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En chirurgie vasculaire, l’accès à l’artère fémorale, qu’il soit par une incision chirurgicale ou par une approche percutanée, est très fréquemment utilisé pour une multitude d’interventions vasculaires ou endovasculaires; pour des pontages divers, le traitement d’occlusions artérielles, la réparation d’anévrismes et la pose d’endoprothèses. L’objectif général de ce projet de recherche est de faciliter et réduire les risques des approches de l’artère fémorale par une meilleure compréhension anatomique du triangle fémoral. La méthodologie a été réalisée grâce à l’utilisation de cadavres spécialement embaumés par la méthode développée par Walter Thiel. Les résultats présentés dans ce mémoire ont permis de proposer des solutions en réponse à des problèmes cliniques en chirurgie vasculaire. Dans un premier temps, l’étude de la vascularisation cutanée du triangle fémoral a mené à proposer de nouvelles incisions chirurgicales afin de limiter la dévascularisation cutanée des plaies et ainsi réduire les problèmes de cicatrisation observés. Ensuite, nous avons validé l’identification radiographique et échographique de l’artère fémorale à son croisement avec le ligament inguinal afin de faciliter l’identification d’un site de ponction artérielle adéquat. Enfin, nous avons développé une méthode échographique simple qui facilite l’approche percutanée de l’artère fémorale, même chez les patients obèses. Les retombées de ce projet de recherche sont multiples pour les cliniciens, l’étude fournit une meilleure compréhension anatomique tridimensionnelle du triangle fémoral et les techniques proposées dans ce mémoire pourront apporter une amélioration de la pratique chirurgicale et faciliter le travail des médecins. Toutefois, ces propositions devront maintenant être validées en clinique. / In vascular surgery, access to the femoral artery is frequently used either through a surgical incision of the groin or by a percutaneous approach in a wide variety of vascular and endovascular procedures; for multiple bypasses, treatment of arterial occlusions, aneurysms repair and placement of various stents. The general purpose of this study is to facilitate and reduces the risks of both the surgical and the percutaneous approaches of the femoral artery through a better anatomical understanding of the femoral triangle. The methodology was conducted on specifically embalmed cadavers according to the method developed by Walter Thiel. The results presented in this memory allowed us to propose solutions to clinical problems in vascular surgery. First, the study of the cutaneous vascularisation of the femoral triangle led to suggest new surgical approaches in order to reduce lesions of the cutaneous arteries and the potential devascularization of the borders of the wound yielding a better postoperative outcome. Then, we validated the radiographic and ultrasonographic position and identification of the inguinal ligament and the proximal femoral artery to facilitate the identification of a safe arterial puncture site. Moreover, we developed a simple method for ultrasound-guided arterial puncture, suitable for obese patients, to facilitate the percutaneous approach of the femoral artery. The benefits of this research project are multiple for clinicians, the study provides a better tridimensional anatomic understanding of the femoral triangle and the techniques proposed will lead to an improved surgical practice and facilitate the work of doctors. However, our work and propositions still need to be validated clinically.

O domínio da técnica de microanastomose vascular é um pré-requisito essencial para a realização de procedimentos microcirúrgicos reconstrutivos, como reimplantes e transferência livre de tecidos. Até hoje, a técnica de sutura convencional é a mais aceita na prática clínica, por sua segurança e versatilidade. Apesar disso, ela apresenta alguns problemas por ser tecnicamente difícil, consumir tempo considerável e causar traumatismo adicional à parede do vaso. O objetivo deste estudo, foi testar um método alternativo de microanastomose arterial, reduzindo o número de pontos de sutura com aplicação do adesivo de fibrina. Sessenta ratos da raça Wistar foram submetidos a microanastomose vascular nas artérias femorais ou carótidas. Os animais foram divididos em quatro subgrupos de acordo com a artéria operada e a técnica de sutura empregada: FSC (femoral - sutura convencional), FAF (femoral - sutura mínima com adesivo de fibrina), CSC (carótida - sutura convencional) e CAF (carótida - sutura mínima com adesivo de fibrina). As duas técnicas de anastomose foram comparadas através de análise estatística dos parâmetros clínicos e histopatológicos. A média de pontos de sutura por anastomose nos subgrupos FSC e CSC foi de 7,7 e 9,5, respectivamente. No subgrupo FAF, as anastomoses foram realizadas com apenas quatro pontos de sutura e no subgrupo CAF, com apenas seis. O tempo de anastomose foi, em média: 15,81 minutos no subgrupo FSC, 13,62 minutos no subgrupo FAF, 18,87 minutos no subgrupo CSC e 17,33 minutos no subgrupo CAF. A aplicação do adesivo de fibrina reduziu, significativamente, o número de pontos e o tempo necessário para realização das anastomoses, nos subgrupos FAF e CAF. A intensidade do sangramento anastomótico também foi reduzida de maneira significativa nestes subgrupos. A freqüência da permeabilidade imediata e tardia foi de 100% em todos os subgrupos, exceto no subgrupo FAF, onde a permeabilidade tardia foi de 93,33%. Não foram observadas diferenças significativas entre as duas técnicas, em relação aos parâmetros histopatológicos avaliados (processo inflamatório, fibrose da camada média e hiperplasia subintimal). O autor concluiu que a técnica de sutura mínima com aplicação do adesivo de fibrina foi mais fácil e rápida que a técnica de sutura convencional, sem aumento da trombogenicidade das anastomoses, no modelo experimental utilizado. / Mastering of the microvascular anastomosis technique is an essencial requirement to perform reconstructive microsurgical procedures, such as replantation surgery and free tissue transfers. Until now, the conventional suture technique is the most widely accepted in the clinical setting, for its safety and versatility. However, this technique presents some problems for being technically difficult, time consuming and causes additional trauma to the vessel wall. The aim of this study was to test an alternative method of microvascular arterial anastomosis, by reducing the number of sutures with application of fibrin adhesive. Sixty Wistar rats underwent to microvascular anastomosis at the femoral or carotid arteries. The animals were divided into four subgroups, according to the operated artery and the employed suture technique: FCS (femoral - conventional suture), FFA (femoral - minimal suture with fibrin adhesive), CCS (carotid - conventional suture) and CFA (carotid - minimal suture with fibrin adhesive). Both anastomosis techniques were compared by means of statistical analisys of the clinical and histopathological parameters. The mean number of sutures required to complete the anastomosis was 7,7 in subgroup FCS and 9,5 in subgroup CCS. In subgroup FFA, the anastomosis was performed with only four sutures and in subgroup CFA, with only six. The mean anastomotic time was 15,81 minutes in subgroup FCS, 13,62 minutes in subgroup FFA, 18,87 minutes in subgroup CCS and 17,33 minutes in subgroup CCS. The application of fibrin adhesive, significantly reduced the number of sutures and the time taken to perform the anastomosis, in subgroups FFA and CFA. The amount of anastomotic bleeding was also significantly reduced in these subgroups. The immediate and late patency rates were 100% in all subgroups, except in subgroup FFA where it was 93,33%. No significant differences were observed among the two techniques, concerning the evaluated histopathological parameters (inflammatory process, medial fibrosis and subintimal hyperplasia). The author concluded that, the fibrin adhesive application with minimal suture technique was faster and easier than the conventional suture technique, without increasing the trombogenicity of the anastomosis, in this experimental model.

O domínio da técnica de microanastomose vascular é um pré-requisito essencial para a realização de procedimentos microcirúrgicos reconstrutivos, como reimplantes e transferência livre de tecidos. Até hoje, a técnica de sutura convencional é a mais aceita na prática clínica, por sua segurança e versatilidade. Apesar disso, ela apresenta alguns problemas por ser tecnicamente difícil, consumir tempo considerável e causar traumatismo adicional à parede do vaso. O objetivo deste estudo, foi testar um método alternativo de microanastomose arterial, reduzindo o número de pontos de sutura com aplicação do adesivo de fibrina. Sessenta ratos da raça Wistar foram submetidos a microanastomose vascular nas artérias femorais ou carótidas. Os animais foram divididos em quatro subgrupos de acordo com a artéria operada e a técnica de sutura empregada: FSC (femoral - sutura convencional), FAF (femoral - sutura mínima com adesivo de fibrina), CSC (carótida - sutura convencional) e CAF (carótida - sutura mínima com adesivo de fibrina). As duas técnicas de anastomose foram comparadas através de análise estatística dos parâmetros clínicos e histopatológicos. A média de pontos de sutura por anastomose nos subgrupos FSC e CSC foi de 7,7 e 9,5, respectivamente. No subgrupo FAF, as anastomoses foram realizadas com apenas quatro pontos de sutura e no subgrupo CAF, com apenas seis. O tempo de anastomose foi, em média: 15,81 minutos no subgrupo FSC, 13,62 minutos no subgrupo FAF, 18,87 minutos no subgrupo CSC e 17,33 minutos no subgrupo CAF. A aplicação do adesivo de fibrina reduziu, significativamente, o número de pontos e o tempo necessário para realização das anastomoses, nos subgrupos FAF e CAF. A intensidade do sangramento anastomótico também foi reduzida de maneira significativa nestes subgrupos. A freqüência da permeabilidade imediata e tardia foi de 100% em todos os subgrupos, exceto no subgrupo FAF, onde a permeabilidade tardia foi de 93,33%. Não foram observadas diferenças significativas entre as duas técnicas, em relação aos parâmetros histopatológicos avaliados (processo inflamatório, fibrose da camada média e hiperplasia subintimal). O autor concluiu que a técnica de sutura mínima com aplicação do adesivo de fibrina foi mais fácil e rápida que a técnica de sutura convencional, sem aumento da trombogenicidade das anastomoses, no modelo experimental utilizado. / Mastering of the microvascular anastomosis technique is an essencial requirement to perform reconstructive microsurgical procedures, such as replantation surgery and free tissue transfers. Until now, the conventional suture technique is the most widely accepted in the clinical setting, for its safety and versatility. However, this technique presents some problems for being technically difficult, time consuming and causes additional trauma to the vessel wall. The aim of this study was to test an alternative method of microvascular arterial anastomosis, by reducing the number of sutures with application of fibrin adhesive. Sixty Wistar rats underwent to microvascular anastomosis at the femoral or carotid arteries. The animals were divided into four subgroups, according to the operated artery and the employed suture technique: FCS (femoral - conventional suture), FFA (femoral - minimal suture with fibrin adhesive), CCS (carotid - conventional suture) and CFA (carotid - minimal suture with fibrin adhesive). Both anastomosis techniques were compared by means of statistical analisys of the clinical and histopathological parameters. The mean number of sutures required to complete the anastomosis was 7,7 in subgroup FCS and 9,5 in subgroup CCS. In subgroup FFA, the anastomosis was performed with only four sutures and in subgroup CFA, with only six. The mean anastomotic time was 15,81 minutes in subgroup FCS, 13,62 minutes in subgroup FFA, 18,87 minutes in subgroup CCS and 17,33 minutes in subgroup CCS. The application of fibrin adhesive, significantly reduced the number of sutures and the time taken to perform the anastomosis, in subgroups FFA and CFA. The amount of anastomotic bleeding was also significantly reduced in these subgroups. The immediate and late patency rates were 100% in all subgroups, except in subgroup FFA where it was 93,33%. No significant differences were observed among the two techniques, concerning the evaluated histopathological parameters (inflammatory process, medial fibrosis and subintimal hyperplasia). The author concluded that, the fibrin adhesive application with minimal suture technique was faster and easier than the conventional suture technique, without increasing the trombogenicity of the anastomosis, in this experimental model.

Introduction: Cardiovascular surgery is a relatively young but progressively evolving field in medicine. More specifically, in the past decades, cardiac surgery achieved significant advances in understanding the causes, progression and treatments of ischemic heart disease (IHD). The IHD is the most common coronary disease, and it ranks first in morbidity and mortality in the developed world. It justifies the need for significant fundamental research as well as its study in clinical practice. It now includes specialized cardiovascular centres with the complex specialized treatments. A group of interventional cardiologists capable of performing routine examinations of the coronary veins using selective angiography has been established. They can eventually also perform percutaneous coronary interventions with direct stent implants. Thus the advances have been made in comprehensive indication of the patients towards their optimal treatments under the regime of a cardio-team. Such team comprises of a cardio-surgeon, interventional cardiologist, echocardiography specialist and the attending physician who is usually the cardiologist. The IHD treatments involve preventive cardiology with the regime measures and checks, pharmacotherapy, interventional cardiology and cardiac surgery to spa treatment and...

Introduction: Cardiovascular surgery is a relatively young but progressively evolving field in medicine. More specifically, in the past decades, cardiac surgery achieved significant advances in understanding the causes, progression and treatments of ischemic heart disease (IHD). The IHD is the most common coronary disease, and it ranks first in morbidity and mortality in the developed world. It justifies the need for significant fundamental research as well as its study in clinical practice. It now includes specialized cardiovascular centres with the complex specialized treatments. A group of interventional cardiologists capable of performing routine examinations of the coronary veins using selective angiography has been established. They can eventually also perform percutaneous coronary interventions with direct stent implants. Thus the advances have been made in comprehensive indication of the patients towards their optimal treatments under the regime of a cardio-team. Such team comprises of a cardio-surgeon, interventional cardiologist, echocardiography specialist and the attending physician who is usually the cardiologist. The IHD treatments involve preventive cardiology with the regime measures and checks, pharmacotherapy, interventional cardiology and cardiac surgery to spa treatment and...

We reviewed 13 cases of ultrasound-guided thrombin injection of femoral pseudoaneurysms. All cases occurred within a 17-month period from January 1998 through May 1999 and were complications of femoral artery puncture. Immediate total thrombosis occurred in nine of 13 patients. Twenty-four-hour follow-up ultrasound in seven patients revealed no recurrence of pseudoaneurysm. Two of 13 patients required operative repair. One pseudoaneurysm thrombosed with 15 minutes of compression after injection and one case required a second injection. No cases of arterial thrombosis were noted. Ultrasound-guided thrombin injection for femoral artery pseudoaneurysm represents a safe and effective alternative to operative repair.

Η οπτική συνεκτική τομογραφία με τη χρήση συχνοτήτων ( FD-OCT) είναι μια ενδαγγειακή απεικονιστική μέθοδος που χρησιμοποιεί εγγύς στο υπέρυθρο φως, για να παράγει υψηλής ανάλυσης εικόνες του τοιχώματος του αυλού του αγγείου. Όπως και στην τεχνολογία υπερήχων, εκπέμπεται φωτεινή ενέργεια η οποία ανακλάται και εξασθενεί, σύμφωνα με την υφή του προσπιπτομένου ιστού. Το OCT μπορεί να απεικονίσει, με ανάλυση από 10 έως 20 μm, μικροδομές του αγγειακού τοιχώματος με εξαίσια λεπτομέρεια. Μέχρι σήμερα, η δυνατότητα εφαρμογής της μεθόδου είχε περιοριστεί σε μικρές αρτηρίες διαμέτρου έως 4mm και δεν είχε εφαρμοστεί in vivo στα αγγεία των κάτω άκρων, κάτωθεν του επιπέδου των βουβώνων. Σκοπός της παρούσας μελέτης είναι να αναφερθεί για παγκοσμίως πρώτη φορά η ασφάλεια και η σκοπιμότητα της απεικόνισης με Οπτική Συνεκτική Τομογραφία του αρτηριακού άξονα των κάτω άκρων , κάτωθεν του επιπέδου της βουβώνας ( μηροϊγνυακός άξονας και κνημιαία αγγεία), καθώς και οι σχετιζόμενες με το FD-OCT επιπλοκές. Επιπρόσθετα, να διερευνηθούν για πρώτη φορά, με τη χρήση FD-OCT, τα χαρακτηριστικά του αγγειακού τοιχώματος του ανωτέρω άξονα (τόσο πριν όσο και μετά από αγγειοπλαστική ή/και τοποθέτηση stent), η μορφολογία της αθηρωματικής πλάκας, η μορφολογία και η ποσοτικοποίηση της υπερπλασίας του νέου εσωτερικού χιτώνα (neointima) εντός του stent, η επαναστένωση εντός του stent (ISR) και η κακή εναπόθεση (malapposition) των stent struts σε μια σειρά από ασθενείς που πάσχουν από περιφερική αρτηριοπάθεια (PAD). Μελετήθηκαν, με ποσοτική ανάλυση του αυλού τους (Quantitative vascular analysis), αρτηρίες με διάμετρο έως 7 χιλιοστά. Μικτά χαρακτηριστικά από περιοχές πλούσιες σε λιπίδια, εναποθέσεις ασβεστίου και ασβεστοποιημένες πλάκες, νεκρωτικές περιοχές και ίνωση εντοπίστηκαν σε όλες τις απεικονιζόμενες αθηροσκληρωτικές βλάβες. Ωστόσο, με βάση το επικρατέστερο από τα παραπάνω απεικονιστικά χαρακτηριστικά, οι βλάβες στο πλαίσιο της έρευνας ταξινομήθηκαν ως αμιγώς ινωτικές, ως ινοασβεστοποιημένες, ως πλούσιες σε λιπίδια και τέλος ως νεκρωτικές/ασβεστοποιημένες. Συσσώρευση των μακροφάγων εντός της αθηρωματικής πλάκας σημειώθηκε σε μικρό ποσοστό των de novo αθηρωματικών αλλοιώσεων. Ποικίλοι βαθμοί υπερπλασίας του νέου έσω χιτώνα απεικονίσθηκαν σε όλες τις περιπτώσεις ISR αλλοιώσεων, με καθαρά ινωτικά χαρακτηριστικά και σημαντική νεοαγγείωση σε κάποιες από αυτές. Η νεοαγγείωση συνέπεσε με το επίπεδο της μέγιστης στένωσης του αγγειακού αυλού. Σημαντικού βαθμού διαχωρισμός με μεγάλο περιορισμό του αγγειακού αυλού, τέτοιος ώστε να απαιτηθεί να τοποθετηθεί ενδοαυλικό stent, ανιχνεύθηκε σε αρκετές περιπτώσεις της de novo αθηρωμάτωσης. Η ψηφιακή αφαιρετική αγγειογραφία παρέλειψε να προσδιορίσει μεγάλο ποσοστό των σοβαρών διαχωρισμών μετά από αγγειοπλαστική. Η νεοαθηροσκλήρυνση εντός του νέου έσω χιτώνα των κνημιαίων φαρμακευτικών stents (DES), είναι ένα συχνό εύρημα τόσο στους συμπτωματικούς όσο και στους ασυμπτωματικούς ασθενείς. Μπορούμε να υποθέσουμε ότι, κατά αναλογία με τα εμφυτευμένα DES στα στεφανιαία αγγεία, η ελαττωματική ενδοθηλιοποίηση που προκαλείται από την εκλυόμενη φαρμακευτική ουσία, μαζί με την νεοαγγείωση που αναπτύσσεται μεταξύ των stent struts, μπορούν να υποδαυλίσουν την νεοαθηροσκλήρυνση εντός του νέου έσω χιτώνα των κνημιαίων DES, η οποία μπορεί να οδηγήσει σε επαναστένωση εντός του stent (ISR) και απώλεια του εμβαδού του αυλού των περιφερικών αρτηριών. Οι παρατηρήσεις της μελέτης αυτής θέτουν σε αμφισβήτηση το παραδοσιακό τρόπο κατανόησης της περιφερειακής επαναστένωσης εντός του stent ως μιας απλής υπερπολλαπλασιαστικής απάντησης στο βαρότραυμα. Η απεικόνιση με FD-OCT είναι ένα βέλτιστο πειραματικό εργαλείο για την αξιολόγηση της εξέλιξης της αθηροσκληρωματικής νόσου και την επαναστένωση του αγγείου. Μπορεί να παρέχει υψηλής ευκρίνειας ενδοαγγειακή απεικόνιση κατά τη διάρκεια αγγειοπλαστικών επεμβάσεων στα κάτω άκρα και θα μπορούσε να αποδειχθεί κλινικά χρήσιμο για τον προσδιορισμό της εντός του stent πρόπτωσης ιστού και του strut malapposition. Παρ 'όλα αυτά, δεν πρέπει να χρησιμοποιηθεί ως εργαλείο για τη συνήθη κλινική πρακτική μέχρι να προκύψουν στοιχεία από περαιτέρω κλινικές δοκιμές για τον καθορισμό των ειδικών ενδείξεων της απεικόνισης με FD-OCT στις περιφερικές αρτηρίες. / Optical coherence tomography (OCT) is a catheter-based imaging method that employs near-infrared light to produce high-resolution intravascular images. OCT can readily visualize vessel microstructure at a 10- to 20-μm resolution with exquisite detail. To date, however, applicability of the method has been limited to small diameter arteries (≤4 mm). To the best of the author’s knowledge, this study is the first worldwide that demonstrates the safety and clinical feasibility of frequency domain Optical Coherence Tomography (FD-OCT) imaging of infrainguinal vessels in vivo during infrainguinal angioplasty procedures. It is also the first study that reports the use of intravascular FD-OCT to detect and characterize in-stent neointimal tissue following infrapopliteal drug eluting stent (DES) placement in patients suffering from critical limb ischemia. Quantitative lumen analysis of arteries with diameter up to 7 mm was performed. High-resolution OCT images provided exquisite two-dimensional axial and longitudinal views of the infrainguinal arteries and allowed thorough investigation of a variety of angioplasty sequela, including and not limited to intimal tears and dissection flaps, white and red thrombus, stent mesh malapposition, and intrastent plaque prolapse. Of interest, OCT identified cases of suboptimal postangioplasty outcome that single-plane subtraction angiography did not recognize and accounted. Mixed features of lipid pool areas, calcium deposits and calcified plaques, necrotic areas, and fibrosis were identified in all of the imaged atherosclerotic lesions. However, based on the predominant baseline imaging findings, lesions under investigation were classified as purely fibrotic, fibrocalcific, mostly lipid-laden and necrotic/calcified. Intraplaque accumulation of macrophages was noted in some of de novo atheromatic lesions. Varying degrees of neointimal hyperplasia were demonstrated in all cases of in stent restenosis (ISR) lesions with purely fibrotic features and considerable neovascularization in some of them. The latter finding coincided with the level of maximum vessel stenosis in all cases. Neoatherosclerosis following infrapopliteal DES placement is a frequent finding in both symptomatic and asymptomatic patients. Our preliminary observations allow us to speculate that analogous to coronary implanted DES, defective endothelialization induced by the eluted drug, along with neovascularization developing between the stent struts, may incite neointimal neoatherosclerosis, which may result in ISR and lumen loss of the peripheral arteries. It also seems that infrapopliteal neoatherosclerosis may be a significant contributing factor for ISR rather than a minor and sporadic process, highlighting the clinical significance of the phenomenon. Our observations put in dispute the traditional way of understanding peripheral in-stent restenosis as a simple hyperproliferative response to barotraumas and may explain the paramount importance of aggressive risk factor modification strategies. Neointimal neoatherosclerosis as identified by FD-OCT may have a role in the development of below-the-knee restenosis and thus warrants further investigation by larger controlled studies. Moreover, it may prove clinically useful for the determination of intrastent tissue prolapse and strut malapposition. FD-OCT should not be utilized as a tool for routine clinical practice until evidence from further clinical trials emerge to determine the specific indications for OCT imaging of the peripheral arteries.