Objectives/Background ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus) is a prospective multicentre randomized controlled trial including consecutive patients with ...ruptured aorto-iliac aneurysms (rAIA) eligible for treatment by either endovascular (EVAR) or open surgical repair (OSR). Inclusion criteria were hemodynamic stability and computed tomography scan demonstrating aorto-iliac rupture. Methods Randomization was done by week, synchronously in all centers. The primary end point was 30 day mortality. Secondary end points were post-operative morbidity, length of stay in the intensive care unit (ICU), amount of blood transfused (units) and 6 month mortality. Results From January 2008 to January 2013, 107 patients (97 men, 10 women; median age 74.4 years) were enrolled in 14 centers: 56 (52.3%) in the EVAR group and 51 (47.7%) in the OSR group. The groups were similar in terms of age, sex, consciousness, systolic blood pressure, Hardman index, IGSII score, type of rupture, use of endoclamping balloon, and levels of troponin, creatinine, and hemoglobin. Delay to treatment was higher in the EVAR group (2.9 vs. 1.3 hours; p < .005). Mortality at 30 days and 1 year were not different between the groups (18% in the EVAR group vs. 24% in the OSR group at 30 days, and 30% vs. 35%, respectively, at 1 year). Total respiratory support time was lower in the EVAR group than in the OSR group (59.3 hours vs. 180.3 hours; p = .007), as were pulmonary complications (15.4% vs. 41.5%, respectively; p = .050), total blood transfusion (6.8 vs. 10.9, respectively; p = .020), and duration of ICU stay (7 days vs. 11.9 days, respectively; p = .010). Conclusion In this study, EVAR was found to be equal to OSR in terms of 30 day and 1 year mortality. However, EVAR was associated with less severe complications and less consumption of hospital resources than OSR.
Objectives The aim of this work was to study physiological aortic arch three-dimensional displacement using non-rigid registration methods and magnetic resonance imaging (MRI). Materials and methods ...Ten healthy volunteers underwent thoracic MRI. Prospective cardiac gating was performed with a 3D turbo field echo sequence to obtain end-systolic and end-diastolic MR images. The rigid and elastic behavior between these two cardiac phases was detected and compared using either an affine or an elastic registration method. To assess reproducibility, a second MRI acquisition was performed 14 days later. Results Affine registration between the end-systolic and end-diastolic MR images showed significant global translations of the aortic arch and the supra-aortic vessels in the x, y, and z directions (2.02 ± 1.6, −0.71 ± 1.1, and −1.21 ± 1.4 mm, respectively). Corresponding elastic registration indicated significant local displacement with a vector magnitude of 5.1 ± 0.89 mm for the brachiocephalic artery (BCA), of 4.26 ± 0.83 mm for the left common carotid artery (LCCA), and of 4.8 ± 0.86 mm for the left subclavian artery (LSCA). There was a difference in displacement between the supra-aortic trunks of the order of 2 mm. Vector displacement was not statistically different between the repeated acquisitions. Conclusions The present results showed important deformations in the ostia of supra-aortic vessels during the cardiac cycle. It seems that aortic arch motions should be taken into account when designing and manufacturing fenestrated endografts. The elastic registration method provides more precise results, but is more complex and time-consuming than other methods.
The authors sought to determine in a retrospective analysis whether carotid plaque soft TD on CT is associated with recent ischemic neurologic events. Among 141 patients (99 asymptomatic), 106 ...plaques with more than 50% stenosis were selected for density measurements. They found an odds ratio for neurologic events associated with a 10-point decrease in density of 1.54 (p = 0.002), showing an association between plaque density and neurologic events.
Summary Purpose To evaluate the agreement and diagnostic accuracy of Contrast enhanced magnetic resonance angiography (CE-MRA), Doppler ultrasound (DUS) and Digital subtraction angiography (DSA) in ...the assessment of carotid stenosis. Methods DUS, CE-MRA and DSA were performed in 56 patients included in the Carotide-angiographie par résonance magnétique-échographie-doppler-angioscanner (CARMEDAS) multicenter study with a carotid stenosis ≥ 50%. Three readers evaluated stenoses on CE-MRA and DSA (NASCET criteria). Velocities criteria were used for stenosis estimation on DUS. Results CE-MRA had a sensitivity and specificity of 96–98% and 66–83% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 94% and 76–84% respectively for carotid stenoses ≥ 70%. The interobserver agreement of CE-MRA was excellent, except for moderate stenoses (50–69%). DUS had a sensitivity and specificity of 88 and 75% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 83 and 86% respectively for carotid stenoses ≥ 70%. Combined concordant CE-MRA and DUS had a sensitivity and specificity of 100 and 85–90% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 96–100% and 80–87% respectively for carotid stenoses ≥ 70%. The positive predictive value of the association CE-MRA and DUS for carotid stenoses ≥ 70% is calculated between 77 and 82% while the negative predictive value is calculated between 97 and 100%. CE-MRA and DUS have concordant findings in 63–72%, and the overestimations cases were recorded only for carotid stenosis ≤ 69%. Conclusion Combined DUS–CE-MRA is excellent for evaluation of severe stenosis but remains debatable in moderate stenosis (50–69%) due to the risk of overestimations.
Background
The benefits of endovascular repair of ruptured abdominal aortic aneurysm remain controversial, without any strong evidence about advantages in specific subgroups.
Methods
An ...individual‐patient data meta‐analysis of three recent randomized trials of endovascular versus open repair of abdominal aortic aneurysm was conducted according to a prespecified analysis plan, reporting on results to 90 days after the index event.
Results
The trials included a total of 836 patients. The mortality rate across the three trials was 31·3 per cent for patients randomized to endovascular repair/strategy and 34·0 per cent for those randomized to open repair at 30 days (pooled odds ratio 0·88, 95 per cent c.i. 0·66 to 1·18), and 34·3 and 38·0 per cent respectively at 90 days (pooled odds ratio 0·85, 0·64 to 1·13). There was no evidence of significant heterogeneity in the odds ratios between trials. Mean(s.d.) aneurysm diameter was 8·2(1·9) cm and the overall in‐hospital mortality rate was 34·8 per cent. There was no significant effect modification with age or Hardman index, but there was indication of an early benefit from an endovascular strategy for women. Discharge from the primary hospital was faster after endovascular repair (hazard ratio 1·24, 95 per cent c.i. 1·04 to 1·47). For open repair, 30‐day mortality diminished with increasing aneurysm neck length (adjusted odds ratio 0·69 (95 per cent c.i. 0·53 to 0·89) per 15 mm), but aortic diameter was not associated with mortality for either type of repair.
Conclusion
Survival to 90 days following an endovascular or open repair strategy is similar for all patients and for the restricted population anatomically suitable for endovascular repair. Women may benefit more from an endovascular strategy than men and patients are, on average, discharged sooner after endovascular repair.
Strong evidence of equivalence
Objectives: To evaluate the outcomes of ischemic diabetic foot lesions for which distal arterial bypass grafting was considered as the first-line vascular procedure.
Patients and Methods: Between ...November 2004 and November 2006, 19 lower limbs of 17 diabetic patients with lower limb critical ischemia were operated in our department. The bypass grafts included five femoro-popliteal bypass grafts below knee and 14 distal bypass grafts. The 14 distal bypass grafts included; seven venous grafts on the dorsalis pedis artery, four femorotibial pTfE grafts and three femoroperoneal grafts. Arterio-venous fistula was applied to the distal anastomosis site in three limbs.
Results: At the time of discharge, the graft patency rate was 93.75%. The mean follow up period was 24 months. The primary cumulative patency rate was 63% at 2 year. The corresponding secondary patency rate was 87%. Among six ischemic ulcers, four ulcers healed within 2 to12 months (66.6%). At 24 months, the cumulative rate of limb salvage was 76% and that of survival was 74%.
Conclusion: Distal arterial bypass in diabetic lower limb ischemia improves blood circulation that accelerates foot ulcer healing. It can also avoid amputation or lower its level, and thus improving the patient's quality of life.
Background
The aim of this study was to develop a 48‐h mortality risk score, which included morphology data, for patients with ruptured abdominal aortic aneurysm presenting to an emergency ...department, and to assess its predictive accuracy and clinical effectiveness in triaging patients to immediate aneurysm repair, transfer or palliative care.
Methods
Data from patients in the IMPROVE (Immediate Management of the Patient With Ruptured Aneurysm: Open Versus Endovascular Repair) randomized trial were used to develop the risk score. Variables considered included age, sex, haemodynamic markers and aortic morphology. Backwards selection was used to identify relevant predictors. Predictive performance was assessed using calibration plots and the C‐statistic. Validation of the newly developed and other previously published scores was conducted in four external populations. The net benefit of treating patients based on a risk threshold compared with treating none was quantified.
Results
Data from 536 patients in the IMPROVE trial were included. The final variables retained were age, sex, haemoglobin level, serum creatinine level, systolic BP, aortic neck length and angle, and acute myocardial ischaemia. The discrimination of the score for 48‐h mortality in the IMPROVE data was reasonable (C‐statistic 0·710, 95 per cent c.i. 0·659 to 0·760), but varied in external populations (from 0·652 to 0·761). The new score outperformed other published risk scores in some, but not all, populations. An 8 (95 per cent c.i. 5 to 11) per cent improvement in the C‐statistic was estimated compared with using age alone.
Conclusion
The assessed risk scores did not have sufficient accuracy to enable potentially life‐saving decisions to be made regarding intervention. Focus should therefore shift to offering repair to more patients and reducing non‐intervention rates, while respecting the wishes of the patient and family.
Not much help
Objectives: to assess the prognosis of atherosclerotic popliteal aneurysms (APAs), according to whether they were occluded or patent at the time of diagnosis. Design: retrospective study. Patients ...and methods: fifty-two APAs were investigated in 35 patients. Nineteen were occluded (group I) and 33 patent (group II). In group I, 11 lower limbs had critical ischaemia, and eight had severe claudication. In group II, 27 were asymptomatic, 3 were painful, and 3 presented with symptomatic distal occlusion. In group I, treatment consisted of six bypasses, five thrombectomies, four thrombolyses, but for five APAs, no revascularisation was possible due to lack of runoff. In group II, 30/33 APAs were treated by graft replacement; the other three were not operated on due to the patients» poor general condition. Results: the 4-year survival rate was 72% in group I vs. 77% in group II, and the limb salvage rate was 72% in group I vs. 100% in group II, p<0.01. Conclusion: prophylactic treatment of asymptomatic popliteal aneurysms may avoid amputation caused by thrombosis and embolisation of runoff.
In order to show the value of CT angiography in the pretherapeutic assessment of lower leg ischemia, we studied 93 CT angiographies in 85 patients. Two groups were defined according to the level of ...revascularization: 52 angioscanner were made prior to suprainguinal revascularization and 41 prior to infrainguinal reconstruction. Two decision attitudes were chosen by two different physicians, a radiologist and vascular surgeon, members of the same team. The attitudes where then compared in order to evaluate the value of CT angiography. The first attitude was a pragmatic strategy based on the images as interpreted by the first physician and on the intraoperative information including surgical treatment and, if necessary, angiography. This indicates that the results of this attitude cover the performed revascularizations. The second attitude determined a virtual strategy and was chosen by the second physician a posteriori, based solely on the medical file with the same CT angiography images. These two strategies were compared in order to assess the agreement on the level of the lesion and the choice of revascularization. In 84 CT angiographies (90.3%), the analysis of the lesions and the choice of lesions to be treated were identical. In 9.6% of scans the strategies were not comparable because the lesions were interpreted differently or the scans were difficult to read. The sensitivity of CT angiography in detecting lesions and guiding the therapeutic strategy was 96% and its positive predictive value was 93%. Follow-up was reported according to the life-table method to assess the overall outcome and the results in both groups. The overall survival rate at 12 months for 85 patients was 90%. Secondary patency rates at 12 months in the group of patients who underwent a suprainguinal and infrainguinal revascularization were 98% and 71% respectively. Overall limb salvage at 12 months was 94%. In this setting, CT angiography allowed us to select adequate treatment in the majority of cases. These results obtained after a strategy based on CT angiography images are comparable with the results as published in the literature after the strategy based on conventional angiography.
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