OBJECTIVE:Inflammatory abdominal aortic aneurysms (InflAAAs) account for 5 - 10% of aortic aneurysms and are characterised by retroperitoneal fibrosis. Diagnosis is often delayed, and doubts remain about the optimal management strategy. This scoping review describes the current state of knowledge on InflAAAs. METHODS:Medline, PubMed, EMBASE, and Scopus were searched for relevant studies that evaluated the diagnosis and treatment of InflAAAs. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol was followed. RESULTS:Fifty-seven papers were selected (low level of evidence), which included 1 554 patients, who were mostly male and heavy smokers. A triad of chronic abdominal or back pain, weight loss, and elevated inflammatory markers was highly suggestive of the diagnosis but rarely present, and fever was noted only randomly. A mantle sign was seen on computed tomography angiography (CTA) in 73 - 100% of patients. Open surgical repair (OSR) and endovascular aortic aneurysm repair (EVAR) was reported in 1 376 and 178 patients, respectively. OSR was associated with significant iatrogenic bowel (n = 22), urinary tract system (n = 7), venous (n = 30), pancreatic (n = 6), and splenic (n = 5) injuries, while EVAR was associated with lower 30 day mortality (0 - 5% vs. 0 - 32%). One and two year mortality rates were similar between the two treatment modalities (0 - 20% and 0 - 36%, respectively). EVAR was more often associated with post-operative progression of inflammation (17% vs. 0.4%), and a higher frequency of persistent hydronephrosis (> 50%) and limb occlusion (20%). Used in < 10% of patients, corticosteroids led to complete pain relief and a reduction in peri-aortic inflammation within 6 - 18 months. CONCLUSION:InflAAAs are characterised by non-specific symptoms, with the mantle sign on CTA being pathognomonic. Corticosteroids may be considered a basic treatment that all patients should receive initially. Low quality data indicate that EVAR (vs. OSR) is associated with fewer intra-operative complications and lower peri-operative mortality but more late fibrosis related adverse events. International multicentre registries are required to gather more insights into this challenging pathology.

Lo stent ha dimostrato la sua fattibilità nel trattamento delle stenosi carotidee. Gli studi randomizzati controllati attualmente pubblicati che confrontano lo stent e la tromboendoarteriectomia trovano un beneficio dello stent sui tassi di danno alle coppie di nervi cranici e di ematoma della via d’accesso, ma significativamente più eventi cardiovascolari (ictus) e morti perioperatorie. Questo rischio sembra essere maggiore nei pazienti di età superiore ai 70 anni e nelle stenosi sintomatiche, soprattutto nei primi 14 giorni. Lo stent carotideo rimane quindi essenzialmente riservato ai pazienti ad alto rischio chirurgico di tromboendoarteriectomia, che comprende rischi tecnici o anatomici (paralisi controlaterale del ricorrente, immobilità del collo, tracheotomia, gravi lesioni tissutali [da radiazioni] o stenosi inaccessibili), clinici (insufficienza cardiaca con frazione di eiezione ≤ 30%, grave insufficienza respiratoria, cardiopatia ischemica instabile, cardiopatia valvolare grave) ed emodinamici (occlusione della carotide controlaterale). L’analisi preoperatoria deve tenere conto dell’anatomia dell’arco aortico e della lesione e delle condizioni generali del paziente. La tecnica è ormai ben codificata: l’accesso femorale è per il momento il più utilizzato, con un catetere guida o un lungo introduttore che permettono di stabilizzare il materiale a livello della carotide comune, mentre i sistemi di protezione cerebrale e lo stent limitano il rischio embolico. Progressi tecnici, come l’uso di stent a cellule chiuse o addirittura di micromesh (doppio strato), i sistemi di protezione cerebrale mediante inversione di flusso e l’accesso carotideo diretto (che consente di evitare il rischio di embolia durante la navigazione nell’arco aortico) sembrano fornire risultati paragonabili a quelli della tromboendoarteriectomia negli studi preliminari, i cui risultati restano da confermare. Le attuali raccomandazioni dovranno quindi potenzialmente essere riviste sulla base dei risultati dei vari studi randomizzati controllati attualmente in corso.

Le traitement chirurgical des patients atteints d'infection de prothèse vasculaire (IPV) est souvent complexe du fait de comorbidités importantes et de risques anesthésiques et opératoires majeurs. Ainsi, de nombreux patients ne peuvent pas bénéficier du traitement optimal qu'est la dépose totale du matériel infecté, or peu de données sont disponibles à ce jour sur le traitement conservateur des IPV. Les patients atteints d'IPV aortique et récusés d'une dépose totale de prothèse ont été inclus dans 2 cohortes rétrospectives monocentriques anglaise et française entre 2006 et 2020. Le critère d'évaluation principal était l'analyse des facteurs associés à la survie sans récidive infectieuse clinique. Nous avons inclus 74 patients, d'âge médian 71 ans. L'implantation prothétique initiale était soit chirurgicale (45%), endovasculaire (26%) ou hybride (30%). La documentation microbiologique a été obtenue chez 56 patients (76%), polymicrobienne dans 27% des cas (20/56) dont 18% de co-infections fongiques (13/56). Lors de la prise en charge initiale, 26 patients ont nécessité une intervention de sauvetage (35%), le plus souvent une chirurgie ouverte (22/26, 30%), majoritairement pour un drainage d'abcès (13), un geste digestif (7) ou une dépose partielle de prothèse (5). Un drainage radiologique d'abcès a été effectué dans 17 cas (23%) et seuls 8 patients ont bénéficié de la pose d'une endoprothèse (11%). Tous les patients ont bénéficié d'un traitement anti-infectieux, d'une durée médiane de 42 jours (EIQ 30-66), suivi dans 53% des cas d'une antibiothérapie suppressive à vie (38%) ou pendant 202 jours en médiane (EIQ 92-400). Sous traitement suppressif, 10 patients (23%) ont acquis une résistance au traitement après une médiane de 360 jours (EIQ 29-630). Au cours du suivi, 17 patients (23%) ont nécessité un drainage radiologique et/ou chirurgical et 15 une chirurgie de sauvetage (20%), principalement une dépose de prothèse dans 11 cas, totale dans 5 cas, un geste digestif (9) ou urétéral (2), un drainage (4) ou une pose d'endoprothèse (1). A l'issue du suivi, 14 patients ont bénéficié d'une dépose totale malgré la contre-indication initiale, après un délai médian de 18 mois (EIQ 8-43). De nombreuses complications sont survenues au décours du suivi, pseudo-anévrisme (19%), rupture aortique (12%), hémorragie digestive (18%), embols septiques (5%) et/ou thrombose (16%). La mortalité intra-hospitalière était de 20%, la survie globale de 70% (IC 95% 58-80) à 1 an et de 43% (IC 95% 29-56) à 5 ans. La médiane de survie était de 3 ans. Une récidive septique est survenue dans la moitié des cas. Les facteurs de risque indépendants de décès et/ou de récidive étaient la dénutrition (p=0,01), les douleurs abdominales (p=0,02), le choc hémorragique (p=0,009) et la présence d'une fistule aorto-digestive (p=0,05). La morbi-mortalité chez les patients récusés d'une dépose totale de prothèse aortique infectée était élevée. La dénutrition pré-opératoire serait un facteur modifiable qui pourrait améliorer le pronostic de ces infections graves. Aucun lien d'intérêt

I recenti progressi nelle tecniche endovascolari, compresi le guide di ricanalizzazione, i cateteri di supporto o i palloncini, hanno ampliato la portata dei trattamenti endovascolari nella gestione del danno arterioso della gamba e del piede nei pazienti con ischemia critica. L’approccio femorale anterogrado rimane la via d’accesso preferita. Tuttavia, gli accessi non convenzionali per via transcollaterale, mediante pedal-plantar loop o mediante punture retrograde occupano un ruolo crescente nella gestione di questi pazienti. L’angioplastica rimane attualmente il trattamento di prima linea per la maggior parte delle lesioni. Tuttavia, gli stent, in particolare gli stent attivi, hanno dimostrato la loro efficacia nelle lesioni corte delle arterie delle gambe. Rimangono ancora necessari ulteriori dati sull’uso di palloncini attivi e sulle tecniche di aterectomia in questa indicazione.

L’occlusione aortica acuta (OAA) è rara, ma resta un’urgenza grave in chirurgia vascolare. I segni clinici dipendono dal livello di occlusione e possono essere confusi con un accidente vascolare cerebrale o una patologia neurologica, generando un notevole ritardo diagnostico. Occorre concentrarsi sulla ricerca dell’eziologia, che influisce pesantemente sulla prognosi. L’avvento del catetere di Fogarty ha permesso di ridurre il tasso di mortalità postoperatoria dal 75% al 20% odierno. La prognosi resta comunque infausta e l’epidemiologia si è notevolmente modificata negli ultimi 20 anni, con le trombosi in situ che sorpassano le cause cardioemboliche e insorgono spesso dopo una chirurgia endovascolare. L’angio-TC è divenuta uno strumento diagnostico di elezione e la gestione chirurgica di prima intenzione è la tromboembolectomia con catetere di Fogarty per via femorale bilaterale, ora integrata da un’eventuale procedura endovascolare a seconda del risultato del controllo arteriografico. La sindrome da riperfusione è la sua principale complicanza e può portare alla morte. È necessario prevenirne le conseguenze realizzando delle fasciotomie di scarico, un lavaggio dell’arto e una gestione rianimatoria attiva, che associa diuresi alcalinizzata forzata, correzione dei disturbi metabolici e depurazione extrarenale precoce, se necessario.

Purpose: The purpose of this study was to determine retrospectively the safety and technical success rate of embolization using ethylene vinyl alcohol copolymer (Onyx (R)) for persistent type 1A endoleaks after chimney endovascular aneurysm repair (EVAR) for complex aortic aneurysms. Material and methods: Nine consecutive patients (6 men, 3 women) with a mean age of 78.6 years (range: 62-87 years) presenting with persistent type IA endoleaks after chimney EVAR and an increase of aneurysm size were treated using transarterial embolization with Onyx (R). Results: Technical success was obtained in all patients (100%) and no complications were observed. Mean follow-up was 16 months (range: 3-35 months). Primary clinical efficacy was obtained for 8/9 patients (89%) and primary technical efficacy for 6/9 patients (67%). Secondary clinical efficacy was 100%, and secondary technical efficacy was 78%. Conclusion: Our results suggest that arterial embolization using Onyx (R) appears as a feasible and safe endovascular procedure of type IA endoleaks after chimney EVAR, although further validation is now required. (C) 2017 Editions francaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

Purpose: To retrospectively evaluate the safety and efficacy of embolization of persistent type II endoleaks occurring after abdominal endovascular aneurysm repair (EVAR) using ethylene vinyl alcohol copolymer (Onyx (R)).Material and methods: Between 2008 and 2016, 28 consecutives patients (25 men, 3 women) with a mean age of 75.3 years +/- 9 (SD) (range: 59-90 years) were treated for 29 persistent type II endoleaks with increasing aneurysm size > 5 mm occurring after EVAR. A total of 35 embolization procedures were performed using Onyx (R), via a transarterial route (n = 25) or direct puncture (n = 10), with or without additional metallic coils. The endpoints were to evaluate the clinical efficacy, corresponding to the stabilization or decrease of aneurism size, and the technical efficacy, corresponding to the ability to complete the embolization.Results: No severe complications were observed during and after embolization. The primary and secondary clinical efficacies were 75% (21/28) and 96.4% (27/28), respectively. Overall primary technical efficacy rate was 58.6% (17/29), greater for transarterial technique (72.8%) than for direct puncture (14.3%) (P = 0.01). Secondary technical efficacy was 72.4% (21/29), with no differences between transarterial (81.8%) and direct puncture (42.8%) (P = 0.06).Conclusion: Embolization with Onyx (R) of type II endoleaks after EVAR appears a safe and effective procedure. (C) 2017 Editions francaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

Objective: The primary objective of this retrospective study was to analyze the early impact of chimney (CG) versus fenestrated grafts (FG) on renal parenchymal vascularization and function.Methods: All consecutive patients with juxta-renal abdominal aortic aneurysm (JR-AAA) treated by endovascular repair from December 2013 to July 2014 at the vascular unit, Pellegrin University Hospital, Bordeaux, France, were included. Serum creatinine (SCr) and estimated glomerular filtration rate (eGFR) were reported at baseline and at J2 for acute kidney injury (AKI) incidence, and at J7 for AKI staging (KDIGO criteria); renal resistive indices (RRI) were reported for renal parenchymal repercussion at J-1, J0, and J1.Results: Ten patients were included in the CG group and 25 in the FG group, with 13 and 50 renal target vessels, respectively. Successful target vessel revascularization was achieved in 92.3% and 100.0% of patients. The incidence of AKI (10% and 32%), baseline SCr, and eGFR did not differ significantly. SCr was more elevated in the FG group at J1 (p = .025), J2 (p = .051), and J7 (p = .052), and eGFR was significantly lower from baseline to J1 (p = .015) and J2 (p = .014). RRI did not differ significantly between both groups. RRI augmentation was only noted in the FG group from J-1 to J0 (p = .039) and J-1 to J1 (p = .059). Patients with a KDIGO score <2 versus >= 2 showed significantly different RRI at J0 (p = .038) and J1 (p = .007). ROC curve analysis showed that RRI measures could be a predictive factor for AKI at J0 (cutoff = 0.72, sensitivity [Se] = 50%, specificity [Sp] = 86%) and J1 (cutoff = 0.71, Se = 70%, Sp = 84%).Conclusions: This study showed no significant difference in terms of RRI, eGFR, and the incidence of AKI or CKD between CG and FG. However, post-operative SCr levels were higher with FG, which was corroborated by comparison between pre- and post-operative RRI. Results are limited by the small sample size, but early repeated measures of RRI could be helpful in alerting the clinician to post-operative renal degradation, allowing better informed attempts to preserve renal function. (C) 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Objective: Increasing experience with fenestrated endovascular aortic repair (FEVAR) of complex aortic aneurysms has shown excellent shortto long-term results, even in high-risk patients. However, anatomical constrains, high price, and lengthy manufacturing time restrict their use to elective patients in specialized centers. Off-the-shelf availability of chimney EVAR (CHEVAR) offers a new alternative, but uncertainties remain over long-term target vessels patency and risk of type Ia endoleak (EL). Our objective was to review the literature reporting comparative results between FEVAR and CHEVAR of complex aortic aneurysms. Methods: A systematic PubMed, EMBASE, CENTRAL, and Ovid search was performed between January 2005 and September 2016. Inclusion criteria were original comparative articles reporting more than 5 patients with complex aneurysms treated by FEVAR or CHEVAR with a minimum 12-month follow-up. Results: Five comparative studies were selected. A total of 126 patients were included in the CHEVAR group (174 target vessels) and 227 in the FEVAR group (510 target vessels). Patients were significantly older in the CHEVAR group (75.8±1.9 vs 72.6±1.5 in the FEVAR group; P=.02) and 30 were symptomatic (23.8%, including 4 ruptured aneurysms [3.2%]). There were significantly fewer reconstructed vessels per patient treated by CHEVAR (1.4±0.1 vs 2.3±0.5; P=.004). Technical success rate was 92.9% after CHEVAR vs 91.2% after FEVAR (odds ratio [OR]=1.19; 95% confidence interval [CI]: 0.40, 3.55). The 30-day mortality rate was 4.8% after CHEVAR vs 4.4% after FEVAR (OR=0.64; 95% CI: 0.23, 1.76). The 12-month overall target vessels patency rate was 95.9% after CHEVAR vs 97.8% after FEVAR (OR=0.57; 95% CI: 0.17, 1.90). The 12-month rates of type I EL (3.7% vs 1.7%; OR=0.32; 95% CI: 0.08, 1.32), type II EL (6.3% vs 10.1%; OR=1.26; 95%CI: 0.55, 2.89) and type III EL (0.0% vs 0.9%; OR=1.27; 95% CI: 0.13, 12.78) did not differ significantly between both techniques; neither did the rates of secondary interventions (10.0% vs 13.6%; OR=1.23; 95% CI: 0.53, 2.88), overall mortality (9.6% vs 10.5%; OR=0.77; 95% CI: 0.31, 1.87) and aneurysm-related mortality (4.8% vs 4.4%; OR=0.64; 95% CI: 0.23, 1.76). Conclusion: Both CHEVAR and FEVAR are safe and effective in treating complex aortic aneurysms, with numerous advantages and limitations depending on the anatomy and clinical presentation of the patient. Both should remain in the armamentarium of physicians treating complex aortic aneurysms. VASCULAR DISEASE MANAGEMENT 2016;13(12):E265-E274

Un tiers des patients en ischémie critique chronique (ICC) présente une artérite jambière nécessitant la restauration d’un flux direct dans le pied. Cependant, beaucoup sont inéligibles à une chirurgie ouverte. Les objectifs premiers sont devenus le soulagement de la douleur et le sauvetage de membre plus que la perméabilité. Le concept d’angiosome aide à déterminer l’artère cible à traiter en priorité. L’approche endovasculaire a permis de diminuer significativement la morbi-mortalité comparée aux pontages distaux ; tandis que les techniques subintimales, rétrogrades, trans-collatérales et « loop » repoussent les limites de la chirurgie ouverte en permettant de réouvrir l’arche plantaire et d’améliorer ainsi le lit d’aval. Les phénomènes de resténose précoce après angioplastie ont pu être améliorés par l’utilisation de ballons actifs enduits de – limus et de stents sertis sur ballon en cas de dissection limitant le flux ou de « recoil » permettant ainsi d’augmenter les taux de sauvetage de membre. Par ailleurs, des stents actifs ont été proposés et permettent une diminution des taux de réintervention et de resténose intra-stent dans les lésions courtes ; cependant, les résultats sur les taux d’amputation ou de survie restent limités. La préparation des vaisseaux est un point primordial pour surmonter certaines limitations actuelles avec notamment l’athérectomie qui augmente les taux de succès technique et diminue les taux de resténose, notamment dans les lésions calcifiées, les occlusions totales chroniques et les resténoses. Ces avancées techniques dans la revascularisation endovasculaire distale ont révolutionné le sauvetage de membre et supportent l’intérêt d’une prise en charge endovasculaire première dans le traitement de l’ICC.

Peripheral arterial disease has become more and more present in daily practice, mostly due to the increase of cardiovascular risk factors, especially in below the knee (BTK) area in diabetic patients. Critical limb ischemia (CLI) is the most usual clinical presentation with a major amputation rate of 30%, mortality rate of 25%, and chronic pain of 20% at one year. Nowadays, endovascular treatment is usually the first choice, given the high comorbidity of those patients. Angioplasty and stenting in BTK lesions have already proven their efficacy in CLI treatment. However, BTK revascularization remains highly controversial in the treatment of intermittent claudication in TASC 2 recommendations. Restenosis being the major pitfall in BTK procedures, the use of drug-coated devices is one of the actual answers. We performed an extensive review of the literature over the last 15 years on the use of drug-eluting stents (DES) in BTK revascularization. DES has been compared to balloon angioplasty, in the ACHILLES trial, bare metal stents (BMS), in the DESTINY and YUKON trials, drug eluting balloons, in a trial guided by Siablis, and paclitaxel has even been compared to sirolimus in the PARADISE trial. In conclusion, DES is one of the solutions to the increase of BTK arteriopathy in CLI patients. Angiographic results are better, compared to BMS, in terms of primary patency, restenosis and TLR rates. However clinical results are missing. Treated lesions in the literature are short lesions. And DES is a metal balloon expandable stent with greater risks of compressions and stent fractures than nitinol self expandable stents, and such complications are known to increase post operative restenosis rates. Further reports are still needed on this matter.

Topological imaging is a recent method. So far, it has been applied to bulk waves, and high resolution has been demonstrated for imaging scatterers even with a single ultrasonic insonification of the inspected medium. This method consists in (i) emitting waves and measuring the response of the medium; (ii) solving two propagation problems: the direct problem, where the source is the one used for the insonification, and the adjoint problem, where the source is the time-reversed difference between the wave field measured and that obtained in the direct problem; (iii) computing the image from the two wave fields simply by multiplying both fields in the frequency domain, and integrating over frequency. The quickness of the method only depends on the cost of the field computations that are performed in the defect-less medium. The present work deals with the application of the topological imaging to guided waves. Combining modal theory and Fourier analysis, the computations are performed in a very short time. An isotropic plate was experimentally investigated with a single mode. Despite very high dispersion, scatterers are accurately localized and the spatial resolution is equal about one wavelength. Numerical experiments on an anisotropic plate investigated with two modes simultaneously also lead to an accurate image of the medium.

Objectives: A straightforward original Chimney Graft (CG) protocol has been developed at our institution in selected cases of juxtarenal aortic aneurysm (JRAA). The aim of this study was to present our clinical experience of consecutive series with use of uncovered self-expanding stent (SES) as "Open Chimney" (OCh) in the endovascular repair (EVAR) of JRAA.Methods: A standard endograft with suprarenal fixation struts is delivered with its proximal covered edge just below the highest RA in JRAA presenting the ostium of the two renal arteries at a different aortic level and the distance between the highest renal artery and the beginning of the aneurysm (improved landing zone) >= 10 mm. The low-lying renal artery is maintained patent by the OCh graft (standard SES) delivered from left brachial access (6 Fr). All clinical, anatomical, and operative data were prospectively collected and retrieved for the study analysis.Results: From July 2010 to November 2012, OCh EVAR was offered to 22 consecutive patients considered unfit for JRAA open repair. All procedures were technically successful with aneurysm exclusion and patent OCh graft. One small perioperative type la endoleak spontaneously disappeared at the 3-month CT control. One patient died because of acute decompensated heart failure. One patient presented a left hemispheric stroke. The median follow-up of 18 months (range 7-35) showed aneurysm exclusion in all patients without type I and Ill endoleaks, SES stenosis, and/or renal impairment.Conclusions: OCh-EVAR is a straightforward technique that can be employed in selected cases of JRAA, avoiding the more complex and expensive fenestrated EVAR. (C) 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.