vaatheelkunde

VAATHEELKUNDE
APPELDOORN C.C.M., BONNEFOY A., LUTTERS B.C.H.,
DAENENS K., VAN BERKEL T.J.C., HOYLAERTS M.F.,
BIESSEN E.A.L.: Gallic acid antagonizes P-selectinmediated platelet-leukocyte interactions. Implications for
the French paradox. Circulation, 2005; 111(1): 106-112.
Background: Current paradigm attributes the low
incidence of cardiovascular disorders in Mediterranean
countries despite a high saturated fat intake, the "French
paradox," to the antioxidant capacity of red wine
polyphenols. Conceivably, other anti-inflammatory
pathways may contribute to at least a similar extent to
the atheroprotective activity of these polyphenols. We
have investigated whether gallic acid (GA), an abundant
red wine polyphenol, modulates the activity of P-selectin,
an adhesion molecule that is critically involved in the
recruitment of inflammatory cells to the vessel wall and
thus in atherosclerosis.
Methods and Results: GA potently inhibited the binding
of a peptide antagonist (IC50, 7.2 micromol/L) and biotinPAA-Le(a)-SO3H, an established high-affinity ligand, to
P-selectin (IC50, 85 micromol/L). Under dynamic flow
conditions, GA markedly and dose dependently
attenuated the rolling of monocytic HL60 cells over Pselectin-transfected Chinese hamster ovary cells (EC50,
14.5 micromol/L) while increasing the velocity of Pselectin-dependent rolling of human blood leukocytes
over a platelet monolayer. In vivo tests established that
GA administration to normolipidemic C57/Bl6 and aged
atherosclerotic apolipoprotein E-deficient mice impaired
the baseline rolling of conjugates between activated
platelets and circulating monocytes over femoral vein
endothelium, as judged by online video microscopy
(ED50, 1.7+/-0.3 and 1.5+/-0.4 mg x kg(-1) x h(-1),
respectively).
Conclusions: Our findings provide a solid mechanistic
foundation through which GA intervenes in major
inflammatory pathobiologies by binding and antagonizing
P-selectin.
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BOSIERS M., PEETERS P., ELST V.F., VERMASSEN F,
MALEUX G., FOURNEAU I., MASSIN H.: Excimer laser
assisted angioplasty for critical limb ischemia: results of
the LACI Belgium Study. Eur. J. Vasc. Endovasc. Surg.,
2005; 29: 613-619.
Background: The purpose of this study was to assess
the safety and efficacy of translating into national
practice methodology for infrainguinal excimer laserassisted angioplasty, for the treatment of critical limb
ischemia in poor surgical bypass candidates.
Methods: A prospective five centre Belgian registry
enrolled 48 patients, who presented with 51 chronic
critically ischemic limbs (Rutherford category 4, 5 or 6)
and were poor candidates for bypass surgery. Treatment
included crossing the occlusion or stenosis by
conventional guidewire followed by excimer laser
angioplasty with, or without, adjunctive balloon
angioplasty or stenting. A step-by-step technique was
used in cases where the guidewire could not pass the
occluded site. The primary endpoint was limb salvage, at
6 months, of the treated limb.
Results: Initial treatment was successful in all 51 limbs.
By 6 months there had been six deaths, six minor and
four major amputations and further intervention was
required in four patients. Among survivors, limb salvage
rate at 6 month was 38/42 (90.5%), with freedom from
critical limb ischemia in 86%.
Conclusions: This Belgian study of excimer laser
assisted angioplasty, in high-risk patients who were poor
candidates for surgical re-vascularisation, had a low
incidence of surgical re-interventions and limb salvage
rate in excess of 90%.
DAENENS K., MALEUX G., FOURNEAU I., NEVELSTEEN A.:
Hemobahn stent-grafts in the treatment of femoropopliteal
occlusive disease. J. Cardiovasc. Surg., 2005; 46: 25-29.
Aim: The aim of this study was to determine our results
and indications for the Hemobahn stent-graft in
femoropopliteal occlusive disease.
Methods: Since 1999, 38 patients with femoropopliteal
occlusive disease in 40 legs have been treated by
endovascular dilation or recanalisation and additional
endografting. All have been followed up prospectively at
6 month intervals by clinical examination, Doppler and
duplex.
Results: In 40 legs, 15 high grade stenoses were dilated
and 25 occlusions needed first recanalization. Additional
Hemobahn stent-graft deployment was successful in all
cases (total grafts n=60). The median length of the
stented segment was 15 cm. Immediate complications
during the procedure were stent-graft thrombosis (n=1)
and distal embolization (n=3), instantly treated with
thrombolysis and thrombus aspiration. The median
ankle-brachial index in rest increased from 0.5
preoperatively to 1 postoperatively. With a median
follow-up time of 28.2 months (range from 1 to 48
2
months), there were 4 high grade stenoses and 13 stentgraft occlusions (1 year primary patency rate of 66%). All
4 stenoses were treated with balloon dilation (1 year
assisted primary patency rate of 76%) and 4 of the
occluded grafts were recovered by thrombectomy (n=1)
or thrombolysis (n=3), resulting in a 1 year secondary
patency rate of 87%.
Conclusions: The Hemobahn stent-graft can be used in
the treatment of femoropopliteal occlusive disease with a
low complication rate and acceptable patency rates in
the short-term. We had the best results when there was
no recanalization needed before.
FOURNEAU
I.,
DAENENS
K.,
NEVELSTEEN
A.:
Conventional versus video-assisted aortic surgery: a
randomized study. In: Controversies and updates in vascular
surgery. Eds.: J.P. Becquemin, Y.S. Alimi, J. Watelet, Edizioni
Minerva Medica, Torino, 2005:216-221.
To minimize the learning curve of totally laparoscopic
aortic surgery and to make it more accessable for the
whole vascular society, hand-assisted laparoscopy
(HALS) was introduced for aortic-iliac procedures.
However, skepticism arised whether HALS was less
invasive than conventional open surgery as HALS still
requires a minilaparotomy and as the wound edges are
stretched throughout the procedure.
Therefore we performed a prospective randomized trial
of HALS versus conventional open surgery for patients
with
severe
aortic-iliac
disease,
necessitating
aortobifemoral bypass grafting, to study immediate
clinical outcome of HALS compared with conventional
open surgery.
According to these data, we could conclude that for
aortic-iliac reconstructions HALS is a very accessible,
but still minimal invasive technique resulting in an earlier
return to oral diet and a shorter length of stay.
HALS should be considered as a useful adjunct to
overcome the learning curve of totally laparoscopic
aorto-iliac surgery, especially for those vascular
surgeons not familiar with laparoscopy.
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FOURNEAU I., DAENENS K., NEVELSTEEN A.: Handassisted laparoscopic aortobifemoral bypass for occlusive
disease. Early and mid-term results. Eur. J. Vasc. Endovasc.
Surg., 2005; 30(5): 489-493.
Objectives: To evaluate the early and mid-term results of
hand-assisted laparoscopic surgery (HALS) for aortoiliac reconstruction.
Design: Prospective survey.
Materials and methods: Between February 2002 and
January 2004, 46 patients received an aortobifemoral
bypass for advanced occlusive disease by HALS.
Result: There was one conversion to open surgery.
Mortality was 4.5%. The median return to solid oral diet
took 36h (24-182), the median hospital stay was 5 days
(3-26). Primary patency rate at 1 year was 97.5%. The
incidence of incisional hernia was 19.5%.
Conclusions: HALS aorto-iliac reconstruction should be
considered as a minimal invasive technique with good
early and mid-term results.
GEUSENS E., PANS S., PRINSLOO J., FOURNEAU I.: The
widened mediastinum in trauma patients. Eur. J.
Emergency Med., 2005; 12(4): 179-184.
Mediastinal widening is a frequent radiological finding in
the emergency department patient. The causes of
mediastinal widening can be divided into traumatic and
nontraumatic mediastinal widening. An important
association of moderate to high velocity trauma is the
mediastinal haematoma. It may be the result of traumatic
transsection of the aorta, or it may be due to bleeding
from other mediastinal vessels. Before the era of
multidetector spiral CT, angiography was the gold
standard for the evaluation of patients with a widened
mediastinum. Meanwhile, angiography as a risk-carrying
invasive examination has widely been replaced by
MDCT. However, conventional radiography remains an
important diagnostic tool; so does angiography,
especially in the context of interventional radiology.
Multidetector spiral CT plays an important role (Alkadhi
et al., Radiographics 2004; 24:1239-1255), but usually
as a second line procedure. This article discusses the
radiological signs of traumatic mediastinal widening.
Different traumatic lesions resulting in a widened
mediastinum are presented, and some nontraumatic
causes of a widened mediastinum are shown, in order to
facilitate the differentiation between both entities.
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HEYE S., NEVELSTEEN A., MALEUX G.: Internal iliac artery
coil embolization in the prevention of potential type 2
endoleak after endovascular repair of abdominal aortoiliac
and iliac artery aneurysms: effect of total occlusion versus
residual flow. J. Vasc. Interv. Radiol., 2005; 16: 235-239.
Purpose: To evaluate whether the presence of type 2
endoleak after internal iliac artery (IIA) coil embolization
in patients with residual antegrade flow through the coils
is more frequent than in patients who presented with
total occlusion of the IIA after embolization.
Materials and methods: Records were reviewed of 45
patients who underwent unilateral (n = 37) or bilateral (n
= 8) IIA coil embolization between 1998 and 2004 for
endovascular repair of aortoiliac aneurysms (n = 32),
iliac artery aneurysms (n = 12), pseudoaneurysm (n = 1),
or distal type 1 endoleak after placement of an aortoiliac
stent-graft (n = 8). A total of 53 IIAs were embolized by
means of coils and/or microcoils. Computed tomography
(CT) was used for follow-up in 40 patients, angiography
was used in three, and color Doppler ultrasonography
was used in three.
Results: At the end of the embolization procedure, 23
IIAs were occluded and 30 IIAs demonstrated residual
antegrade flow through the coils. Control CT
demonstrated two type 2 endoleaks after endovascular
stent-graft placement resulting from retrograde blood
flow into the left IIA main branch via a patent illiolumbar
artery. One of these two patients showed residual
antegrade flow through the coils at the end of the IIA
embolization procedure, and the other patient underwent
complete coil embolization of the ostia of the anterior
posterior division but not of the main trunk of an
aneurysmal IIA.
Conclusion: IIA coil embolization with residual antegrade
flow through the coils causes no greater incidence of
type 2 endoleak after aortoiliac or iliac stent-graft
placement. However, care must be taken in case of a
proximal postostial origin of the iliolumbar artery on the
IIA, which may cause type 2 endoleak if not embolized.
KHODJA H., FEUGIER P., FAVRE J.P., NEVELSTEEN A.,
FERREIRA J.: Traitement chirurgical conventionnel des
anévrysmes de l’aorte abdominale sous-rénale: prothèse
tubulaire versus bifurquée. In: Actualités de Chirurgie
Vasculaire. Traitement des anévrysmes de l’aorte abdominale.
Eds. E. Kieffer, F. Koskas. Editions AERCV, 2005: 57-64.
L’analyse de la littérature et notre étude montrent que
dans le cadre de la chirurgie des AAA, la mise en place
d’une prothèse tubulaire est justifiée même en cas de
dilatation modérée (inférieure à 18 mm) des AIC.
L’utilisation systématique d’une prothèse bifurquée au
cours de cette chirurgie ne nous paraît donc pas
justifiée. Les anévrysmes iliaques communs de diamètre
pré-opératoire supérieur ou égal à 25 mm augmentent
plus rapidement de taille et doivent être traités dans le
même temps opératoire que l’AAA par la pose d’une
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prothèse bifurquée. Le potentiel évolutif des AIC de
diamètre supérieur ou égal à 18 mm et inférieur à 25 mm
justifie l’utilisation d’une prothèse bifurquée si le
diamètre de l’aorte coeliaque est supérieur à 25 mm ou
si l’espérance de vie du malade est supérieure ou égale
à 8 ans.
LANGE C., HOBO R., LEURS L.J., DAENENS K., BU TH J.,
MYHRE H.O., on behalf of the Eurostar Collaborators: Results
of endovascular repair of inflammatory abdominal aortic
aneurysms. A report from the Eurostar database. Eur. J.
Vasc. Endovasc. Surg., 2005; 29(4): 363-370.
Objectives: To investigate the results following
endovascular treatment of patients with inflammatory
abdominal
aortic
aneurysms
(IAAA).
Design:
Retrospective study based on the EUROSTAR registry.
Material and methods: Patients included in the
EUROSTAR registry with IAAA (n=52, 1.4%) were
compared to those having aneurysms without aortic
fibrosis (n=3613, 98.6%). The mean follow-up period in
patients with IAAA was 23 months (range 1-60). In 11 of
the patients detailed information on the effect of
endovascular repair and perianeurysmal fibrosis and
ureteral entrapment was obtained by a dedicated
questionnaire.
Results: Twelve patients (23%) with IAAA had
preoperative impairment of renal function and five had
known hydronephrosis. Variables that were significantly
associated with IAAA included younger age (p<.0001,
mean difference 5.9, CI 3.7-7.9) and lower pulmonary
risks score (OR 0.38, CI 0.19-0.74). At completion of the
endovascular procedure, device stenosis was more
frequently observed in patients with IAAA (OR 18.1, CI
3.52-93.0). There were no differences with regard to the
rates of mortality, rupture or conversion in patients with
IAAA and controls. In the majority, the aneurysm size
regressed irrespective of nature of aneurysm. Of the 11
patients with a detailed assessment three had
deterioration of renal function and three still had ureteral
entrapment during follow-up.
Conclusion: Despite persistence of perianeurysmal
inflammation in a proportion of patients operative and
midterm results of endovascular repair were comparable
in the patients with inflammatory and standard AAA.
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MALEUX G., BIELEN D., HEYE S., VAN SCHAEYBROECK P.,
NEVELSTEEN A., VANBECKEVOORT D.: Translumbar
thrombin embolization of an aortic pseudoaneurysm
complicating lumbar disk surgery. J. Vasc. Surg., 2005; 42:
163-167.
We report a case of translumbar embolization of an
aortic pseudoaneurysm complicating lumbar disk
surgery. The iatrogenic pseudoaneurysm was initially
treated by open repair, but due to failure of this
treatment, we opted for direct translumbar thrombin
injection under computed tomography (CT) guidance.
The patient recovered completely, and follow-up CT
scans showed progressive shrinkage of the residual
retroperitoneal hematoma. This minimally invasive
treatment should be considered in selected cases as a
valuable treatment option for pseudoaneurysms that
arise from the aorta.
MALLIET C., FOURNEAU I., DAENENS K., MALEUX G.,
NEVELSTEEN A.: Endovascular stent-graft and first rib
resection for thoracic outlet syndrome complicated by an
aneurysm of the subclavian artery. Acta Chir. Belg., 2005;
105: 194-197.
Purpose: To report our experience with a combined
endovascular and surgical approach for arterial thoracic
outlet syndrome (TOS) complicated by an aneurysm of
the subclavian artery.
Methods: We treated three consecutive patients
suffering from arterial thoracic outlet syndrome
complicated by an aneurysm of the subclavian artery by
the use of a stent-graft and a first rib resection. These
patients were reviewed retrospectively.
Results: At a mean follow-up of 37.3 months all patients
were free of symptoms without late complications.
Conclusions: Endovascular stent-grafting followed by
decompression of the costoclavicular space is an
attractive alternative to the conventional surgical
approach of complicated arterial TOS.
MERTENS J., DAENENS K., FOURNEAU I., MARAKBI A.,
NEVELSTEEN A.: Fibromuscular dysplasia of the superior
mesenteric artery – case report and review of the
literature. Acta Chir. Belg., 2005; 105: 523-527.
Fibromuscular dysplasia is a multifactorial arteriopathy
most commonly affecting the renal and carotid arteries.
In this report we present a case of visceral ischemia.
Treatment consisted of superior mesenteric artery
reimplantation. Visceral artery FMD can present as
occlusive or aneurysmal disease and treatment depends
on patient characteristics and symptoms.
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NEVELSTEEN A., DAENENS K., FOURNEAU I.: Traitement
chirurgical des anévrysmes de l’aorte abdominale: voie
d’abord abdominale versus rétropéritonéale. In: Actualités
de Chirurgie Vasculaire. Traitement des anévrysmes de l’aorte
abdominale. Eds. E. Kieffer, F. Koskas. Editions AERCV, 2005:
45-55
Les données des quatre principales études randomisées
sont résumées dans le tableau VIII. D’après ces études,
il n’y a pas de preuve solide que la voie rétropéritonéale
doit être préférée à la voie transpéritonéale pour la
chirurgie habituelle de l’aorte sous-rénale. Les résultats
péri-opératoires montrent également que les malades ne
sont pas mis en danger par l’une ou l’autre voie d’abord,
bien que deux études aient montré une claire supériorité
de la voie rétropéritonéale en ce qui concerne la
récupération de la fonction gastro-intestinale. Sieunarine
et Coll ont eu la même impression clinique mais leurs
données ne montraient pas de différence significative.
Deux études ont également montré une diminution du
taux global de complications en faveur de la voie
rétropéritonéale. Les données concernant le suivi sont
rapportées dans trois études. Ici, il semble que la voie
rétropéritonéale soit associée à significativement plus de
douleurs cicatricielles et de voussures, éléments qui
doivent être pris en compte en particulier pour les
malades les plus jeunes. Bien qu’il n’y ait pas de
supériorité définie de l’une ou l’autre voie d’abord dans
la chirurgie aortique habituelle, il est clair que la voie
rétropéritonéale a des indications propres bien définies.
Tout chirurgien vasculaire devrait donc se familiariser
aves les deux voies d’abord et les malades seront traités
au mieux lorsque la voie d’abord sera choisie en fonction
des nécessités anatomiques et techniques de chaque
cas particulier.
NEVELSTEEN A., DAENENS K., FOURNEAU I., COPPIN V.:
Ruptured mycotic aortic aneurysm. In: Unexpected
challenges in vascular surgery. Eds. A.Branchereau,
M.Jaqcobs. Blackwell Futura, 2005: 129-142.
Arterial infection represents a rare but dramatic and
often lethal disease. Ambroise Paré described the first
th
case of infected aneurysm in the mid-16 century when
he reported the autopsy findings of a patient with a
ruptured syphilitic aneurysm. In 1885 Sir William Osler
introduced the term mycotic aneurysm to describe these
infected aneurysm, which develop as a result of
embolism from bacterial endocarditis. Since there was
no apparent association with fungal disease, the term
mycotic aneurysm has always been a source of
discussion and confusion among vascular surgeons.
Strictly speaking, the term mycotic aneurysms should be
reserved for infected aneurysms resulting from bacterial
endocarditis complicated by septic arterial emboli or an
infected aneurysm of the sinus of Valsalva resulting from
contiguous spread from an infected aortic valve.
Nonetheless, the majority of the vascular surgeons
8
nowadays keep to the commonly used definition of
mycotic aneurysms to include all kind of infected
aneurysms. In this chapter, we will focus on infected
aneurysms of the thoracic and abdominal aorta, which is,
after the common femoral artery, the most frequent
anatomic location of this kind of disease. Aorto-enteric
fistulas,
postreconstruction
septic
anastomotic
aneurysms and arterial graft infections are excluded.
NEVELSTEEN A., FOURNEAU I., DAENENS K.: Aortoiliac
lesions: vascular options (TASC type D). In: Towards
Vascular and Endovascular Consensus. Editor: Roger M.
Greenhalgh, 2005: 390-401.
TransAtlantic Inter-Society Consensus (TASC) type D
aortoiliac lesions are characterized by diffuse occlusive
involvement of the aortoiliac vessels:
1. diffuse, multiple unilateral stenoses involving the
common iliac artery, the external iliac artery and
common femoral artery (usually over 10 cm in
length);
2. unilateral occlusion, involving both the common iliac
artery and the external iliac artery;
3. bilateral external iliac artery occlusions:
4. diffuse disease involving both the aorta and the iliac
arteries; or
5. iliac stenoses in a patient with an abdominal aortic
aneurysm or other lesion requiring aortic or iliac
surgery.
The vascular solution to these problems – as
recommended in the TASC document – is direct
aortoiliac reconstruction, and aortofemoral prosthetic
bypass remains the prototype. Extra-anatomical
bypasses may be an alternative in selected cases.
Unilateral iliac occlusion might be handled by
axillofemoral or preferably femoro-femoral cross-over
bypass. Axillobifemoral bypass might serve for bilateral
aortoiliac disease.
NEVELSTEEN A., FOURNEAU I., DAENENS K.: The
retroperitoneal approach to the abdominal aorta. Acta Fac.
Med. Naiss., 2005; 22(3): 115-119.
Within the community of the vascular surgeons, it has
always been a matter of debate which surgical approach
is tolerated better by the patient undergoing a
reconstruction of the abdominal aorta. Transperitoneal
approach offers several advantages: 1) simple and very
fast approach (very important in emergency cases), 2)
allows evaluation of the whole intra-abdominal cavity, 3)
it is easy to expose common iliac arteries, iliac
bifurcation and both external iliac arteries, 4)
reconstruction of both renal arteries, as well as visceral
arteries, can be performed from the infrarenal aorta, 5)
inferior mesenteric artery and eventually polar renal
arteries can be incorporated in infrarenal aortic graft.
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Anterolateral retroperitoneal approach, and various
modifications (e.g. extended retroperitoneal) have been
described as a well-accepted alternative to the
transperitoneal approach. In most centers, the
retroperitoneal approach is used actually in well-defined
indication both depending on the patient and the
anatomy of the aortic aneurysm. Disadvantages are also
listed: 1) quite time consuming comparing with
transperitoneal approach which makes it less attractive
in emergency situations, 2) redo-operations might
present a problem, 3) reimplantation of the inferior
mesenteric artery is made more difficult, 4) access to the
right common iliac artery and iliac bifurcation, as well as
right renal artery is cumbersome, 5) retroperitoneal
approach is contraindicated in the presence of venosus
anomalies. The general conclusion might be that none of
the different approaches has a uniform advantage or
disadvantage and that surgeons and their patients will be
served best by both approaches, the choice of which is
primarily dependent on the anatomical and technical
requirements in each individual.
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