AIM The aim of this retrospective study was to evaluate the patency and limb salvage rates after prosthetics or venous bypasses for asymptomatic or mildly symptomatic popliteal aneurysms, in order to determine if small uncomplicated aneurysms (caliber <300%) should be operated or periodically controlled when a venous conduit is not available. METHODS During a 18 years period, 100 popliteal aneurysms, including 85 asymptomatic and 15 associated with intermittent claudication, were operated on: group I consisted of 80 venous bypasses, and group II consisted of 20 prosthetic bypasses. RESULTS Demographics and risks factors were similar in both groups. Local complications were more frequent in group I (17% vs 10% p=NS). Early vascular complications were rare in both groups. Late arterial complications were more frequent in group II. Primary patency, assisted primary patency, and secondary patency rates at 2 years were 94.3%, 97.3% and 98.7% in group I, and 61.5%, 89% and 88.4% in group II (p<0.05). In contrast, the limbs salvage rates were not significantly different for each type of graft (98.7% vs 100% p=NS). CONCLUSIONS Our data shows that aneurysms treated with a prosthetic graft are at higher risk of late occlusion than those operated with a vein graft. This should be taken into account when facing a small uncomplicated aneurysm without available venous conduit. The presence of a suitable vein should be checked before deciding to operate a small uncomplicated popliteal aneurysm.

Femoral artery exposure can lead to local complications, which can compromise the postoperative course of effective arterial reconstruction. We report a new technique of vascular reconstruction in which a videoscopic approach to the femoral bifurcation is used. To our knowledge, the videoscopic approach to the femoral bifurcation has not been previously described. The main advantages of this technique include a limited cutaneous incision and avoidance of skinfolds, especially in obese patients.

Objective. The da Vinci(TM) Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) is a computer-enhanced telemanipulator that may help to overcome some limitations of traditional laparoscopic instruments. This prospective study was performed to assess the safety and feasibility of robotically assisted aorto-femoral bypass grafting W).Methods. Five patients undergoing elective AF were enrolled in this study. In three patients, a laparotomy of 6 cm was first performed, the aorta being exposed using an Omnitractdegrees retractor. In two patients, aortic dissection was performed with laparoscopy, with the patient in a modified right lateral decubitus position. In all patients, the proximal anastomosis was attempted with the da Vinci(TM) system by a remote surgeon. The role of the assistant at the patient's side was limited to exposure, haemostasis and maintaining traction on the running sutures performed by the robot. Six weeks after the operation, all patients underwent a duplex scan of the graft.Results. Mean operative time was 188 min. Robotically assisted aortic anastomoses were successfully completed in four out of five patients. In these four patients, adequate blood flow was observed within the graft with no need for conversion for haemostasis. In the fifth patient, despite an adequate laparoscopic aortic dissection, the anastomosis was impossible to perform due to external conflicts between the robotic arms. A conversion using conventional suture was successfully performed. No robot-related complications were noted. Six weeks after the operation, the duplex scans demonstrated a graft patency of 100%.Conclusion. Robotically assisted anastomoses are possible by their unique ability to combine conventional laparoscopic surgery with stereoscopic 3D magnification and ultra-precise suturing techniques due to the flexibility of the robotic-wristed instruments using different motion scaling of surgeon hand movements. In addition, prior training in laparoscopic aortic surgery is not necessary for surgeons to obtain the level required for suturing. Further clinical trials are needed to explore the clinical potential and value of robotically assisted AF.

We report a case of a successfully resected retroperitoneal benign schwannoma using laparoscopic surgery. A 62-year-old woman presented with an asymptomatic retroperitoneal mass. Computed tomography (CT) scan revealed a solid tumor compressing the inferior vena cava (IVC). First, we performed an intraoperative biopsy analysis, which revealed a benign neurologic tumor. We then proceeded with the complete laparoscopic resection of the tumor. Pathology revealed a benign schwannoma 8 x 5 cm in size. To our knowledge, only three other cases of the laparoscopic resection of retroperitoneal schwannoma have been reported. In our case, despite the large size of the tumor and the high level of compression of the IVC, a totally laparoscopic resection was feasible.

Eur J Vasc Endovasc Surg 26, 223-224 (2003)

The patient is placed in a right lateral and rotated decubitus, with the abdomen rotated at 45 (Fig. 1a). The abdominal slope obtained with the maximal right rotation of the operating table (ALM, OrleÂans, France) reaches 65 . The video monitor is viewed distally on the left side of the patient. The surgeon is facing the patient's abdomen (Fig. 1b). The 0 endoscope (Storz-France SA, Paris, France) is positioned through a 10 mm-trocar (Storz-France SA, Paris, France) introduced on the anterior axillary line 3 cm below the costal margin. Figure 1b shows the position of the other trocars. A left retrocolic dissection is conducted in line of the Told fascia, down to reach the left renal vein. Due to the right lateral decubitus, the small bowel and left mesocolon drop fall to

Intimal hyperplasia is extensively studied in order to improve arterial reconstruction outcome. The mechanisms leading to stenosis or restenosis may vary according to the technique used for arterial reconstruction. Lesions are mostly made of an accumulation of smooth muscle cells and fibroblasts, with only sparse inflammatory cells. The accumulated material reduces the graft lumen and ultimately induces thrombosis. Intimal hyperplasia with smooth muscle cell and matrix accumulation is the prominent feature in all these situations with evidences of intense cell proliferation and cell death. The purpose of this review is to present the biology of intimal hyperplastic response based on the recently published data. Experiments in the rabbits have shown that the vein wall thickening is mainly regulated by the tangential wall stress which is applied transversely to the vein wall as a blood pressure. Experiments in the rat carotid artery balloon injury suggested that heparin could be used as a treatment to prevent intimal hyperplasia. Treatments for preventing restenosis after angioplasty or stenoses development in bypasses have been disappointing clinical evaluation suffers from insufficient prospective randomized studies. Intimal hyperplasia is the major cause of failure after arterial reconstruction. The biology of intimal hyperplasia is complex, and treatment disappointing. Some types of hyperplasia may need to be preserved in order to prevent functional atrophy and aneurysmal dilatation of vein grafts.

Purpose: To report endovascular repair of an iatrogenic superior mesenteric artery (SMA) dissection caused by a balloon occlusion catheter.Case Report: A 68-year-old man with a suprarenal aortic aneurysm underwent conventional prosthetic replacement, during which visceral artery back bleeding was controlled with balloon occlusion catheters. Six hours postoperatively, the patient experienced an episode of bloody diarrhea with abdominal pain and tenderness and mild metabolic acidosis. Colonoscopy revealed colitis (grade I) without necrosis of the right and left colon. An emergent abdominal computed tomographic scan showed signs of mesenteric ischemia with bowel dilatation and SMA wall hematoma; angiography identified a dissection 1 cm distal to the SMA origin. An Easy Wallstent was deployed percutaneously, successfully reestablishing SMA patency. The postoperative course was uneventful, and the patient remains asymptomatic with a patent SMA stent and aortic graft at 1 year.Conclusions: latrogenic SMA dissection should be suspected after suprarenal aortic aneurysm repair if signs of mesenteric ischemia arise. Prompt and thorough imaging studies are necessary to confirm the diagnosis and assess the potential for an endoluminal treatment.

Objectives: to prospectively evaluate the mid-term results of endovascular and open repair in patients with abdominal aortic aneurysm (AAA) anatomically suitable for endovascular repair.Material and methods: between January 1995 and March 1999, among 438 patients treated for AAA, 180 (41%) were suitable for endovascular repair as assessed by computed tomography (CT) scan and angiogram. Seventy-three were treated by various commercially available endovascular grafts (EV) and 107 by open repair (OR). Postoperatively, patients were followed every 6 months with clinical examination, duplex scan and in the EV group, CT scans. Patients' demographic data, intra- and postoperative events were recorded prospectively in a computerised database and compared for each group.Results: median age, sex ratio, preoperative risk factors and aneurysm diameters were not statistically different between the two groups.Respectively in the EV and OR, the average duration of operation was 149+/-73 mn, and 133+/-44 mn (NS), blood loss 96 ml +/- 28 and 985 ml +/- 113 (p<0.01), duration of hospitalisation 7 days +/- 2 and 13 days +/- 7 (p<0.01).The one-month mortality was 2.7% (n=2) for EV and 2.8% (n=3) for OR. The rate of cardiac and pulmonary complications was significantly higher in the OR group (6.9% versus 19.6%, p=0.017).At a mean follow-up of 1 year, the cumulative survival rate was 82.2% +/- 7.5 for EV and 96% +/- 2.12 for OR (log-rank test p=0.43). No patients died of rupture, but three patients had to be converted to open surgery. Twenty-two percent (n=16) patients in the EV and 7.5% (n=8) in the OR were submitted to a subsequent minor or major reintervention (p=0.007). At 1 year, the cumulative rates free of any reintervention were respectively 78.8% +/- 6.7% and 92.9% +/- 2.7% (p=0.001). In the EV there were 17 early endoleaks (23.3%). At the end of patient's follow-up seven endoleaks (9.6%) persisted. The primary success rate defined by the absence of endoleak and the absence of reintervention was 54 (74%) with EV and 101 (94%) with OR (p=0.001) .Conclusion: EV ia a promising technique. However, with current devices and indications the immediate benefits, mainly less blood loss, fewer cardiac and pulmonary complications, and shorter hospitalisation time, are outweighted by a higher rate of reinterventions to treat endoleak, or to maintain patency of the graft.