Screening for abdominal aortic aneurysm: time for action.
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Biomedical subjects
Jean-Baptiste Ricco
Publications and source records attributed to Jean-Baptiste Ricco.
Stent-graft repair for thoracic aortic disease: results of an independent nationwide study in France from 1999 to 2001.
BACKGROUND: The purpose of this study was to assess the overall short-term outcome of stent-graft repair for thoracic aortic disease in France between June 1999 and May 2001. METHODS: This retrospective study was designed by the French National Health Insurance Fund for Salaried Workers. To ensure objectivity, data were retrieved at each center and checked by a team of medical advisors. RESULTS: Between June 1999 and May 2001, a total of 166 stent-graft repairs for thoracic aortic disease were performed in 166 patients, mainly by surgeons in the operating room (88%). Patients were classified according to the American Society of Anesthesiologists as status I or II in 24% of cases, status III in 56%, and status IV or V in 20%. The diameter of the thoracic aneurysm was less than 50 mm in 17% of cases. Seventeen patients (10%) died during the first 3 months, including 8 within the first 30 days after the procedure. A total of 49 complications were noted in 34 patients (20.5%). Endoleaks occurred in 27 patients (16.3%), including 8 that necessitated further treatment. Other stent-related complications included rupture (n = 3), aortoesophageal or tracheal fistula (n = 3), paraplegia (n = 6), stent migration (n = 2), visceral embolism (n = 5), and cerebral embolism (n = 2). There were 14 delivery-related complications (8%) at the catheterization site. Non-stent-related complications occurred in 14 (8%). CONCLUSIONS: This nationwide study demonstrates that stent-graft repair for thoracic aortic disease can be performed with acceptable postoperative morbidity. However, it is not a risk-free procedure and should continue to be used in an investigative setting.
Adult↗
Long-duration temporary vena cava filter: a prospective 104-case multicenter study.
BACKGROUND: Nonpermanent caval filters are placed in critical thromboembolic situations in which anticoagulation therapy is transiently contraindicated, ineffective, or the source of complications. The purpose of this study was to assess the safety and effectiveness of a second-generation long-duration temporary caval filter in these situations and compare its utility with that of other temporary filters. METHODS: This prospective study, including patients who underwent temporary caval filtration with the Tempofilter II, was conducted in nine European centers. All filters were successfully implanted. The filter was removed when the indication for caval filtration ceased. RESULTS: A total of 104 filters were inserted in 103 patients with an average age of 60 +/- 15.5 years (range, 22-92 years). Most patients (85%) had pulmonary embolism, deep venous thrombosis, or both. The main indications for caval filter placement were complications of or contraindications to anticoagulation therapy (n = 85; 82.5%) or for ineffectiveness of anticoagulation therapy (n = 12; 11.7%). The average duration of implantation was 29.5 +/- 14.0 days (range, 2-86 days). One filter migrated in the right atrium, followed by pulmonary embolism. No other case of pulmonary embolism or of infectious or mechanical complications related to the filter was observed. Thrombus was trapped within the filter in 24 cases (23.3%). All filters but one were removed, regardless of whether thrombus had been trapped. Retrieval was always successful after implantation periods up to 12 weeks. In 16 cases (15.5%), the filter was replaced by a permanent filter. CONCLUSIONS: The Tempofilter II is safe, effective, and useful in critical thromboembolic situations. It offers a valuable alternative to retrievable optional filters.
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InterGard silver bifurcated graft: features and results of a multicenter clinical study.
OBJECTIVES: Recent research in vascular surgery has focused on development of infection-resistant prosthetic grafts. This article describes the results of a multicenter study to evaluate safety, patency, and infection rates after implantation of the InterGard Silver bifurcated polyester graft coated with collagen and silver. METHODS: Between October 2000 and February 2002, 289 consecutive patients were implanted with a collagen and silver acetate-coated polyester bifurcated graft at 16 French vascular surgery centers. Mean patient age was 65.3 +/- 10.9 years. The indication for prosthetic bypass was aortic aneurysm in 160 patients (55.4%) and symptomatic aortoiliac occlusive disease in 129 (44.6%). All but four patients received prophylactic antibiotic therapy. Patency was assessed at 30 days, 1 year, 2 years, and 3 years, primarily by duplex scan. RESULTS: Two patients (0.7%) died during the first 30 days. Median duration of hospitalization was 11 days. The Kaplan-Meier survival rate at 3 years was 85.7% +/- 4.1%. Primary and secondary patency rates at 3 years were 94.9% +/- 2.6% and 97.5% +/- 1.8%. Thrombectomy was performed successfully in seven patients, and a major amputation was required in two patients with patent grafts. Postoperative complications, including 39 nosocomial infections, were observed in 107 patients (37.0%). Eleven patients presented with 12 wound infections that were classified Szilagyi grade I in eight cases, grade II in two cases, and grade III with graft infection in two cases (0.7%). Among the 149 patients undergoing aortofemoral bypass, eight (5.4%) presented with wound infection, including two graft infections (1.3%). Among the 140 patients undergoing aortoiliac bypass, only three patients (2.1%) presented wound infection and none with graft infection (P = .15). Three (16.7%) of 18 patients who had undergone previous femoral revascularization and eight (3%) of 271 patients without previous femoral revascularization presented with wound infection. This difference was statistically significant (P = .03), with a relative risk of 5.6 (95% confidence interval [CI], 1.6 to 19.5). Five (11.9%) of 42 diabetic patients and six (2.4%) of 247 nondiabetic patients presented with wound infection. This difference was also statistically significant (P = .01), with a relative risk of 3.4 (95% CI, 1.7 to 6.9). Lymphorrhea or lymphocele developed in the groin of 25 patients (8.6%) with negative culture. CONCLUSION: This multicenter prospective study shows that the InterGard Silver graft is safe with no side effects. The primary patency rate was excellent, and the graft infection rate was low, despite a high incidence of nosocomial infections.
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Surgical revascularization of renal artery after complicated or failed percutaneous transluminal renal angioplasty.
PURPOSE: The purpose of this study was to evaluate the feasibility and effectiveness of surgical reconstruction of the renal artery after complicated or failed percutaneous transluminal renal angioplasty (PTRA). METHODS: This was a retrospective study of 45 consecutive patients who were referred to our centers for surgical renal artery reconstruction after 52 complicated or failed PTRA procedures performed between 1980 and 2003. There were 27 women and 18 men, with a median patient age of 28 years (25th percentile, 13.5 years; 75th percentile, 59.5 years). The mean number of PTRA per artery per patient was 1.4 +/- 0.6. Renal artery stenosis was due to arterial fibrodysplasia in 25 patients, atherosclerosis in 17, and inflammatory arteritis in three. RESULTS: Forty-eight renal artery revascularizations were performed (3 bilateral). The procedure consisted of in situ surgery in 38 patients (79%) and extracorporeal repair in 10 (21%). Primary nephrectomy was required in three patients. One patient did not undergo surgical repair after failed PTRA because of kidney atrophy. Major technical problems were encountered during surgical revascularization in 14 (74%) of the 19 patients treated after complicated PTRA and in four (12%) of the 33 patients treated after failed PTRA. Multiple organ failure led to one death on postoperative day 90 in a patient with atherosclerosis and severe kidney insufficiency. Postoperative thrombosis of the repaired renal artery led to kidney loss in three patients, but only one patient required secondary nephrectomy. Primary patency for the overall series of renal revascularizations was 93.5% +/- 6.5% at 5 years. CONCLUSION: Surgical reconstruction after complicated or failed PTRA is feasible and effective and allows kidney salvage in most patients. Technical problems during surgical revascularization may require extracorporeal repair in some patients. The results of this study underline the need for careful patient selection and skillful PTRA technique.
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Totally laparoscopic aortic repair: a new device for direct transperitoneal approach.
On the basis of our experience with more than 71 cases of totally laparoscopic aortic surgery by the retrocolic approach, we have developed a new technique by a simple transperitoneal approach. The purpose of this report is to describe that technique and the novel laparoscopic bowel retractor used to ensure stable exposure of the aorta.
Aorta, Abdominal↗
Modalities of surveillance after carotid endarterectomy: impact of surgical technique.
The purpose of this study was to assess the need for follow-up duplex scan (DS) 1 year after carotid endarterectomy (CE) performed with prosthetic patching and intraoperative completion arteriography. Between April 1994 and December 2000, a total of 605 CE procedures with prosthetic patch closure and intraoperative completion arteriography were performed in 540 patients. All patients underwent DS at 4 days and then yearly after the procedure. Five patients died during the early postoperative course and eight suffered a nonfatal stroke (combined neurological morbidity-mortality rate, 2.4%). Intraoperative completion arteriography showed abnormalities in 114 cases, including 17 involving the internal carotid artery (ICA) and 73 involving the external carotid artery (ECA). Successful revision was achieved in all cases and confirmed by repeat arteriography. Postoperative DS at 4 days detected three abnormalities involving the ICA (0.5%), including asymptomatic occlusion in one case and residual stenosis >50% in two cases. Ninety-eight percent of patients were stenosis-free at 1 year. Actuarial stroke-free survival was 98.3% at 3 years. Diameter reduction of the contralateral carotid artery progressed over 70% within 1 year after CE in 22.9% of patients with contralateral carotid stenosis over 50% at the time of the initial intervention. The findings of this study indicate that DS follow-up 1 year after CE with intraoperative completion arteriography is unnecessary unless postoperative DS demonstrates residual stenosis of the ICA. However, DS at 1 year is beneficial for patients presenting with contralateral carotid artery disease with diameter reduction >50% at the time of CE.
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Carotid bypass with polytetrafluoroethylene grafts: a study of 110 consecutive patients.
BACKGROUND: Carotid endarterectomy (CEA) is the standard treatment for atherosclerotic lesions involving the carotid bifurcation. However, CEA can be challenging under some conditions. We describe the technique and outcome of prosthetic carotid bypass grafting (PCB) with polytetrafluoroethylene (PTFE) grafts as an elective alternative to CEA. PATIENTS AND METHODS: This retrospective analysis of prospectively collected data came from a series of 110 consecutive PCBs, that is, 9.6% of 1140 carotid revascularization procedures performed in our department between September 1986 and July 2002. Primary indications for PCB were extensive atherosclerotic lesions (n = 45, 40.9%), carotid stenosis associated with kinking (n = 29, 26.4%), recurrent stenosis (n = 18, 16.4%), and stenosis after radiation therapy (n = 7, 6.4%). RESULTS: The combined stroke and death rate at 30 days was 0.9%. Mean duration of follow-up was 647 +/- 71 days. Four carotid bypass grafts (3.6%) became occluded, and stenosis recurred in 1 (0.9%). At 3 years, overall actuarial survival was 81.4 +/- 11.5 and actuarial stroke-free rate was 97.7 +/- 2.3. There were no fatal strokes. CONCLUSION: PCB is a viable technique for treatment of extensive atherosclerotic carotid lesions, recurrent carotid stenosis, and carotid stenosis after radiation therapy. Postoperative stroke, occlusion, and recurrent stenosis rates are comparable to those associated with CEA performed under optimal conditions.
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Use of abdominal aortic endovascular prostheses in France from 1999 to 2001.
BACKGROUND: Since the introduction of endovascular repair (EVR) for infrarenal abdominal aortic aneurysm (AAA), clinical evaluation has been under way in many countries throughout the world. The main purpose of this retrospective study was to determine outcome of EVR with aortic endovascular prostheses (AEPs) and to evaluate the extent to which French practitioners have complied with regulatory and clinical guidelines for the use of these trial devices. METHODS: This retrospective study was conducted by the French National Health Insurance Fund for Salaried Workers. Data were compiled on EVR procedures performed at health care institutions all over mainland France between June 1999 and May 2001. RESULTS: A total of 1012 AEPs were deployed for AAA repair in France during the study period. Only 151 (14.9%) of these EVR procedures were carried out within an approved investigational setting with informed patient consent. Only 149 of the 861 patients (17.3%, 95% confidence interval [CI], 14.9 to 19.9%) who underwent endovascular repair in noninvestigational settings signed informed consent forms. In 452 cases (46.5%), the diameter of the AAA was 50 mm or less. Complete outcome data for the first year were available for 891 patients (88%). Complications occurred in 177 of these patients (19.9%, 95% CI, 17.3 to 22.6%). There were a total of 47 deaths (5.3%, 95% CI, 3.9 to 6.9%), including 27 during the first 30 postoperative days. Other major events during the first year after AEP implantation were ruptured AAA in 5 patients, conversion to open operation in 15, and additional endovascular treatment in 52. Data on clinical surveillance were available for 987 patients (97.5%) with a mean follow-up of 345 days. Only 294 patients (29.8%, 95% CI, 27.0 to 32.7%) underwent complete imaging within the first month after AEP implantation. A total of 184 patients (18.6%, 95% CI, 16.3 to 21.2%) received no surveillance at all. CONCLUSION: This study shows the need for improvement in the clinical evaluation of new devices and medical technologies in France. Study findings also confirm the significant incidence of adverse outcomes and necessity for routine surveillance after EVR of AAA with AEP. However, risk/benefit analysis is difficult because most procedures were not carried out within a proper investigational context.
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Endovascular repair of abdominal aortic aneurysm: one-year results of the French AneuRx trial.
The purpose of this prospective study was to evaluate the results of abdominal aortic aneurysm (AAA) repair using the Medtronic AneuRx endovascular stent graft. Forty-seven patients presenting with asymptomatic AAA were recruited in 17 French vascular centers. The mean age of these patients was 72.2 +/- 7.8 years (range, 54 to 85.2 years). Indications were validated by an independent committee and all procedures were supervised by a trained medicotechnical assistant. Clinical data and follow-up imaging were also reviewed by an independent committee. The primary end point was successful implantation, defined as exclusion of the aneurysm without mortality, morbidity, or reintervention. The secondary end point was durable exclusion at 1 year, assessed by serial computed tomography (CT scan). Implantation of the AneuRx endovascular stent graft in this series of highly selected patients was associated with no mortality and low morbidity. One-year follow-up findings showed reduction in aneurysm diameter in 45% of patients. This finding indicates that endovascular treatment is effective. However, observation of stable aneurysm diameter in 50% and increased aneurysm diameter in 5% suggests that careful, indefinite follow-up surveillance is necessary.
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