography. Sensitivity, specificity, positive and negative predictive values for in-stent restenosis were compared with conventional quantitative coronary angiography (QCA). Stenosis with a diameter >or=50% was considered diagnostic of in-stent restenosis. The CT analysis was performed in 131 and 114 patients at baseline and 6 months, respectively. The in-stent lumen was evaluable in 111 (121 stents) and 99 patients (108 stents) at baseline and 6 months, respectively. The prevalence of in-stent restenosis was 22.5%. Restenoses were correctly identified in 91.7 and 87.5% by the two radiologists. The sensitivity, specificity, positive and negative predictive values for the assessment of significant in-stent restenosis were 92, 67, 43, 97% and 87, 66, 41, 95% for the radiologists, respectively. MDCT is a potential non-invasive technique for the screening of in-stent restenosis of proximal coronary arteries that needs further improvements.

International audience; OBJECTIVE: To analyse coronary stents with multislice spiral computed tomography (MSCT) in comparison with coronary angiography. PATIENTS AND METHODS: 310 patients referred for conventional coronary angiography underwent MSCT on the next day (16 x 0.75 mm cross section, 420 ms rotation, 110 ml contrast agent intravenously at 4 ml/s). Two independent blinded reviewers analysed the MSCT. RESULTS: 143 patients had previous stenting (232 stents) and 190 (82%) of the 232 stents were detected. Intrastent lumen was interpretable in 126 (64%) of the detected stents. Lumen interpretability depended on stent diameter: for stent diameter > 3 mm, 81% of lumens were interpretable, as against 51% with < or = 3 mm stent diameter (p < 0.001). Restenosis detection likewise depended on stent diameter: with small stents (< or = 3 mm), sensitivity and specificity of MSCT were 54% and 100%, respectively; positive and negative predictive values were 100% and 94%. For stents with > 3 mm diameter, corresponding values were 86%, 100%, 100%, and 99%. CONCLUSION: 16 slice MSCT allows analysis of in-stent lumen in about half of all stented angioplasties. It performs better when stent diameter is more than 3 mm and may offer a non-invasive alternative to conventional coronary angiography for monitoring stented coronary arteries. Technical progress may improve interpretability and hence increase the yield of MSCT in this application.

An 81-year-old woman with a past history of systemic hypertension, chronic paroxysmal atrial fibrillation, three-time recurrent ischaemic cerebrovascular accidents, and major intestinal haemorrhagic accident despite optimal warfarin therapy was considered ineligible …

International audience; BACKGROUND: To lower the risk of complications, carotid angioplasty and stenting (CAS) has been proposed as an alternative to open surgery for carotid artery stenosis after neck irradiation. However, there are little postoperative data to support the benefits of this strategy. This study evaluated the outcome of CAS in patients who had undergone neck irradiation. METHODS: This retrospective study was conducted at 15 vascular surgery or interventional radiology centers in France between January 1998 and July 2006. A total of 135 patients (115 men) with a mean age of 67 +/- 8 years (range, 43-88) underwent CAS for 149 irradiation-induced lesions. The interval between irradiation and discovery of the lesions was 12 +/- 8 years. Mean diameter reduction was 81% (range, 50%-95%), and stenosis was symptomatic in 34%. Contralateral carotid lesions were observed in 48% of patients, including thrombosis in 18 and stenosis >50% in 53. RESULTS: Technical failure occurred during CAS in three cases. The overall technical success rate was 98%. A cerebral protection device was used in 59%. No death, one transient ischemic attack, and two strokes occurred during the first postoperative month. Mean follow-up was 30 months. Six patients were lost to follow-up. Survival rates were 93.9% at 1 year and 75.3% at 3 years. Complications after the first postoperative month included neurologic events in six, carotid thrombosis in nine, and restenosis in 18. The rates of freedom from neurologic and anatomic events were, respectively, 96.2% and 93.2% at 1 year and 93.1% and 85.9% at 3 years. CONCLUSION: The immediate outcome of CAS for irradiation-induced carotid artery stenosis was satisfactory. Medium-term neurologic outcome was acceptable, but the incidence of anatomic events such as thrombosis and restenosis was high. A randomized study is needed to confirm that the outcome of the endovascular and surgical therapy is comparable in this indication.

BACKGROUND: The evolution and correlation between the aortic neck and distally located iliac necks after endovascular treatment of abdominal aortic aneurysms (AAAs) was studied. METHODS: Of 179 patients who had undergone AAA repair between 2003 and 2007, 61 received the same radiologic follow-up and were included in this retrospective study. Data for 61 aortic necks and 115 iliac arteries were analyzed using the preoperative scan, 1-month visit, and final follow-up, with a minimum mean follow-up of 24 ± 15.2 months. Three measurements were taken of the aortic neck: subrenal (D1a), 15 mm below the lowest renal artery (D1b), and at the origin of the aneurysm (D1c). Three measurements were taken at the level of the iliac arteries: origin (Da), middle (Db), and the iliac bifurcation (Dc). These measurements were analyzed using analysis of variance and Spearman correlation coefficient. The results were evaluated for subsequent endoleaks, migrations, and reinterventions. All diameters were compared between patients with a regression of >10% in the greatest diameter of AAA at last follow-up (group A, n = 35) and those without (group B, n = 26). RESULTS: All diameters (in mm) increased significantly over time at the level of the proximal neck (D1a = 3.7 ± 2.8, P = .018; D1b = 4.4 ± 2.5, P = .016; D1c = 4.3 ± 3.1, P = .036) and iliac arteries (Da = 2.1 ± 0.2, P = .0006; Db = 2.5 ± 0.5, P = .0006; Dc = 3 ± 0.7, P = .007). The increase in diameters at the proximal neck and iliac arteries evolved independently (insignificant correlation), with the exception of D1b and Dc (P = .006), which showed a weak correlation (r = 0.363). The group A patients presented increases in all diameters, although to a less significant extent (P < .05) than group B patients. During follow-up, a proximal endoleak and a distal endoleak occurred, both requiring reintervention. CONCLUSIONS: Our results show a trend toward dilatation of the aortic neck and iliac arteries, with no correlation between the two levels, even in patients with a regression of the aneurysm sac during follow-up. Although this study found no correlation with the occurrence of endoleaks, our results suggest the need for a longer follow-up, especially on the landing sites.

1. Departement of Interventional Cardiology, Cardiovascular Hospital and Claude Bernard University, and INSERM 886, Lyon, France; 2. Department of Biomedical Engineering, Indiana-Purdue University, Indianapolis, IN, USA; 3. Laboratory TIMC-IMAG, DynaCell, CNRS UMR 5525, Institut de l’Ingenierie et de l’Information de Sante (In3S), Grenoble, France; 4. INSERM UMR915, Institut du Thorax, Service d’Hemodynamique, and Centre Commun de Microscopie Electronique, Nantes, France

Background Stents are commonly used to treat patients with coronary artery disease. However, the quality of reporting internal and external validity data in published reports of randomised controlled trials (RCTs) of stents has never been assessed. The objective of our study was to evaluate the quality of reporting internal and external validity data in published reports of RCTs assessing the stents for percutaneous coronary interventions. Methods A systematic literature review was conducted. Reports of RCTs assessing stents for percutaneous coronary interventions indexed in MEDLINE and the Cochrane Central Register of Controlled Trials and published between January 2003 and September 2008 were selected. A standardized abstraction form was used to extract data. All analyses were adjusted for the effect of clustering articles by journal. Results 132 articles were analyzed. The generation of the allocation sequence was adequate in 58.3% of the reports; treatment allocation was concealed in 34.8%. Adequate blinding was reported in one-fifth of the reports. An intention-to-treat analysis was described in 79.5%. The main outcome was a surrogate angiographic endpoint in 47.0%. The volume of interventions per center was described in two reports. Operator expertise was described in five (3.8%) reports. The quality of reporting was better in journals with high impact factors and in journals endorsing the CONSORT statement. Conclusion The current reporting of results of RCTs testing stents needs to be improved to allow readers to appraise the risk of bias and the applicability of the results.

International audience; Endovascular repair of the thoracic aorta has been adopted as the first-line therapy for much pathology. Initial results from the early-generation endografts have highlighted the potential of this technique. Newer-generation endografts have now been introduced into clinical practice and careful assessment of their performance should be mandatory. This study describes the initial experience with the Valiant endograft and makes comparisons with similar series documenting previous-generation endografts. Data were retrospectively collected on 180 patients treated with the Valiant endograft at seven European centers between March 2005 and October 2006. The patient cohort consisted of 66 patients with thoracic aneurysms, 22 with thoracoabdominal aneurysms, 19 with an acute aortic syndrome, 52 with aneurysmal degeneration of a chronic dissection, and 21 patients with traumatic aortic transection. The overall 30-day mortality for the series was 7.2%, with a stroke rate of 3.8% and a paraplegia rate of 3.3%. Subgroup analysis demonstrated that mortality differed significantly between different indications; thoracic aneurysms (6.1%), thoracoabdominal aneurysms (27.3%), acute aortic syndrome (10.5%), chronic dissections (1.9%), and acute transections (0%). Adjunctive surgical procedures were required in 63 patients, and 51% of patients had grafts deployed proximal to the left subclavian artery. Comparison with a series of earlier-generation grafts demonstrated a significant increase in complexity of procedure as assessed by graft implantation site, number of grafts and patient comorbidity. The data demonstrate acceptable results for a new-generation endograft in series of patients with diverse thoracic aortic pathology. Comparison of clinical outcomes between different endografts poses considerable challenges due to differing case complexity.