Posterior approach for simultaneous access to the popliteal and anterior tibial arteries: applications to distal arterial bypass

Arterial surgery to salvage the lower limb tends to make use of the great saphenous vein, harvested with the subject in the supine position. If this is not possible the small saphenous vein is used, harvested with the subject in the prone position, however this requires a perioperative modification of the procedure. A bypass between the popliteal and anterior tibial arteries can be performed using either a lateral or a medial and lateral approach with the patient supine. In the event of trophic disorders of the lateral compartment of the leg, these approaches are not applicable. In such cases we propose a single posterior approach. The single posterior approach was used on 10 lower limbs from 5 cadavers in the prone position. Approach to the lower part of the popliteal artery was undertaken posteriorly between the two heads of gastrocnemius. The small saphenous vein was entirely dissected 10 cm above the lateral malleolus, the Achilles tendon and short fibular vessels were retracted medially to expose the interossous fascia, which was divided over 10 cm. Medial rotation of the limb by 30 degrees exposed the anterior tibial artery. For 3 of the lower limbs an 8 cm fibular resection was necessary, whereas on the remaining 7 medial rotation enabled excellent exposure of the anterior tibial artery. The single posterior approach to the anterior tibial artery can be applied in cases requiring distal bypass, using the small saphenous vein, between the inferior part of the popliteal artery and the anterior tibial artery.

Possible role of nitric oxide and arachidonic acid pathways in hypoxia-induced contraction of rabbit coronary artery rings

In isolated coronary arteries, hypoxia induces an increase in tone by releasing an unidentified endothelium-derived contracting factor (EDCF). Isometric force was measured in an isolated rabbit coronary artery ring at 37 degrees C in control and high K+ (40 mM) pre-contracted conditions. Hypoxia (15 mmHg pO2) induced by equilibrating the perfusate with nitrogen. Hypoxia did not affect the resting tone but induced an endothelium-dependent contraction on pre-contracted rings. Inhibitors of nitric oxide (NO) were tested, L-NAME (10(-4) M) totally and L-NMMA (10(-4) M) partially convert the hypoxic contraction to an hypoxic relaxation. The addition of L-arginine (10(-4) or 10(-3) M) did not restore the response. Methylene blue (10( -5) M) and ODQ (1 H-[1,2,4] oxadiazolo-[4,3-a] quinoxalin-1-one, 10(-5) M), both inhibitors of guanylate cyclase, also changed the hypoxic contraction into a hypoxic relaxation. Catalase (1200 U/ml), which decomposes hydrogen peroxide (H2O2), and superoxide dismutase (150 U/ml, SOD), a free radical scavenger, did not change the hypoxic response but quinacrine (50 microM), an inhibitor of phospholipase A2, significantly decreased it. Inhibitors of arachidonic acid metabolism (indomethacin, diethylcarbamazine, miconazole) however did not affect the hypoxic response. We conclude that in K+ pre-contracted rabbit coronary artery rings, hypoxia induces a contraction which is nitric oxide and arachidonic acid dependent.

Endovascular repair of aortic allograft aneurysmal degeneration: a case report

Aortoenteric graft fistula remains a dreadful complication of aortic surgery. Good results have been reported using in situ graft replacement with arterial allografts. Late aneurysmal degeneration of the graft itself may necessitate further repair. We report the case of such an aneurysmal degeneration 7 years after implantation of the allograft. Endovascular repair was performed with a Vanguard device; complete exclusion was obtained immediately. At 6-month follow-up, the patient was alive and well. Duplex and computed tomography scans showed an excluded aneurysm with a slight reduction in size. Endovascular stent grafting may be a therapeutic option for treating patients with late allograft degeneration.

Bilateral carotid dissection and factor V mutation: a second case

A young woman 38 years of age underwent Doppler ultrasonography following the spontaneous appearance of cervical pain causing loss of sleep. The examination revealed bilateral dissection of the internal carotid arteries, confirmed by supraaortic arteriography. Two successive CT scans showed no cerebral lesions. A thrombosis of the great saphenous vein was recorded as the only vascular event in her medical history. Thrombophilia was assessed following discovery of the dissection, and upon examination a heterozygotic mutation of Factor V Leiden was revealed. This observation is the second case of carotid dissection occurring in a subject presenting a factor V mutation. At the present time, however, there are no results to justify the assumption of a direct link between these two pathologies.

Influence of coronary artery and contralateral carotid artery status on long-term results of carotid artery surgery

The main cause of death and long-term disability of patients undergoing carotid artery surgery is coronary artery disease. To identify the prognostic value of the status of the contralateral artery, we studied the course of 224 consecutive patients in whom one or both carotid arteries were operated on at our institution between 1985 and 1995. The 224 patients were divided into three groups: group I (n = 56) had an occluded contralateral carotid artery, in group II (n = 56) both carotids were operated on, and group III (n = 112) had a normal contralateral carotid artery. The clinical status of all patients except one was ascertained by one of us. We found that the status of the contralateral artery does not influence the long-term prognosis of patients undergoing carotid artery surgery. A periodic cardiological and vascular follow-up of these patients seems warranted to improve their survival.

[Do the long-term results of carotid surgery influence the status of the contralateral carotid artery?]

AIM

The main cause of long-term death and disability of patients undergoing carotid artery surgery is coronary artery disease. To identify the prognostic value of the status of the contralateral artery, we studied the course of 224 patients operated consecutively on one or both carotid arteries in the same institution between 1985 and 1995.

PATIENTS AND METHODS

The 224 patients were divided into three groups: group I (n = 56) having an occluded contralateral carotid artery; group II (n = 56) in which both carotids were operated on; and, group III (n = 112) having a normal contralateral carotid artery. The clinical status of all patients was ascertained by one of us for all patients except one. This study concerned also the course of 40 patients (group R) belonging to the three groups, who had during the follow-up period a coronary and/or a peripheral vascular intervention with a preoperative coronarography.

RESULTS

The median follow-up was 62.8, 78 and 65 months for groups I, II and III, respectively. Actuarial survival rates were 67%, 73%, 72.5% at 5 years, and 39%, 51.5% and 42% at 10 years, for group I, II and III respectively. Actuarial stroke-free rates were 96%, 100%, 91% at 5 years, and 96%, 100% and 78.5% at 10 years for group I, II and III respectively. Actuarial cardiac death rates were 26%, 23%, 19% at 5 years, and 49%, 42% and 37% at 10 years for group I, II and III, respectively. None of the differences between the three groups regarding these three different end-points was significant. The group R fatal or non-fatal cardiac event-free rates at 5 and 10 years were 88% and 53% respectively. When compared with the rates of other patients (without revascularization): 68% and 25.5% at 5 and 10 years, the results were almost significant (P = 0.07). Average age for group R patients was significantly lower (65 vs. 69 years, P < 0.05). Using Cox's model, age alone emerged as a factor influencing survival (P = 0.07) but not revascularization (P = 0.13).

CONCLUSION

The status of the contralateral artery does not influence the long-term prognosis of patients undergoing carotid artery surgery. A periodic cardiological and vascular follow-up of these patients tends to improve their survival.

[Treatment of false aneurysm of the ascending aorta under circulatory arrest and the Port-access system]

Pseudo-aneurysms of the ascending aorta after thoracic surgery are rare and pose a problem of surgical strategy with respect to the approach, the myocardial protection and type of repair. The authors have solved the problem by using a new technology, the Post-Access TM system, which, by simply introducing a catheter into the femoral artery, allows endoaortic clamping, the administration of cardioplegic solution, and the drainage of the left heart chambers. The system was used with a good result for treating a pseudo-aneurysm of the proximal anastomosis of a bypass between the ascending aorta and the innominate artery, limiting the duration of circulatory arrest and reducing blood loss.

[Intermediary results with the CarboMedics bileaflet valvular prosthesis]

From December 1988 to December 1995, 212 patients underwent valve replacement with a CarboMedics bileaflet valve in our institution (103 aortic valve replacements, 72 mitral valve replacements, and 37 double valve replacements). Fifty-five percent were male patients. Mean age was 53.8 +/- 12.7 years. Forty seven percent of patients were in NYHA clinical status III or IV. Operative mortality was 3.7% (8/212). All patients but eight were followed-up for an average of 2.9 years after their operation and total follow-up was 617 patient-years. At the time of the study, more than 90% of patients were in NYHA class I or II, 26% were in atrial fibrillation and 100% of patients received anticoagulation treatment. There were 15 late deaths. After 7 years, the actuarial survival rate was 84 +/- 7%. Three patients died of valve-related causes. Valve-related complications included 5 thromboembolic episodes (0.8% patient-year), 18 anticoagulant-related complications (2.9% patient-years), 3 endocarditis (0.5% patient-year), and 4 reoperations (0.6% patient-year). After 7 years, freedom from thrombo-embolic complication was 97 +/- 2%, from anticoagulant-related complications was 88 +/- 6%, from endocarditis was 96 +/- 4%, and from reoperation was 95 +/- 5%. We conclude that the 7-year results compare with other bileaflet valves. More follow-up and larger studies are mandated to give definite conclusions.

Does a thoracoscopic approach for surgical treatment of spontaneous pneumothorax represent progress?

OBJECTIVE

Surgical management is indicated in recurrent forms of pneumothorax and for failure of tube drainage. We have for several years performed pleurodesis and apical blebs stapling by axillary thoracotomy. Thoracoscopy has been a well established procedure for 70 years and recently further developed as the result of current technological progress. For 10 years thoracoscopy has been developed as an alternative to thoracotomy in several indications. Spontaneous pneumothorax is ideally suitable for thoracoscopic management. The aim of this retrospective study is to evaluate this new approach.

METHODS

We compare our results of axillary thoracotomy management of spontaneous pneumothorax in 237 patients (group 1) with those of thoracoscopic management in 101 patients (group 2). Sex distribution, average age, indications and stapling of apical blebs were comparable in both groups.

RESULTS

Etiologies were comparable in both groups. The average operation time was 71 min in group 1 and 57 min in group 2. The average duration of chest tube placement was 8 days in group 1 and 6.5 days in group 2. The mean hospital stay was 14 days in group 1 and 9.5 days in group 2. The overall morbidity was 16 and 11% in groups 1 and 2, respectively. The most frequent complication was early or late failure of pleurodesis which required second drainage or a subsequent operation. Late failure occurred more frequently after thoracoscopy (3 vs. 0.4%) but there was no statistically significant difference between the two groups.

CONCLUSIONS

Thoracoscopic management of spontaneous pneumothorax is a safe procedure. Moreover, it offers the benefits of a shorter hospital stay and less postoperative pain.

The Carbomedics prosthetic heart valve: four year follow-up in 100 patients

From December 1988 to December 1991, 100 patients underwent valve replacement with a Carbomedics bileaflet valve in our institution (55 aortic valve replacements, 28 mitral valve replacements, and 17 double valve replacements). Fifty-nine percent were males. Mean age was 55.7+/-12.3 years. Fifty eight percent of patients were in NYHA Clinical status III or IV. Operative mortality was 3% (3/100). All patients but one were followed up for an average of 2.8 years after their operation and total follow-up was 280 patient years. At the time of the study, more than 80% of patients were in NYHA class I or II, 34% were in atrial fibrillation and 100% of patients received anticoagulation treatment. There were 3 late deaths. After 4 years, the actuarial survival rate was 94%+/-5%. No patients died of valve-related causes. Valve-related complications included 2 thromboembolic episodes (0.7%-patient-year), 8 anticoagulant-related complications (2% patient-year), and one reoperation (0.3% patient-year). After 4 years, freedom from thromboembolic complication was 96%+/-4%, from endocarditis was 100%, from reoperation was 99%+/-1%, and from anticoagulant-related complications was 93%+/-5%. We conclude that the 4-year results compare with other bileaflet valves. More follow-up and larger studies are mandated to give definite conclusions.

New procedure to replace the aortic valve with autologous pericardium: a clinical case

Primary tissue failure is a major problem with pericardial or porcine heterografts, and the causes of calcification of the tissue are not yet known. The deterioration of bioprostheses may be due in part to immunologic response. Using autologous tissue is a current approach of research. We present a case of replacement of the aortic valve using an original procedure with autologous pericardium.

[Partial pulmonary embolectomy without extracorporeal circulation. Apropos of a case]

The authors report a case of massive pulmonary embolism compromising the haemodynamic status of a 52 year old man with a formal contraindication to thrombolytic therapy. Unilateral pulmonary embolectomy was performed without cardiac pulmonary bypass, preceded by partial interruption of the inferior vena cava. Postoperative controls confirmed the success of the surgical procedure. Although the indications of surgical embolectomy are limited, especially without cardiopulmonary bypass, it may be considered for the treatment of certain cases of massive pulmonary embolism.