Introduced in France in 2011 as an alternative to surgery (OR), the endovascular treatment of popliteal aneurysms (PAs) with Viabahn (ER) remains debated. A retrospective multicentric study was undertaken to validate or not this technique.

PURPOSE:To report a case of type IIIb endoleak developed six years after endovascular abdominal aortic aneurysm repair (EVAR).CASE REPORT:A 75-year-old man underwent successful Talent™ stent-graft positioning to treat a 53 mm abdominal aortic aneurysm. Subsequently the patient did well and yearly routine control computerized tomography (CT) was unremarkable. Six years later the patient suddenly developed abdominal pain irradiating to the back. An emergency angio-CT showed the presence of a type IIIb endoleak arising from the main body of the endograft. There weren't signs of fissuration or rupture. Aneurysm diameter was 85 mm as compared to 52 mm on a CT performed ten months earlier. The patient underwent successful positioning of an aorto-monoiliac endograft followed by the occlusion of the controlateral limb and a femoro-femoral crossover dacron bypass graft. Three months later the patient presented again because of the sudden onset of abdominal pain. On angio-CT aneurysm size was increased up to 11 cm. A distal type I endoleak was found and treated by placing an iliac extension to the right external iliac artery. After uneventful postoperative course the patient was discharged in good general conditions. Control angio-CT done after six months showed the complete exclusion of the large aneurysm sac.CONCLUSIONS:Type IIIb endoleaks can be safely treated by endovascular positioning of an aorto-monoiliac stent-graft followed by the occlusion of the controlateral limb and a femoro-femoral crossover dacron bypass graft. Continuous surveillance after EVAR is mandatory.

PURPOSE:To evaluate the feasibility of endovascular exclusion of popliteal artery aneurysm (PAA) using stent grafts. METHODS:The clinical data of all patients who underwent endovascular exclusion of PAA at three French vascular departments between December 1999 and December 2007 were retrospectively analyzed. Outcome measures included graft patency and endoleak. The Kaplan-Meier method was used to calculate the primary and secondary patency curves. RESULTS:A total of 57 PAA in 50 patients (48 men; mean age, 72 +/- 11 years; range, 57-96 years) were treated. The type of stent graft used was Hemobahn/Viabahn in 42 (73.7%) cases, Wallgraft in 14 (24.5%) and Passager in one. The mean duration of hospitalization was 5 +/- 1.8 days (range, 3-11 days). No patients were lost from follow up (mean, 36 +/- 19.4 months; range, 6-96 months). Nine (16%) occlusions and six (10.5%) endoleaks occurred. The global limb salvage rate was 96.5% (55 of 57 PAA). Kaplan-Meier estimates for primary and secondary patency were 85.8% and 87.5% at one year and 82.3% and 87.5% at three years. CONCLUSIONS:Endovascular treatment of PAA is feasible in selected patients. The main determinants of success are suitable aneurysm anatomy and dual antiplatelet postoperative therapy. Further studies are warranted to determine long-term outcomes of endovascular repair for PAA.

Popliteal-to-distal bypass is still the gold standard for limb salvage. However, some patients, especially elderly or diabetic patients, are not eligible for such treatment; and problems may arise, including poor healing of distal surgical wounds, delayed resumption of ambulation, and prolonged hospitalization. This prospective multicenter study carried out on an intent-to-treat basis includes 53 extremities in 48 patients presenting critical ischemia due to infrageniculate arterial lesions with no proximal lesions. Two populations were isolated: diabetic patients (56.6%) and elderly patients over 80 years (45%). In 82% of cases the arterial lesions were long, i.e., more than 1 cm. The limb salvage rate at 1 year was 81%. Postoperative mortality was 9%, and mortality at 1 year was 22.6%. These results show that cutting balloon angioplasty can be proposed as primary treatment in patients with critical ischemia due to popliteal and distal artery lesions.

Les pontages poplitéo-jambiers pour sauvetage de membre restent la méthode de référence mais ils ne sont pas toujours possibles surtout chez le sujet âgé ou le diabétique et sont souvent suivis de troubles de la cicatrisation des plaies opératoires distales, de retards à la marche et de durées de séjour prolongées. Notre étude prospective, multicentrique, en intention de traiter porte sur 53 membres chez 48 patients en ischémie critique présentant des lésions artérielles infragéniculées sans lésion d'amont associée et traités par angioplastie par cutting balloon. Deux populations ont été isolées : les diabétiques (56,6%) et les patients âgés de plus 80 ans (45%). Dans 82% des cas les lésions artérielles étaient longues, supérieures à un centimètre. Le taux de sauvetage de membre à un an a été de 81,1%. La mortalité post-opératoire a été de 9% et la mortalité à un an de 22,6%. Ces résultats montrent que l'angioplastie par cutting balloon peut être proposée en première intention devant une lésion poplitéo-jambière chez un malade en ischémie critique.

El bypass poplíteo-distal sigue siendo el patrón de referencia en la revascularización de la extremidad. No obstante, algunos pacientes, especialmente los ancianos o diabéticos, no son candidatos para este tratamiento, pudiendo surgir complicaciones, tales como mala cicatrización de las heridas quirúrgicas distales, retraso en la reanudación de la deambulación, u hospitalización prolongada. Este estudio prospectivo y multicéntrico realizado sobre la base de la intención de tratar, incluye 53 extremidades en 48 pacientes que presentaron isquemia crítica con lesiones en arterias infrapoplíteas sin lesiones proximales. Se seleccionaron dos subpoblaciones de pacientes: diabéticos (56,6%) y ancianos de más de 80 años (45%). En el 82% de los casos las lesiones arteriales fueron largas (más de 1 cm). La tasa de revascularización de la extremidad a 1 año fue del 81%. La mortalidad postoperatoria fue del 9%, y la mortalidad a 1 año, del 22,6%. Sobre la base de estos resultados, la angioplastia con cutting balloon puede proponerse como tratamiento de primera elección en pacientes con isquemia crítica de miembros inferiores por lesiones en las arterias poplítea y distales.

Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) is a French multicenter, non-inferiority randomized trial with national research organisation funding. In brief, patients are eligible if they have experienced a carotid TIA or non-disabling stroke within 4 months before randomisation and if they have an atherosclerotic stenosis of the region of the ipsilateral carotid bifurcation of 60% or more, as determined by the NASCET method, that investigators believe is suitable for both carotid surgery and angioplasty. Carotid surgery is performed using standard operative techniques. Carotid angioplasty consists of primary stenting with cerebral protection. The primary endpoints are: (a) any stroke or death within 30 days of the procedure and (b) any stroke or death within 30 days of the procedure plus ipsilateral stroke. To join the study, a centre must form a multidisciplinary team, including a vascular neurologist, a vascular surgeon and an interventionalist. Operator experience must be substantiated through documentation of a sufficient number of cases performed.

The goal of cerebral protection in carotid surgery is to reduce postoperative central neurological complications and thus reduce morbidity-mortality of carotid endarteriectomy. With improving understanding of the mechanism leading to neurological complications, means of achieving cerebral protection have been developed. Preoperative evaluation of the ischemic risk is based on the neurological examination and on computed tomography and magneticresonance imaging findings. The possibilities of arterial supply during, carotid cross-clamping can be recognized with the help of arteriography, transcranial Doppler or angio-MRI. Selective or systematic use of an intraluminal shunt and peroperative heparinotherapy are the main methods used for cerebral protection. The risk of early postoperative stroke can also be reduced by careful peroperative anatomic control to detect any technical failure. Discussion on the usefulness of monitoring cerebral function during the procedure is closely related to the experience of the surgical team. The only method currently accepted by all surgeons is the use of stents during carotid angioplasty to achieve cerebral protection.

The goal of cerebral protection in carotid surgery is to reduce postoperative central neurological complications and thus reduce morbidity-mortality of carotid endarterectomy. With improving understanding of the mechanism leading to neurological complications, means of achieving cerebral protection have been developed. Preoperative evaluation of the ischemic risk is based on the neurological examination and on computed tomography and magnetic resonance imaging findings. The possibilities of arterial supply during carotid cross-clamping can be recognized with the help of arteriography, transcranial Doppler or angio-MRI. Selective or systematic use of an intraluminal shunt and preoperative heparin therapy are the main methods used for cerebral protection. The risk of early postoperative stroke can also be reduced by careful preoperative anatomic control to detect any technical failure. Discussion on the usefulness of monitoring cerebral function during the procedure is closely related to the experience of the surgical team. The only method currently accepted by all surgeons is the use of stents during carotid angioplasty to achieve cerebral protection.

A prospective study was done in 100 patients operated on for a stenosis of the carotid artery by the eversion endarterectomy method of Van Maele (section-eversion-anastomosis) between January 1994 and August 1995. Ten patients were operated on bilaterally (thus, 110 procedures). The distribution of the patients was as follows 81 males and 19 females, mean age 71 years. Clinically, 50 patients were asymptomatic, 44 stage I, 2 stage II and 3 stage III. Arteriography of these patients showed 42 stenoses greater than or equal to 90 %, 56 stenoses between 70 and 90 % and 12 ulcerated plaques (according to the ESCT measurement standards). Concerning the supra-aortic vessels, 24 lesions of the vertebral-subclavian branches and 21 lesions of the intra-cerebral vessels were observed. Five endarterectomies out of the 110 (5.4 %) could not be performed by this eversion method because of the immediate poor technical result before angiography. At the end of the procedure digital angiography was performed for all the patients who underwent an eversion endarterectomy (105 cases). Six images of the internal carotid artery presenting stenoses less than 30 % were observed at the level of the implantation site. Two narrow stenoses of the distal part of the endarterectomy made the interposition of a PTFE graft necessary in 20 % of the cases, a secondary procedure was necessary after the peri-operative angiography 2 implantations of PTFE in the internal carotid artery, 8 additional endarterectomies of the external carotid artery, 11 infiltrations with Papaverine. The immediate post-operative results were 1 death after hemiplegia, 1 hemiplegia with sequelae (mortality/morbidity approximately 2 %, i.e 2/103 eversions), 3 regressive hemipareses. Angiographic follow-ups after 1 year were performed on 100 out of 110 operated carotid arteries. With regard to the internal carotid artery, 4 patients showed a stenosis less than 30 8, 1 patient a 50 % stenosis, I patient a pre-occlusive stenosis making an operation with the interposition of a PTFE graft necessary (restenosis rate after one year 2 %). All the patients followed after one year remained asymptomatic. Eversion endarterectomy is possible for the majority of the atheromatous stenoses of the carotid artery (5.4 % were not possible for technical reasons). We fmd this method not appropriate when a shunt must be placed. Immediate results are comparable to those of classical surgical endarterectomy with or without patching. The restenosis rate at 1 year in our series is 2 %. This technique provides an excellent anatomic result by peri-operative angiography and can especially be adapted to stenoses with excess of length of the carotid artery.

A prospective study was done in 100 patients operated on for a stenosis of the carotid artery by the eversion endarterectomy method of Van Maele (section-eversion-anastomosis) between January 1994 and August 1995. Ten patients were operated on bilaterally (thus, 110 procedures). The distribution of the patients was as follows 81 males and 19 females, mean age 71 years. Clinically, 50 patients were asymptomatic, 44 stage I, 2 stage II and 4 stage III. Arteriography of these patients showed 42 stenoses greater than or equal to 90%, 56 stenoses between 70 and 90% and 12 ulcerated plaques (according to the ESCT measurement standards). Concerning the supra-aortic vessels, 24 lesions of the vertebral-subclavian branches and 21 lesions of the intra-cerebral vessels were observed. Five endarterectomies out of the 110 (5.4%) could not be performed by this eversion method because of the immediate poor technical result before angiography. At the end of the procedure digital angiography was performed for all the patients who underwent an eversion endarterectomy (105 cases). Six images of the internal carotid artery presenting stenoses less than 30% were observed at the level of the implantation site. Two narrow stenoses of the distal part of the endarterectomy made the interposition of a PTFE graft necessary in 20% of the cases, a secondary procedure was necessary after the peri-operative angiography 2 implantations of PTFE in the internal carotid artery, 8 additional endarterectomies of the external carotid artery, 11 infiltrations with Papaverine. The immediate post-operative results were 1 death after hemiplegia, 1 hemiplegia with sequelae (mortality/morbidity approximately 2%, i.e. 2/103 eversions), 3 regressive hemipareses. Angiographic follow-ups after 1 year were performed on 100 out of 110 operated carotid arteries. With regard to the internal carotid artery, 4 patients showed a stenosis less than 30%, 1 patient a 50% stenosis, 1 patient a pre-occlusive stenosis making an operation with the interposition of a PTFE graft necessary (restenosis rate after one year 2%). All the patients followed after one year remained asymptomatic. Eversion endarterectomy is possible for the majority of the atheromatous stenoses of the carotid artery (5.4% were not possible for technical reasons). We find this method not appropriate when a shunt must be placed. Immediate results are comparable to those of classical surgical endarterectomy with or without patching. The restenosis rate at 1 year in our series is 2%. This technique provides an excellent anatomic result by peri-operative angiography and can especially be adapted to stenoses with excess of length of the carotid artery.

While angioplastic techniques for atherosclerotic stenoses of the internal carotid artery remain controversial, their value appears clearer in nonatherosclerotic pathology [I]. These diseases, obviously being of minor importance as compared with atherosclerotic otic lesions, include postoperative restenoses within two years after endarterectomy! dysplastic lesions, carotid dissections, radiation arteritis and inflammatory arteritis. Literature analysis about the results of endovascular techniques in this area of carotid pathology is difficult, because of the rarity of the disease and because the publications include it in series of angioplasty for carotid stenoses of different etiologies. During the most recent congresses, however, individualization of these indications has begun to occur.

Purpose: The aim of this study was to seek a relationship between the morphologic features of abdominal aortic aneurysms and the feasibility of endoaortic grafting.Methods: Between June 1995 and January 1996, 86 patients were prospectively studied with contrast-enhanced spiral computed tomographic scans, which provided 35 parameters concerning the aorta and iliac arteries. Four groups were established according to the diameter of abdominal aortic aneurysms: group A, 40 to 49 mm, 36 patients; group B, 50 to 59 mm, 26 patients; group C, 60 to 69 mm, 10 patients; and group D, greater than 70 mm, 14 patients.Results: There was a correlation between the diameter and length of the aneurysm (p < 0.0001) and between aneurysm diameter and length of the proximal neck (p < 0.001). Presence of a proximal neck or a distal neck was more frequent in groups A and B than in groups C and D (p < 0.01). The feasibility of endovascular grafting was estimated at between 50% and 61.6% and was higher in groups A and B than in groups C and D (p < 0.01).Conclusions: This study has shown an inverse relationship between the diameter of the aneurysm and the length of the aortic neck (correlation coefficient, -0.3640, p < 0.001). The diameter of an aneurysm was the most useful of the 31 parameters measured in predicting the feasibility of endoaortic grafting, estimated at 71% for aneurysms less than 60 mm in diameter and 37.5% for aneurysms greater than 60 mm in diameter (p < 0.01).