Background: Aortic endograft infection is uncommon, and fastidious organisms may escape routine culture. Case: A 58-year-old man presented 15 months after urgent EVAR with fever, anemia, and an inflammatory syndrome. CTA and FDG PET/CT supported endograft infection, whereas blood and operative cultures were negative. Complete explantation and in situ aorto-bi-iliac reconstruction were performed. Broad-range 16S rRNA gene analysis identified Helicobacter bilis. Doxycycline was continued for six weeks after surgery, with no recurrence at one year. Conclusion: Molecular testing aids culture-negative diagnosis, but complete surgical source control remains essential.

Buts de l’étude La chirurgie carotidienne par endartériectomie est actuellement remise en cause à la fois par l’amélioration des traitements médicamenteux mais aussi par les techniques endovasculaires. Nous avons réalisé une étude multicentrique (TREC) à la recherche de facteurs de risques chirurgicaux de resténoses carotidiennes par hyperplasie myo-intimale. Le but de cette présentation est de rapporter les principaux résultats de cette étude dont le taux cumulé de morbi-mortalité (TCMM) et les taux de resténoses précoces. Matériel et méthodes Après accord du Comité d’éthique (2021-133), nous avons inclus tous les patients opérés d’une endartériectomie carotidienne par éversion dans 8 hôpitaux publics français entre septembre 2021 et novembre 2022. Nous avons recueilli les données démographiques et indications opératoires, ainsi que les complications opératoires dont les décès précoces et accidents vasculaires cérébraux (AVC) définissant le TCMM, ainsi que les taux de resténoses précoces à 1 an. Résultats Nous avons inclus 601 patients dont 417 hommes (70 %) de 73 ans±9 d’âge moyen. Ils ont été opérés pour des sténoses carotidiennes quantifiées<50 %, entre 50 et 69 % et>70% dans 2 %, 15 % et 83 % des cas respectivement. Celles-ci étaient symptomatiques et asymptomatiques dans 36,3 % et 63,7 % des cas. Durant la période des 30 jours postopératoires, 2 décès et 9 AVC ont été recensés. Ces 11 complications majeures sont toutes survenues chez des patients opérés pour des sténoses symptomatiques sauf 1 avec 1 AVC controlatéral à j28 chez un patient initialement asymptomatique. Aussi le TCMM global de l’étude était de 1,8 %, le TCMM pour les patients symptomatiques était de 4,5 % et celui des patients asymptomatiques de 0,2 %. À 1 an nous avons observé 46 (9 %) resténoses>50 % et 11 (2,2 %) resténoses>70 %. Conclusion Même s’il ne s’agissait que d’un critère de jugement secondaire, le TCMM de l’étude TREC est bien inférieur aux diverses recommandations. Les taux de resténoses précoces sont ici également plus faibles que ceux rapportés dans la littérature. Ces résultats reflètent la qualité de la chirurgie carotidienne française et permettent de justifier la compétitivité de l’endartériectomie particulièrement pour les sténoses asymptomatiques.

Objective: A proximal scallop design allows aortic arch repair without complex endovascular manipulation in the aortic arch. The aim was to assess the safety and efficacy at one year of the Relay proximal scallop stent graft.Methods: A prospective multicentre study evaluated consecutive patients treated with the Relay proximal scallop stent graft in 10 French aortic centres. All consecutive patients eligible for elective thoracic endovascular repair with proximal scallop in the 10 participating centres between January 2015 and July 2018 were included. Primary endpoints were 30 day mortality, stroke, and spinal cord ischaemia (SCI) rates. Outcomes including safety and efficacy, technical and clinical success, all cause death, neurological events, vessel patency, and device specific complications were analysed. Survival and survival without severe complications were estimated using Kaplan -Meier estimates.Results: Ten aortic centres treated 40 patients for thoracic aortic aneurysm (45% ), penetrating atherosclerotic aneurysm ( 30%), and dissection (25%). Half of the procedures (50%) targeted zone 0 of the aortic arch (zone 0 in 17.5% and zones 0/1 in 32.5%), 37.5% targeted zone 2 (35% zone 2 alone; 2.5% zones 1/2), and 15% targeted zone 1 (12.5% zone 1 alone). Median follow up was one year. Thirty day mortality, stroke, and SCI rates were 10%, 5%, and 0% respectively. Primary technical success was 95%. Type Ia, Ib, and III endoleaks rates were 5.4%, 0%, and 0% respectively at one month. The overall mortality rate at one year was 17.5%. Aneurysm expansion was > 5 mm in one case at one year associated with type Ia endoleak ( 3%). There was no supra-aortic trunk thrombosis, one (2%) graft kink, and no migration.Conclusion: One year outcomes showed that the Relay proximal scallop stent graft is an acceptable answer to thoracic aortic disease to deal with short proximal landing zones.

Complex abdominal aortic aneurysms (CAAAs) are defined as the absence of an infrarenal aortic collar allowing the placement of a standard aortic stentgraft. They include juxtarenal aneurysms (JRAs), suprarenal aneurysms (SRAs), and type IV thoracoabdominal aneurysms (TAA IV). Open surgery (OS) and fenestrated stentgrafts (FSG) are currently the two gold standard procedures for the treatment of CAAAs. Some data in the literature suggest that FSGs could reduce early morbidity and mortality but the real cost/effectiveness advantage over the mid- and long-term is uncertain. A prospective randomized study would provide robust comparative data but it is difficult to set up because of the expertise acquired by some surgeons and/or centers for either technique, and the anticipated difficulties in obtaining patient consent for randomization. A prospective, multicenter, comparative cost-effectiveness study that does not change current practice in each center but reduces confounding bias by applying a propensity score in the analysis and excluding patients who cannot benefit from both techniques appears to have the best feasibility/evidence ratio. The objective of the multicenter ORFEVAR study was to compare prospectively the 36-month cost-utility ratio of OS versus FSGs in the real-life management of CAAAs.

Myointimal hyperplasia restenosis remains a concern following carotid endarterectomy. It occurs in about 6% of people. The 3-year rate of stroke after restenosis is 5.2%. Several risk factors for restenosis have been identified, such as smoking, hypertension, female gender, diabetes, dyslipidemia, or small carotid diameter. The primary objective of this prospective multicenter study was to determine whether the technical characteristics of the eversion technique influence the 1-year rate of restenosis.

Aberrant Left Subclavian Artery with Kommerell’s Diverticulum And Right Sided Aortic Arch: Hybrid Approach Abstract A 58 years-old woman presented a rare right-sided aortic arch with an aberrant left subclavian retro-esophageal artery, originates from Kommerell’s diverticulum. After left subclavian to carotid transposition, we implanted a thoracic endoprosthesis under ventricular fibrillation. Type IA symptomatic proximal endoleak was treated with a second endograft a week later. We shared here technical aspects and challenges of endovascular management, including precise preoperative imaging (CT angiography, lymphangio-MRI), the need of a hybrid operative room, conformable endoprosthesis and right ventricle overstimulation.

Purpose: The STABILISE technique has extended the treatment of aortic dissection to the thoracoabdominal aorta to achieve complete aortic remodeling. The aim of this multicenter study was to analyze the short- and midterm anatomical results of the STABILISE technique. Materials and Methods: We retrospectively analyzed patients treated with the STABILISE technique for complicated aortic dissection at 3 French academic centers. The aortic diameter at different levels was measured preoperatively, postoperatively, and at 1 year. Results: Between 2018 and 2020, 58 patients, including 47 men (average patient age: 60±11 years), were treated for type B aortic dissection in 34 cases and residual aortic dissection after type A repair in 24 cases. Three (5.2%) patients died postoperatively. Complete aortic remodeling (false lumen thrombosis and complete reapposition of the intimal flap) was achieved in 45/55 patients (81.8%), and false lumen thrombosis in the thoracic aorta was achieved in 52/55 patients (94.5%). At 1 year, with a computed tomographic (CT) scan available for 98.2% (54/55) of patients, we observed a significant decrease in the maximal thoracic aortic diameter and a significant increase in the aortic diameter at the bare-stent level compared with the preoperative CT scan. Severe aortic angulation (p=0.024) was a risk factor for incomplete aortic remodeling and significantly increased the aortic diameter (p=0.032). Chronic aortic dissection was associated with an increased risk of incomplete aortic remodeling (p=0.002). Conclusions: STABILISE for complicated aortic dissection results in false lumen thrombosis, complete reapposition of the intimal flap, and a decrease in the maximum aortic diameter in most cases. Incomplete reapposition of the intimal flap, which is more frequent in cases of chronic aortic dissection and severe aortic angulation, is a risk factor for a significant increase in the aortic diameter at the bare-stent level, and this risk justifies close follow-up and better patient selection. Clinical impact STABILISE technique for complicated aortic dissection results in false lumen thrombosis, complete aortic remodeling and a decrease in the maximum aortic diameter in most cases. At the bare-stent level, incomplete reapposition of the intimal flap, more frequent in chronic aortic dissection and severe aortic angulation, is a risk factor for an increased aortic diameter. This finding justifies close follow-up and better patient selection; thus, the STABILISE technique should be used with care in chronic aortic dissection and severe aortic angulation.

BACKGROUND:Thoracic endovascular aortic repair (TEVAR) is the standard treatment for acute complicated type B aortic dissection (TBAD). However, long-term results reveal that TEVAR does not achieve a complete aortic remodeling and poses a risk of aneurysmal aortic degeneration. Distal re-entry treatment at the abdominal level seems to be necessary to obtain a complete remodeling in TBAD. Moreover, it is necessary to treat the aortoiliac bifurcation in patients with persistent true lumen collapse or limb ischemia.METHODS:Between January 2018 and October 2019, 11 patients with acute or sub-acute complicated TBAD or non-A non-B aortic dissection were treated in our institution in an endovascular fashion. We performed the stent-assisted, balloon-induced intimal disruption and relamination in aortic dissection repair (STABILISE) technique in all cases, but 2 cases required complementary treatment of the aortoiliac bifurcation with a bifurcated AFX endograft system for limb ischemia due to true lumen collapse.RESULTS:Technical success was obtained in all patients. No procedural complications occurred. No postoperative deaths, stroke, paraplegia, mesenteric, or renal ischemia were observed, and no secondary intervention was necessary. Satisfactory aortic re-modeling was obtained after the follow-up periods with a 57.5% mean true lumen expansion.CONCLUSIONS:Our initial experience using the extended STABILISE (e-STABILISE) technique using a bifurcated AFX endograft did not result in any postoperative mortality or complications. Without additional data, this technique should be reserved for specific patients who require revascularization of the aortoiliac bifurcation.

The STABILISE technique made it possible to extend the treatment of type B aortic dissections (AD) to the thoracoabdominal aorta by prolonging the covered stent with a bare stent which is inflated in order to reaffix the intimal flap and induce aortic healing. The aim of this multicentric study was to analyze the short and mid-term anatomical results on the thoracic and thoracoabdominal aorta of the treatment of ADs by the STABILISE technique.

This was a prospective and multicentric study evaluating the postoperative and one-year results of proximal scalloped custom-made stentgrafts for the endovascular treatment of the lesions of the aortic arch.

ObjectiveVascular complications (VCs) occurring in transcatheter aortic valve implantation (TAVI) procedures have frequently been reported in the past. Considering significant technical improvements in delivery systems and vascular closure devices, the goal of this study was to determine the incidence, impact, and prognostic factors of VCs in a recent real-world cohort.MethodsWe report a bicentric prospective analysis of 479 consecutive patients who underwent TAVI between January 2017 and December 2017. VCs were defined according to criteria set out by the Valve Academic Research Consortium (VARC)-2.ResultsThe incidence of VCs was 26.1% (n = 125 patients), of which 2.9% were major (n = 14) and 23.2% were minor (n = 111). VCs were related to the primary puncture point in 69% of cases compared with 31% at the secondary puncture site. Treatments implemented were medical in 76% of cases and surgical in 24% of cases. The risk factors for VCs were as follows: iliac morphology score, sheath to iliofemoral artery ratio (SIFAR), and moderate-severe iliofemoral calcifications or tortuosity. In the case of major VCs, only sheath to iliofemoral artery ratio was a risk factor. Major VCs significantly increased intrahospital mortality (30.7% vs 1.1% for minor VCs and 1.3% for no VCs; log-rank, P < .0001) and 1-year mortality (40.6% vs 5.6% for minor VCs and 5.6% for no VCs; log-rank, P < .0001).ConclusionsUsing strictly VARC-2 end point definitions, more than one-quarter of TAVI procedures were associated with VCs, primarily minor ones. Secondary puncture points were responsible for one-third of VCs and should therefore also be actively monitored. Major VCs have a significant impact on short-term and midterm survival.

Introduction - Endovascular treatment of brachiocephalic artery (BCA) stenosis/occlusion has become a safe and reliable alternative to conventional open surgery. However, there is no specific recommendation regarding the type of stent to use. The aim of our study was to look for any difference of patency rate between bare metal and covered stents in this location Methods - We conducted a multicentre retrospective study including patients treated with stent implantation for brachiocephalic artery stenosis/occlusion, from 2006 to 2016. Demographic data, operative indications and complications, type of stent implanted (bare metal or covered) and follow-up events were collected. We particularly looked for restenosis > 50% (Dupplex or CT-scan) and reoperations Results - From 9 university hospitals, 79 patients, including 52 men (65.8%), of 63 ± 11.5 years of mean age were included. Patients were treated for carotid symptoms (n=15, 15.0%), and/or vertebro-basilar insufficiencies (n=19, 24.1%), and/or brachial symptoms (n=16, 20.3%) and/or an anisotension> 15 mmHg (n=35, 44.0%). Brachiocephalic artery stenoses were about 50% in 1 case (1.3%), between 70 and 90% in 44 cases (55.6%), pre-occlusive in 24 cases (30.4%). There were 7 (8.9%) BCA occlusions. Procedures were performed mainly under general anaesthesia (n = 53, 67.1%) through carotid retrograde approaches (n = 57, 72.2%). The implanted stents were bare metal in 55 cases (69.6%) and covered in 24 cases (30.4%). The perioperative stroke rate was 5.1% (n = 4), including one left sylvian stroke. During the mean follow-up of 38.2 ± 33.8 months, 30 restenoses (39.0%) were detected and 14 reoperations (29.2%) were performed. Multivariate analysis determined that both restenoses and reoperations were more frequent in bare metal stents (p=0,011, RR=4,8 - IC95= [1,45-16,0] ; p=0,018, RR=10,4 - IC95= [1,3-87,1] respectively). The degree of lesion did not significantly affect results Conclusion - This study is the first to demonstrate the interest of covered stents for the endovascular treatment of atheromatous lesions of the BCA in order to limit the risks of restenoses and reoperation, in this particular location where operative indications remain infrequent

Aortic infection is a challenging condition. Fortunately, surgical revision of infected aorta with in situ reconstruction can provide long-term cure. The material for aortic repair remains an area of debate. The Omniflow II (LeMaitre Vascular, Burlington, Mass) prosthesis is a biosynthetic graft made to resist long-term degeneration and allows growth of host tissue with reduction of the risk of arterial infection. It has already been used for peripheral bypass with very low infection rates. Herein, we describe an original case of first-line native aorta replacement by a straight Omniflow II biologic prosthesis for infected aortic aneurysm.

Stenosing and occlusive atheromatous lesions of the brachio-cephalic arterial trunk (BCAT) are now treated by endovascular route in first intention. There is however no specific recommendation regarding the material to use. The aim of this study was to determine a possible difference in patency between bare stents and covered stents in this localization.

A type 2 endoleak (EL2) persists at one year in 15 to 30% of the cases after EVAR. The EVAS (EndoVascular Aneurysm Sealing System; Nellix®, Endologix, Inc.) concept is a new approach in the endovascular treatment of AAAs. Our aim was to analyze the capacity of Nellix® to limit the risk of EL2 in high-risk patients. 25 AAA patients (24 men, mean age=71 years) were included in a retrospective study by four French centers of vascular surgery according to the following criteria: non complicated AAA with surgical indication; AAA meeting the indications for the implantation of Nellix®; AAA with at least three patent collateral branches (≥2.5mm). The operated patients were followed by ultrasound and/or angio-CT. The principal criterion of judgment was therapeutic success. The secondary criteria were the global rate of EL and the rate of EL2. The average maximal diameter (D) of the AAAs was 55±6mm. The proximal neck was on average: L=33mm, D=22mm, ang=31°. The average volume of the circulating channel was 110mL (48-255mL). IMA was patent in all the cases (D=3mm). The number of lumbar arteries varied from two to five (D=2.7mm). In three patients, there were two accessory renal arteries (D=2.8mm). The success rate of the procedure was 100%. One type 1b EL was treated by hypogastric embolization and iliac extension with a covered stent. One external iliac dissection required a complementary stenting. The average volume of polymer injected was 95mL (45-204mL). The final angiography did not find an EL2. Postoperative mortality was 0%. Morbidity was 8%: one limb thrombosis, one acute respiratory insufficiency. At one month, no EL was detected. The average follow-up was 10 months (one lost to follow-up at one month). 100% of the AAAs were excluded. Mortality was 4% (one CVA). Two patients (8%) presented a thrombotic complication: one popliteal thrombosis, two successive limb thromboses requiring the explantation of the stentgraft (14 months). Diameters were stable: D max=54±8mm (-2.4%; NS). No EL was observed. One noted no complication related to the endobags. The endovascular treatment of the non- complicated AAA by EVAS has encouraging short and mid-term results in selected patients. Our study suggests that the EVAS concept of the Nellix stentgraft is effective to avoid EL2. A longer-term follow-up is necessary.

Traditionally, patients with symptomatic external carotid stenosis present with neck or face pain, retinal ischemic symptoms or jaw claudication and rarely as ipsilateral cerebrovascular events. In this present case, our patient suffered a stroke from a paradoxical embolism from the external carotid, without involvement of the internal carotid artery. A plaque ulceration of the external carotid's origin was the cause of this cerebral emboli. Duplex ultrasound showed a pathologic left external carotid, with a floating thrombus in the internal carotid. The diagnostic was confirmed by a computerized tomography scan. An external carotid thromboendarterectomy was performed 6 days after symptom onset, and intraoperative findings confirmed the plaque rupture with an extensive clot in the carotid bifurcation.

Background: The objective of this retrospective study was to evaluate the tolerance of rapid right ventricular pacing (RRVP) compared with that of the traditional methods of hypotension used during thoracic endovascular aortic repair (TEVAR).Methods: From January 2002 to December 2012, we retrospectively included all the patients treated with TEVAR by comparing the 2 groups: patients operated with RRVP (RRVP+) and those operated without RRVP (RRVP-). The characteristics of the population and the procedures were recorded. The rates of complications were compared up to 1 year.Results: Sixty-one patients were operated. Treated pathologies were multiple with 19 aneurysms, 14 false aneurysms, 12 isthmic ruptures, 11 dissections, 3 coarctations, and 2 endoleaks. Twenty-four patients were RRVP+ and 37 patients were RRVP-. Mortality rates at 1 month in groups RRVP+ and RRVP- were of 0% and 2.7%, respectively (P = 1), and reintervention rates were 0% and 13.5%, respectively (P = 0.15). Three peroperative rhythm disorders (12.5%) were observed in the RRVP+ group including 2 ventricular fibrillations and 1 atrial fibrillation, both reduced without complications. One pacemaker was implanted for atrioventricular block in the RRVP- group. In the RRVP+ group, 83.3% of the patients presented a rise in troponin Ic (TnI) >0.04 ng/mL in 72 hours compared with 40.5% of the patients in the RRVP- group (P = 0.0013), with a spontaneously favorable evolution. No coronary syndrome was observed at 1 year with a mortality rate of 10.8% in the RRVP- group vs. 0% in the RRVP+ (P = 0.15).Conclusions: In spite of a frequent moderate rise of TnI at the time of RRVP, this technique does not present more complications at 1 year than the use of a chemical hypotension. It thus seems an interesting alternative for selected patients, in trained teams.

Background: The local complications are frequent after a femoral approach in vascular surgery and are often the cause of a delay in healing. Electrofusion showed its effectiveness to decrease the complications in general surgery but was not tested in vascular surgery. The aim of our study was to evaluate if the use of electrofusion in the approach to femoral vessels improved healing at 1 month by decreasing the local complications.Methods: This prospective randomized study was conducted in 2 centers from May 1, 2012 to April 30, 2013. All the patients requiring a surgical access of the femoral trigone were included in 2 French teaching hospitals. Femoral artery surgical exposure was carried out using electrofusion or according to the conventional technique (diathermy or cold scalpel) according to a protocol of randomization. The principle criterion of the study was a complete healing at 1 month. The secondary criteria were the appearance of cutaneous, infectious, or lymphatic local complications.Results: Two hundred ninety-two femoral approaches were carried out in 221 consecutive patients. One hundred forty-eight approaches were carried out with electrofusion and 144 according to the conventional technique. The demographic and operative characteristics were similar between the 2 groups. At 1 month, 86.3% of the approaches were healed without statistically significant difference between the 2 groups (88.5% vs. 84%, P = 0.241). There were less local complications (P = 0.012) and seromas (P = 0.012) in the electrofusion group. This difference could be linked with the least quantities (P = 0.036) and durations (P = 0.014) of drainage observed after approaches carried out with electrofusion. On the other hand, the incidence of cutaneous or infectious complications was not different between the 2 groups.Conclusions: In our series, the use of electrofusion decreased the lymphatic complications after a femoral approach. However, the correction of this single parameter was not sufficient to improve the rate of healing at 1 month.