[Postexercise duplex ultrasound to diagnose external iliac endofibrosis]

Arterial endofibrosis is a disease of recent discovery which concerns high-performance athletes, predominantly competitive cyclists. The preferential location is the external iliac artery. The symptoms are diverse (pain, edema, paresthesia), always linked to an effort. The diagnosis may be delayed due to atypical symptoms in athletes. Complementary tests are measure of the systolic pressure index after exercise, duplex ultrasound, CT angiography, MR angiography and arteriography. We report a case of endofibrosis where late diagnosis was established with postexercise duplex ultrasound, while CT angiography and arteriography failed to reveal characteristic abnormalities.

Circulating lipoprotein-associated phospholipase A2 in high-grade carotid stenosis: a new biomarker for predicting unstable plaque

OBJECTIVE

To test plasma levels of lipoprotein-associated phospholipase A2 (Lp-PLA2) in patients with high-grade carotid stenosis according to plaque histology.

METHODS

This cross-sectional single-centre study included patients with ≥70% North American Symptomatic Carotid Endarterectomy Trial (NASCET) carotid stenosis, who were treated surgically. Serum Lp-PLA2 and high-sensitivity C-reactive protein (hs-CRP) were determined on the day of surgery. Histopathological analysis classified carotid plaque as stable or unstable, according to AHA classification.

RESULTS

Of the 42 patients (mean age 70.4 ± 10.5 years; 67% men), neurological symptoms were present in 16 (38%). Unstable plaques were found in 23 (55%). Median plasma level of Lp-PLA2 was significantly higher in patients with unstable plaque compared to those with stable plaque (222.4 (174.9-437.5) interquartile range (IQR) 63.5 vs. 211.1 (174.9-270.6) IQR 37.2 ng ml(-1); p = 0.02). Moreover, median Lp-PLA2 level were higher in asymptomatic patients with unstable plaque (226.8 ng ml(-1) (174.9-437.5) IQR 76.8) vs. stable plaque (206.9 ng ml(-1) (174.9-270.6) IQR 33.7; p = 0.16). Logistic regression showed that only the neurological symptoms (OR = 30.9 (3.7-244.6); p < 0.001) and the plasma Lp-PLA2 level (OR = 1.7 (1.1-12.3); p = 0.03) were independently associated with unstable carotid plaque as defined by histology.

CONCLUSIONS

This study showed that circulating Lp-PLA2 was increased in patients with high-grade carotid stenosis and unstable plaque. Lp-PLA2 may be a relevant biomarker to guide for invasive therapy in asymptomatic patients with carotid artery disease.

The haemodynamics of the distal arterial Y-shaped autograft bypass-flap in a porcine experimental model

BACKGROUND

The haemodynamic effects of revascularisation with combined bypass and free-muscle flap remain controversial. In a porcine experimental model, we investigated the transplantation-induced changes in the haemodynamics of a Y-shaped combined arterial autograft bypass-muscle flap (AABF).

METHODS

Anatomy of AABF was identified in eight dissections in four porcine cadavers. In five animals, AABF served as a superficial femoral artery (SFA) defect replacement. Modelled, triggered pulsatile pressure (P) and flow (Q) waves delivered mean haemodynamics and PQ hysteresis loops before and after transplantation at days 0 and 10.

RESULTS

Anatomically, AABF combined subscapular and circumflex-scapular arteries, and thoracodorsal artery as latissimus dorsi flap pedicle. Surgical feasibility and AABF patency were confirmed in each case. At day 0, the proximal flow was increased in the grafted Y-shaped AABF, which also adopted the specific SFA pulsatile haemodynamics. Regulatory mechanisms of AABF vasomotricity were preserved and AABF-flow-dependence amplified the flow in the distal segment, which otherwise preserved its own flow dependence. At 10 days, the AABF flow was unchanged in the distal segment, and remained elevated in the proximal and pedicle segments.

CONCLUSIONS

Combined AABF, as a single one-piece arterial autograft, was shown highly adaptive to the receiving arteries. The transplantation-induced changes in AABF pulsatile flow profile and vascular reactivity improve the overall graft flow, and strongly advocate for beneficial effects on the blood propelling capacity of the grafted circulation.

Endovascular Treatment of Anastomotic False Aneurysms of the Abdominal Aorta

Conventional surgical treatment of anastomotic false abdominal aortic aneurysms (AFAA) is technically difficult. Morbidity-mortality rates are higher than those for surgery of infrarenal abdominal aortic aneurysm (AAA). Endovascular management without laparotomy or aortic clamping represents an attractive alternative. The purpose of this study was to determine the immediate and middle-term outcome of endovascular management of AFAA. Between 1998 and 2001, 10 patients were treated for AFAA by placement of an endograft. The initial procedure was aortobifemoral bypass for occlusive artery disease in eight cases and resection and grafting for AAA in two cases. Mean age was 70 years. Seven patients were classified ASA 3 or 4. Three patients presented cardiac insufficiency with left ventricular ejection fraction <40%. Eight patients were treated using an aortounilateral iliac artery endograft in association with crossover femorofemoral bypass (3 AneuRx, 2 Endologix, 1 Talent, 1 Zenith, 1 surgeon-made stent). Two patients were treated with an aortoaortic endograft (1 Talent, 1 surgeon-made stent). In two patients extraperitoneal exposure of the common iliac artery was required for introduction of the stent in one case and for surgical closure of the iliac artery in the other case. A total of nine patients underwent another surgical procedure in association with stenting. Four endografts were custom-made. Endograft deployment was successful in all cases. No patient died during the postoperative period. Postoperative computed tomography (CT) scan confirmed exclusion of the aneurysmal sac in all cases. The mean duration of hospitalization was 13 days (range, 5-28 days). During follow-up (mean duration, 17.7 months; range, 5-42 months), one patient died from heart-related causes. No direct or indirect endoleak was detected by CT scan follow-up and a significant reduction in AFAA diameter was noted in the eight patients with follow-up periods lasting 6 months or more. One patient developed occlusion of an aortounilateral iliac artery endograft and was treated by axillobifemoral bypass. In one patient stenosis of the distal end of an aortounilateral iliac endograft was discovered by duplex scan and successfully treated by dilatation. Endovascular treatment of AFAA is technically feasible but requires more complex procedures involving associated surgical procedures and use of custom-made endografts. The morbidity-mortality rate in this small series of high-risk patients was low. Immediate and middleterm exclusion of AFAA was good.

Mortality and morbidity following endovascular repair of abdominal aortic aneurysms: analysis of two single centre experiences

OBJECTIVE

to show how differences in anatomical and physiological risk factors can affect the outcome of endovascular repair of AAA by describing the experience of two centres with different selection policies.

METHODS

one hundred and thirty-five patients (group I) were treated at Queen's Medical Centre (Nottingham, U.K.) using 101 in-house made and 34 manufactured stent-grafts. Median diameter, length and angulation of the proximal aneurysm neck were 26 mm, 27 mm, 40 degrees, respectively. Seventy-six patients had ischaemic heart disease, 47 had left ventricular failure, median forced expiratory volume in one second (FEV1) was 83%, median creatinine was 100 micromol/l and median age was 72 years. Fifty patients (group II) were treated at Timone Hospital (Marseilles, France) using seven in-house made and 43 manufactured stent-grafts. Median diameter, length and angulation of the proximal aneurysm neck were 25 mm, 34 mm, 33 degrees, respectively. Thirteen patients had ischaemic heart disease, two had left ventricular failure, median forced expiratory volume in one second was 101%, median creatinine was 108 micromol/l and mean age was 72 years.

RESULTS

anatomical characteristics of the proximal neck were significantly worse in group I (p=0.02 for the three variables). Cardiac comorbidities were more frequent and mean FEV1 was lower in group I (p<0.0001 and p=0.001, respectively. Median aneurysm diameter was significantly greater in group I (65 mm) than in group II (53 mm) (p<0.001). Postoperative mortality was 9% and 0% in groups I and II respectively (p=0.03). The incidence of technical complications (groin wound complications and side branches endoleaks being excluded) was 20% and 0% in groups I and II, respectively (p=0.0006).

CONCLUSION

postoperative mortality and technical complication rates were significantly greater in group I than in group II, readily explained by poorer general condition and worse anatomical characteristics of the proximal neck in group I.

Endovascular treatment of occlusive lesions in the distal aorta: mid-term results in a series of 31 consecutive patients

The purpose of this study was to evaluate the early and mid-term results of endovascular treatment of occlusive lesions in the distal aorta in a consecutive series of patients. Between February 1996 and March 1999, a total of 31 patients underwent transluminal procedures for treatment of occlusive atherosclerotic lesions located at the lower end of the aorta. Thirty patients presented with intermittent claudication and one had critical ischemia. Manifestations were bilateral in 26 cases and unilateral in 5. The lesion was confined to the lower aorta in 3 patients and extended to the common iliac arteries in 19, with predominant proximal lesions of the common iliac artery occurring in 9 patients. Fourteen patients had concurrent infracrural occlusive lesions. All patients underwent exclusive endovascular treatment without any associated open surgical procedure. The three patients with isolated aortic lesions were treated by angioplasty, followed by stent placement in two cases. The 19 patients with aortobiiliac lesions were treated by bilateral common iliac artery angioplasty according to the "kissing-balloon" technique; 7 of these patients also underwent aortic angioplasty. In these 19 patients, aortic stenting was performed in 3 cases and bilateral iliac stenting in 10 cases, including 3 in association with aortic stenting. The nine patients with a proximal lesion of the common iliac arteries were treated by angioplasty, followed by bilateral stenting in three cases and unilateral stenting in three cases. The findings of this study show that the mid-term anatomical and functional results of endovascular treatment for atherosclerotic lesions of the distal aorta are satisfactory. We recommend it as the initial treatment modality.

Results of lower limb revascularization from the descending thoracic aorta

The aim of this retrospective study was to substantiate our results of lower limb revascularizations from the descending thoracic aorta. From November 1984 to November 1994, we used bypass grafting from the descending thoracic aorta to revascularize 69 lower limbs in 36 patients, 34 men and 2 women, whose mean age was 61.8 years. Patients were divided into two groups. Group I (primary indications) included 10 patients who had not had any prior lower limb arterial reconstruction. Group II (secondary indications) consisted of 26 patients who had had a prior arterial reconstruction that was either occluded or complicated. There were three early graft occlusions, all of them successfully treated. Complete flaccid, paraplegia occurred in one patient. Five patients presented with one or several late graft occlusions. Two patients had to undergo below-knee amputation, bilateral in one patient. Routine late control of the repair was performed by CT scanning, at a mean interval of 50.8 months. The good results recorded for bypasses revascularizing lower limbs from the descending thoracic aorta make this technique a satisfactory alternative when the abdominal aorta cannot be used.

Surgical treatment of extracranial internal carotid artery aneurysms

PURPOSE

Extracranial internal carotid artery aneurysms (EICAs) can be treated by carotid ligation or surgical reconstruction. In the consideration of the risk of stroke after internal carotid artery (ICA) occlusion, the aim of this study was to report the results of reconstructive surgery for these aneurysms, including lesions located at the base of the skull.

METHODS

From 1980 to 1997, 25 ICA reconstructions were performed for EICA: 22 male patients and 3 female patients (mean age, 54.4 years). The cause was atherosclerosis (n = nine patients), dysplasia (n = 12 patients), trauma (n = three patients), and undetermined (n = one patient). The symptoms were focal in 15 cases (12 hemispheric, three ocular), nonfocal in three cases (trouble with balance and visual blurring), and glossopharyngeal nerve compression in one case. Six cases were asymptomatic, including three cases that were diagnosed during surveillance after ICA dissection. In nine cases, the upper limit of the EICA reached the base of the skull. A combined approach with an ear, nose, and throat surgeon allowed exposure and control of the ICA.

RESULTS

After operation, there were no deaths, one temporary stroke, two transient ischemic attacks, and 11 cranial nerve palsies (one with sequelae). The ICA was patent on the postoperative angiogram in all but one case. During follow-up (mean, 66 months), there were two deaths (myocardial infarction), one occurrence of focal epileptic seizure at 2 months, and one transient ischemic attack at 2 years. In December 1998, duplex scanning showed patency of the reconstructed ICA in all but one surviving patient.

CONCLUSION

Surgical reconstruction is a satisfactory therapeutic choice for EICA, even when located at the base of the skull.

Long-term results of arterial allograft below-knee bypass grafts for limb salvage: a retrospective multicenter study

PURPOSE

Arterial allografts (AAs) have been recently reconsidered in the treatment of critical limb ischemia when vein material is absent, because of the disappointing results with artificial grafts. The aim of this study was to report the results observed in three centers where AAs were used for infrainguinal reconstruction in limb-threatening ischemia.

METHODS

Between 1991 and 1997, 165 AA bypass procedures were performed in 148 patients (male, 90) with a mean age of 70 years (range, 20-93 years). Indications for operation were rest pain in 54 cases and tissue loss in 111 cases. Mean resting ankle pressure was 53 mm Hg in 96 patients who did not have diabetes and mean transcutaneous pressure of oxygen was 10 mm Hg in 52 patients who did have diabetes. In 123 cases (75%), there was at least one previous revascularization on the same limb. AAs were obtained from cadaveric donors. The distal anastomosis was to the below-knee popliteal artery in 34 cases, to a tibial artery in 114 cases, and to a pedal artery in 17 cases.

RESULTS

At 30 days, the mortality rate was 3.4%; the primary patency rate was 83.3%; the secondary patency rate was 90%; and the limb salvage rate was 98%. During follow-up (mean, 31 months), 65 grafts failed primarily. Causes of primary failure were thought to be progression of the distal disease in 15 cases, myointimal hyperplasia in 16 cases, graft degradation in 10 cases (four dilations, three stenoses, two ruptures, and one dissection), miscellaneous in eight cases, and not known in 16 cases. Primary patency rates at 1, 3, and 5 years were, respectively, 48.7% +/- 4%, 34.9% +/- 6%, and 16.1% +/- 7%. Secondary patency rates at 1, 3, and 5 years were, respectively, 59. 8% +/- 4%, 42.1% +/- 5%, and 25.9% +/- 8%. Limb salvage rates at 1, 3, and 5 years were, respectively, 83.8% +/- 3%, 76.4% +/- 5%, and 74.2 % +/- 8%.

CONCLUSION

AA leads to an acceptable limb salvage rate but poor patency rates. A randomized trial that will compare AAs and polytetrafluoroethylene should be undertaken.

Vascular surgical society of great britain and ireland: mid-term results of arterial allograft below-knee bypasses for limb salvage

BACKGROUND: Arterial allografts (AAs) have been recently reconsidered in the treatment of critical limb ischaemia when vein material is absent, because of the disappointing results with artificial grafts. The aim of this study was to report the results observed in three centres where AAs were used for infrainguinal reconstruction in critical limb ischaemia. METHODS: Between 1991 and 1997, 165 AA bypasses were performed in 148 patients (90 men) with a mean age of 70 (range 20-93) years. Indications for operation were rest pain in 54 patients and tissue loss in 111. Mean resting ankle pressure was 53 mmHg in 96 non-diabetic patients and mean transcutaneous partial pressure of oxygen was 10 mmHg in 52 diabetic patients. AAs were obtained from cadaveric donors. The distal anastomosis was to the below-knee popliteal artery in 34 cases, to a tibial artery in 114 and to a pedal artery in 17. RESULTS: At 30 days, the mortality rate was 3 per cent, primary patency 83 per cent, secondary patency 90 per cent and limb salvage rate 98 per cent. During follow-up (mean 31 months) 65 grafts failed primarily. Causes of primary failure were thought to be progression of the distal disease in 15 cases, myointimal hyperplasia in 16, graft degradation in ten (four dilatations, three stenoses, two ruptures and one dissection), other causes in eight and not known in 16. Primary and secondary patency rates at 3 years were 35(s.e. 9) per cent and 42(s. e. 10) per cent. The limb salvage rate at 3 years was 76(s.e. 8) per cent. CONCLUSION: AAs lead to a good foot salvage rate but poor patency rates. The results are similar to those obtained with polytetrafluoroethylene grafts.

Surgery for asymptomatic carotid stenosis: a study of three patient subgroups

The purpose of this retrospective study was to determine whether patients who undergo prophylactic surgery for asymptomatic carotid stenosis represent a single homogeneous population. Of the 805 carotid reconstructions performed between January 1984 and December 1992, a total of 357 were for asymptomatic atherosclerotic stenosis in 312 patients (227 men, 85 women) with a mean age of 69.6 years. Patients were divided into three groups. Group I included 141 patients (161 procedures) who presented no neurologic manifestations. Group II included 49 patients (55 procedures) who underwent carotid reconstruction before or at the same time as another cardiovascular procedure. Group III included 122 patients (141 procedures) who presented nonhemispheric manifestations. Patients in group III had a significantly higher number of obstructive lesions in brain arteries (p < 0.01). Seven patients died within the first 30 postoperative days, including three who underwent combined single-stage procedures. Nine patients presented nonfatal stroke, including three who progressively recovered. The cumulative death-stroke rate (CDSR) was 5.12% overall, 3.54% in group I, 12.24% in group II, and 4.09% in group III. The difference between groups I and II was statistically significant (p < 0.05). Taking into account only deaths related to carotid surgery and stroke with permanent disability, the CDSR was 2. 83% in group I and 3.25% in group III. Follow-up ranged from 24 to 132 months (mean: 66.2) with a total of 11 patients being lost from follow-up. Actuarial 5-year survival was 81.99 +/- 7.13% in group I, 70.65 +/- 13.72% in group II, and 68.51 +/- 8.93% in group III. Differences between group I and both groups II (p < 0.01) and III (p < 0.05) were statistically significant. Overall 5-year patency was 95.59 +/- 2.28%. Stroke occurred during follow-up in 13 patients. The probability of stroke-free survival was 95.29 +/- 3.76% in group I, 91.03 +/- 8.52% in group II, and 89.09 +/- 6.39% in group III. The difference between groups I and III was statistically significant (p < 0.05). Patients with asymptomatic carotid lesions can be divided into different prognostic groups. Life expectancy is shorter for patients with multiple artery disease. Long-term stroke risk is higher in patients with nonhemispheric neurological manifestations.

Surgical management of Candida suppurative thrombophlebitis of superior vena cava after central venous catheterization

Septic deep venous thrombosis is a major complication associated with central venous catheterization in intensive care units. The most common causative organisms are Staphylococcus aureus, gram-negative bacilli and Candida species. The incidence of Candida infections is increasing, especially in intensive care patients receiving total parenteral nutrition and long-term broad-spectrum antibiotics. Although intravascular catheter-induced septic thrombophlebitis is quite common, superior vena cava obstruction is a rare complication. However, few data exist concerning the best strategy for managing septic thrombophlebitis, especially when medical therapy fails. We report successful surgical management of Candida albicans suppurative thrombosis of the superior vena cava in a young patient.

Saphenous vein bypass: an alternative to internal carotid reconstruction

OBJECTIVE

Venous grafting is rarely employed for carotid reconstruction; the aim of this retrospective study was to assess its value as an alternative to endarterectomy.

MATERIAL

Between January 1980 and June 1990, we performed 212 carotid artery venous bypasses (CVB) on 208 patients. Twenty-nine patients were asymptomatic, 60 had non-hemispheric symptoms and 119 focal symptoms. The indication for surgery was stenosis in 185 cases, kinking in 18 and aneurysms in nine. The main criteria to use CVB were length of the lesion in 86 cases, extent of atherosclerosis in 75, dysplasia in 12, intraoperative failure of endarterectomy in 21, aneurysms in seven and long-term restenosis or occlusion in 12.

RESULTS

There were 11 deaths, three strokes and nine transient ischaemic attacks. Angiographic control showed one occlusion giving an immediate patency rate of 99.5%. Mean follow-up was 104.3 +/- 46.1 months with 15 patients lost to follow-up. Eighty patients died; life expectancy was 52.4 +/- 7.5 at 10 years. Including occlusions and restenosis as failures, the secondary patency rate was 96.4 +/- 3.7 at 10 years. The annual stroke rate was 1.3% and the neurologic event-free-population 87 +/- 2.4% at 10 years.

CONCLUSION

CVB is a valuable alternative to endarterectomy for reconstruction of the carotid artery. The indications are extensive atherosclerosis involving the common carotid artery, intraoperative anatomic failure of endarterectomy, and long-term restenosis.

Viscoelastic properties of human arteries. Methodology and preliminary results

In order to study the biomechanical properties of the arterial wall and to compare arteries with different histologic structures, we designed a device that allows testing of arterial segments under near-physiologic conditions. A hydrodynamic generator simulates systolo-diastolic pressures in an open loop. An intraarterial pressure sensor and a sonomicrometer connected to two piezoelectric crystals placed in diametric opposition on the arterial wall allow computer calculation of compliance, stiffness, midwall radial arterial stress, Young modulus, and incremental modulus for a given arterial segment at a given pressure setting. Seven healthy common carotid artery (CCA) segments and seven healthy (superficial) femoral artery (FA) segments were studied immediately after removal from brain-dead donors between the ages of 18 and 35 years. Histologic examination was performed to determine the density of elastic fibers in the arterial wall. Hysteresis was observed in all segments regardless of pressure settings. Compliance was greater and modulus values and stiffness were lower in CCA than in FA. No evidence of structural change was noted after testing in the circulation loop. These preliminary results open the way to a wide variety of applications for our hydrodynamic circulation loop. Experiments will be undertaken to compare the mechanical properties of arteries before and after cryopreservation.

Effects of cryopreservation on the viscoelastic properties of human arteries

The purpose of this study was to use our newly developed mock circulation loop to determine the effects of cryopreservation on the common carotid artery (CCA) and the superficial femoral artery (SFA). Fourteen healthy arteries (7 CCA and 7 SFA) harvested from multiple organ donors between the ages of 18 and 35 years were tested before and after cryopreservation at -140 degrees C using dimethyl sulfoxide and the vapor phase of liquid nitrogen. Mean storage time was 4.2 months. The mock pulse rate was 60 beats/min and the following four systolic/diastolic pressures settings were used: 50/110, 80/140, 110/170, and 140/200 mm Hg. Simultaneous measurements of intra-arterial pressure and external arterial diameter were made using an intra-arterial pressure sensor and external piezoelectric sensors. Measured data were used to calculate pulsatility, volumetric compliance, stiffness, midwall radial arterial stress, Young's modulus, and the incremental modulus. After SFA cryopreservation, no significant changes were observed. Conversely, CCA cryopreservation led to a significant decrease in compliance and pulsatility and a significant increase in stiffness. Young's modulus, the incremental modulus, and midwall radial arterial stress did not change significantly. A clearcut decrease in hysteresis was observed after cryopreservation in the CCA. No evidence of structural changes was detected on light and scanning electron microscopy. Baseline findings in this study were consistent with classification of the CCA as an elastic artery and the SFA as a muscular artery. Cryopreservation had no effect on the viscoelastic properties of muscular arteries (SFA). Cryopreservation affected only values related to the cylindrical shape of the elastic arteries (CCA). It had no effect on values related to wall structure.

Popliteal artery entrapment syndrome. Anatomic and embryologic bases, diagnostic and therapeutic considerations following a series of 15 cases with a review of the literature

We report 15 examples of popliteal artery entrapment syndrome observed in 11 patients. The anatomical causes were as follows: in one case, the popliteal artery presented an aberrant course medially to the medial head of the gastrocnemius muscle. In 5 cases, there was a small fibrous band linking the medial head of the gastrocnemius muscle to the lateral condyle and crossing behind the popliteal artery; in 5 cases this anomaly was also found in association with an abnormally high and/or internal insertion of the medial head of gastrocnemius muscle. In the last 4 cases, there was a muscular insertion anomaly associated with muscular hypertrophy causing arterial compression. Arteriography performed in the 11 patients showed evocative signs of the diagnosis in all cases where the artery was patent. Two popliteal arteries were occluded. CT scan and MRI examination of the popliteal fossa enabled us to define the muscular origin of the popliteal compression. All of the patients were operated upon; two received a reversed saphenous bypass and all of the others were treated by liberation of the popliteal artery and/or vein by a posterior approach. Follow-up in all patients at long term showed good prognosis. All of the patients were able to take up their previous physical activities without sequelae. Our review of the literature, which is based on 374 cases of popliteal artery entrapment observed in 280 patients, made it possible to define the frequency of the various anomalies observed, their symptoms and the different therapeutic possibilities. The multiple anatomical classifications as well as the arterial and muscular embryology are also described.

Value of angioscopy for intraoperative assessment of carotid endarterectomy

From March 1992 to November 1993 we used angioscopy and arteriography for intraoperative assessment of 103 carotid endarterectomies in 96 patients. The indication for surgery was asymptomatic stenosis in 55 cases and neurologic and/or ocular symptoms in 48. Intraoperative angioscopy and arteriography were performed to allow comparison of findings. Intraoperative angioscopic images were normal in 67 cases and abnormal in 36. The defect was an intimal flap in 26 cases, detachment of the distal plaque in seven cases, and an intimal wedge in five cases. In two cases both detachment and a wedge were observed. The defect was not considered severe enough to warrant revision in 31 cases and was corrected in five cases by either vein bypass (n = 1) or revision of the endarterectomy (n = 4). In the latter four cases repeat angioscopy showed normal findings. Arteriographic and angioscopic findings were compared in 102 cases. In the 71 cases in which angioscopic findings were normal, arteriography revealed a major abnormality in three cases: kinking in one and stenosis > 40% in two. Kinking was treated by attachment of the common carotid artery and stenosis by venous bypass. In the 31 cases in which angioscopy revealed defects not considered to warrant revision, arteriography revealed stenosis > 40% in three cases treated by either prosthetic bypass (n = 2) or revision of the endarterectomy (n = 1). The false negative rate for angioscopy was 5.9% and concordance between the two methods was 94.1%. The combined mortality-morbidity rate was 1.9% (one stroke and one death). Postoperative evaluation of anatomic findings by arteriography or Doppler ultrasonography revealed asymptomatic internal carotid occlusion in one and internal carotid stenosis < 30% in four cases. Angioscopy is a simple, low-cost method in intraoperative control that can be used either as an adjunct to arteriography or as an alternative if arteriography cannot be performed.

[Anatomic problems involved in the approach to the internal carotid artery]

The portion of the internal carotid artery (ICA) located above the line joining the tip of the mastoid and the angle of the mandible is in close relation with cranial nerves VII, IX, X, XI and XII as well as the middle ear at the beginning of its intrapetrous course. Several procedures have been described for exposure of the ICA at the base of the skull. Extension of the conventional sternocleidomastoid approach by mandibular subluxation associated with division of the posterior belly of the digastric muscle and the styloid apophysis or its attached muscles allows exposure of most of the ICA. To access the last centimeter of the ICA it is necessary ot drill through the mastoid apophysis and the vaginal apophysis of the tympanic bone. This approach preserves the middle ear and the facial nerve.

Surgical management of extracranial internal carotid artery aneurysms

Between 1980 and 1991, 13 of 1312 carotid artery reconstructions were performed for aneurysms of the extracranial internal carotid artery. The patients included 12 men and one woman, mean age 56 years. Postoperative aneurysms and aneurysms involving the common carotid artery were excluded from the study. In six cases, the upper part of the aneurysm was higher than a line joining the mandibular to the tip of the mastoid process. Six aneurysms were atherosclerotic, two post-traumatic, four dysplasic and one post-traumatic and atherosclerotic. Nine patients had focal neurological symptoms (seven hemispherical, two ocular), one presented with cranial nerve compression, two had non-hemispherical symptoms and one was symptom-free. Surgical reconstruction was achieved by 12 venous grafts and one aneurysmorrhaphy. A conventional cervical approach was used in seven cases; in four cases subluxation of the mandible with resection of the posterior belly of the digastric muscle and division of the styloid process and its attached muscles was used. An infratemporal approach with release of the 7th nerve and opening up of the first portion of the carotid canal was used in two patients. There were no deaths or strokes but two patients had a transient ischaemic attack. In four cases, a cranial nerve palsy developed; one involving the 9th nerve did not recover. Patency was assessed by postoperative angiography in all cases. Mean (range) follow-up was 46 (4-126) months. One patient died after 2 years as a result of myocardial infarction. One patient had a transient ischaemic attack during the 2nd postoperative year. All survivors were assessed in January 1992, when all reconstructed arteries were patent.

Surgical reconstruction of the superior vena cava

Ten patients (eight men, two women) who underwent surgical reconstruction of the superior vena cava using an expanded polytretrafluoroethylene (ePTFE) prosthesis between 1981 and 1991 were reviewed to assess the therapeutic value of such surgery. The mean (s.d.) age was 55(12) years. Obstruction of the superior vena cava was caused by pulmonary or mediastinal cancer in nine patients and chronic mediastinitis in one. Eight patients had superior vena cava syndrome and two had symptoms of lung disease. The diagnosis of superior vena cava obstruction was made before surgery by computed tomography or superior venacavography in eight patients and during the surgical procedure in two. Tumour resection was performed in five patients. Venous reconstruction was achieved by interposition of an ePTFE graft between the proximal and distal end of the vena cava in three patients and between one (four cases) or two (three cases) tributaries of the superior vena cava and the right atrium in seven. No patient died during the perioperative period. Symptoms of superior vena cava obstruction disappeared promptly after operation in all patients. Postoperative patency was assessed by cavography or computed tomography; all the grafts were patent. During follow-up no patients presented with recurrent superior vena cava syndrome. Eight patients died. The cumulative survival rates were 70, 25 and 12.5% at 1, 2 and 5 years, respectively. Surgical reconstruction of the superior vena cava with an ePTFE prosthesis provided immediate and long-term relief of symptoms of superior vena cava obstruction with a low surgical morbidity, even in patients with unresectable malignancy.

In vitro antistaphylococcal activity of collagen-sealed Dacron vascular prostheses bonded with rifampin, vancomycin, or amikacin

The goals of this study were to evaluate the in vitro antistaphylococcal activity of vascular Dacron prostheses to which a type I collagen and an antibiotic had been bonded. Collagen was fixed to the prosthesis either by an original grafting procedure or by impregnation. The antibiotics used included rifampin, vancomycin, and amikacin. They were bonded to the prosthesis either at the same time as the collagen or by soaking the prosthesis in an antibiotic solution at the beginning of the experiment. Each prosthesis was sliced into 6 mm diameter circles and preserved in a solution of saline and albumin, which was changed every day. Three disks were retrieved from each prosthesis at the beginning of the experiment and then every 24 hours; these were placed in gelose smeared with Staphylococcus aureus. The diameter of the inhibition area of each disk was measured at 24 hours. The initial inhibition area (So), the time at which the inhibition area was equal to 50% of So, and the time at which the activity was nil were used to characterize the activity of the prostheses and to calculate a beta coefficient of decreasing activity. The prostheses bonded with vancomycin or amikacin did not show adequate activity. Those bonded with rifampin were effective for at least 4 days. When rifampin was grafted to the prosthesis, the So was 278.6 mm2, 50% of So was reached within 10.4 days, the duration of effective activity was 25.7 days, and the beta coefficient was 0.067. The two prostheses soaked in rifampin had a significantly more rapid decrease (beta = 0.19 and 0.56) and a shorter duration of effective activity (12.4 and 4.5 days). Both collagen-coated prostheses, whether impregnated or soaked with rifampin, have a sufficient duration of activity to be tested in an animal model.

[Current status of carotid surgery]

Introduced in the fifties, reconstructive surgery of the carotid arteries has undergone an extensive development in Europe and the United States. Prospective randomized multicentric clinical trials have clearly demonstrated its effectiveness in stroke prevention for both symptomatic and asymptomatic patients with tight carotid stenosis. The diminution of relative risk secondary to surgery is at least 40%; it is 80% for major ipsilateral stroke. There is no benefit if the vessel narrowing is less than 30%. For the 30 to 70% stenosis a benefit has not yet been clearly established. The prophylactic effect of carotid surgery is highly dependent of a low postoperative morbidity. The 30 day stroke plus death rate should not exceed 3% for asymptomatic patients and 5% for symptomatic patients. Postoperative morbidity-mortality has greatly improved over the last twenty years. Several factors are involved; the main improvement may be related to better surgical technique assessed by intra-operative angiographic control rather than the many methods of monitoring or cerebral protection. Ten years patency of arterial reconstruction is greater than 90%. Stroke protection is effective since the annual rate of cerebral events in an operated population is about 2% while it is about 10% in a control population. Inversely, late mortality is still high, primarily due to cardiac disease.

[Intra-arterial thrombolysis using rt-PA for the treatment of occluded infra-inguinal bypasses]

From July 1990 to July 1993, we performed 41 percutaneous intra-arterial thrombolysis procedures for the treatment of obstructed infra-inguinal bypass grafts in 32 patients. There were 27 men and five women with a mean age of 63 +/- 17 years (range 21 to 83 years). The symptoms of occlusion were intermittent claudication in three cases, rest pain in 12 cases, severe ischemia without sensitive-motor loss in 26 cases. Bypasses were achieved using a prosthesis in 18 cases (43.9%), a saphenous vein in 10 cases (24.4%), an arterial allograft in nine cases (21.9%), and a composite prosthesis-vein graft in four cases (9.8%) (table I). The distal anastomosis of the bypass graft was located on the popliteal artery in 26 cases (63.4%) and a crural artery in 15 cases (36.6%). The mean duration of the occlusion was 4.9 +/- 3.4 days (range 1 to 15 days). The percutaneous approach was through the contralateral common femoral artery in 26 cases (63.4%), through the ipsilateral common femoral artery in seven cases (17.1%), through the left humeral artery in eight cases (19.5%). In all cases the thrombolytic agent was the recombinant tissue-type plasminogen activator (rt-PA). Each procedure began with the injection of a five milligram bolus of rt-PA into or onto the thrombus followed by infusion of rt-PA into the thrombus at a dose of 0.05 mg/kg/h. Intravenous heparin was simultaneously administered. Serum fibrinogen, prothrombin time, and partial thromboplastin time (PTT) were measured every three hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Extended operation for lung cancer invading the superior vena cava

Between 1981 and 1991, 845 patients were operated on for right lung cancer. Among them, 50 (6%) had a tumor invading the superior vena cava (SVC). Fifteen patients (14 men and 1 woman, mean age: 58 years) underwent radical resection with concomitant vascular reconstruction. Two patients presented with a superior vena caval syndrome. The SVC was invaded by direct extension from the tumor (n = 11) or by paratracheal nodal involvement (n = 4). The patients required pneumonectomy (n = 13) or upper lobectomy (n = 2), with lateral (n = 11) or circumferential resection (n = 4) of the SVC. The venous pathway was repaired by direct suture (n = 9), prosthetic patch (n = 2) or polytetrafluoroethylene (PTFE) graft (n = 4). Tumor resection was considered macroscopically complete in 12 patients (80%). One patient died postoperatively (7%) and non-fatal complications occurred in 3 (20%). Early patency of the four grafts was assessed by phlebography. In the late course, pulmonary embolism occurred in two patients and extended superior vena caval thrombosis in one; the overall clinical patency rate was 75.7% at 1 and 5 years. Two patients (13.3%) experienced mediastinal recurrence; the overall survival rates at 1 year, 2 years and 5 years were, respectively, 46.7%, 32% and 24% (median: 8.5 months). We conclude that extended resection for lung cancer invading the SVC, when feasible, is justified given the effective control of the primary tumor thereby provided, with an acceptable operative risk.

Internal carotid artery surgery: ten-year results

The twofold purpose of this study was to compare the immediate results of surgery for lesions of the internal carotid artery in two series of patients operated on at 10-year intervals and to assess long-term results in the earliest series. Series I comprised 242 reconstructions in 220 patients (160 men and 60 women, mean age 64.4 years) performed between 1980 and 1982. Seventy patients (35%) were asymptomatic, 113 had monocular or hemispheric symptoms, and 30 had nonhemispheric symptoms. Contrast arteriograms revealed internal carotid artery stenosis of < 30% in 74 cases (30.6%), between 30% and 70% in 49 (20.2%), and > 70% in 119 (49.2%). Reconstruction was achieved by endarterectomy in 164 cases (67.8%), by vein graft in 75 cases (31%), and by other methods in 3 cases (1.2%). Postoperative mortality was 5% (11/110). Nonfatal postoperative stroke occurred in 1.8% (4/220) and transient ischemic attack in 0.5% (1 patient). All reconstructions were patent on postoperative control. The combined mortality/morbidity rate in patients in series II operated on between 1990 and 1991 was significantly lower, that is, 2.4% (4/170) vs. 6.8% (15/220) (p < 0.05). In series I, 11 patients (5%) were lost to follow-up and 124 were still alive at the beginning of the tenth postoperative year. Cumulative survival was 79 +/- 5.6% at 5 years and 60.9 +/- 6.7% at 10 years. The causes of late death were stroke in 7 cases, cardiovascular disease in 30 cases, cancer in 16 cases, and other causes in 20 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemodynamic vertebrobasilar insufficiency caused by multiple arterial lesions: results of surgical treatment

From 1982 to 1990, 111 of 1013 patients undergoing cerebral artery reconstruction presented with signs of vertebrobasilar insufficiency associated with hemodynamically significant lesions of at least three cerebral arteries. There were 71 men and 40 women whose mean age was 70.3 +/- 8.4 years. Forty patients also had hemispheric symptoms, whereas three had ophthalmic symptoms as well. A total of 191 arteries were reconstructed in 139 procedures. During the first 30 postoperative days there were nine deaths (8.1%) attributable to four neurologic events--one myocardial infarction, two hemorrhages, and one acute kidney failure. There were 18 complications including seven neurologic events (four reversible and three irreversible), one myocardial infarction, and 10 reversible local complications. Mortality and morbidity were not affected if one (87 cases) or several (52 cases) cerebral arteries were reconstructed. Of 179 arteries for which follow-up arteriograms were obtained, two (1%) were found to be occluded. Mean follow-up was 41.2 +/- 27.7 months. Four patients were lost to follow-up, and 28 died: five of cerebrovascular causes in the 21 who died of cardiovascular causes and seven secondary to noncardiovascular events. Actuarial 5-year survival and patency rates were 63.3 +/- 10.9% and 97.3 +/- 2.8%, respectively. Functional results were evaluated in 98 patients. At the last follow-up visit 73 were asymptomatic, 13 were improved (80% good results), 5 were unchanged, and 7 were worse. Mortality and morbidity rates were superior to that for isolated carotid or vertebral artery surgery performed during the same period.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bronchial cancer associated with atheromatous arteriopathy. Prognostic and therapeutic consequences in pulmonary excision]

Between January 1980 and January 1985, 462 consecutive patients underwent lung resection for bronchogenic carcinoma. Eighty of these patients (17.3 percent) had atherosclerosis involving mainly the coronary arteries (40 percent). The mortality rate was significantly higher in patients with atherosclerosis (10 percent) than in those without it (4.7 percent), but the long-term survival was not affected with the presence of atherosclerosis. The lung carcinoma-atherosclerosis association raises two problems: what investigations should be carried out in this group of patients at risk, and what treatment should be given priority when vascular lesions are present and likely to become complicated by pulmonary surgery? However, the presence of atherosclerosis should not lead to a re-evaluation of the need for lung resection.

Simultaneous reconstruction of infrarenal abdominal aorta and renal arteries

From 1980 to 1990, 48 (4.7%) of 1,002 patients underwent elective aortic reconstruction and simultaneous renal artery reconstruction. Forty-five men and three women (mean age: 66.5 years) had 59 renal artery lesions (51 stenoses, six occlusions, one dysplasia, and one aneurysm) associated with 20 infrarenal aortic aneurysms and 28 aortoiliac occlusive lesions. One nephrectomy and 58 renal artery reconstructions were performed (35 prosthetic bypasses, 11 vein bypasses, six direct reimplantations, five transaortic endarterectomies, and one resection of an intrahilar aneurysm followed by autotransplantation). Operation was always indicated for the aortic lesions. Indication for renal artery repair was hypertension in 33 cases (17 associated with renal insufficiency) and one with isolated renal insufficiency. In the remaining 14 cases, surgery was deemed preventive. One patient died (2%). There were 12 nonfatal complications two of which were kidney failures requiring chronic extrarenal epuration. Routine follow-up arteriograms showed four postoperative renal artery occlusions. Mean follow-up was 35.8 months. Four patients were lost to follow-up; 10 died secondarily. Five year survival was 72.1 +/- 19.1%. Secondary patency of renal artery reconstruction was 89.5 +/- 9.4% at five years. Late results were favorable in 45% of patients with hypertension and in 39% of patients with renal insufficiency. Mortality in simultaneous aortic and renal artery reconstruction is not superior to that of isolated infrarenal aortic surgery.

Traumatic aneurysms of the internal carotid artery at the base of the skull. Two cases treated surgically

Internal carotid aneurysms at the base of the skull after blunt trauma are infrequent but their management is difficult, leading many surgeons to only attempt ligation. We report 2 cases presenting with high traumatic aneurysms, following motorcycle accidents. The 2 aneurysms underwent repair by a venous graft. The petrous portion of the carotid artery was approached and controlled by an ENT surgeon. This "infratemporal" approach was used exposing the facial nerve, combined with temporary anterior sub-luxation of the temporomaxillary joint to expose the lower part of the carotid canal which was opened up with a drill in order to control the carotid artery in the petrous canal. Both patients developed facial nerve palsies which improved within 3 months. Postoperative angiography showed patent vein grafts and the patients were doing well, without any symptoms 18 and 24 months later.

Use of descending thoracic aorta for lower limb revascularisation

From November 1984 to May 1991, descending thoracic aorta to femoral artery bypass was used to revascularise 51 lower limbs in 27 patients. There were 25 men and 2 women with a mean age of 60.2 years. There were four primary indications because of inability to use the abdominal aorta, and 23 secondary indications for late failure of a previous lower limb revascularisation: two aorto-prosthetic false aneurysms, nine infected aorto-bifemoral bypasses and 12 occluded grafts. Three deaths and one paraplegia occurred during the postoperative period, and three prosthetic occlusions and one popliteal embolism were successfully treated. During follow up (6-72 months) five deaths and three graft occlusions were observed; at 5 years, the cumulative life expectancy was 61.8 +/- 26.8%, and the cumulative secondary graft patency was 72.6 +/- 24.7%. One prosthetic infection and one ureteric fistula occurred and both were successfully treated. Thoracic aorta to femoral artery bypass is a simple extra-anatomic technique which can be used in cases of failure of a previous aorta to lower limb reconstruction. The haemodynamic results are good, and late results are better than axillo-femoral or bifemoral bypass.

Subclavian artery stenosis: hemodynamic aspects and surgical outcome

Ninety seven patients (mean age: 58 years) with lesions involving the subclavian artery were studied to determine the relationship between clinical symptoms, angiographic lesions and Doppler-detected hemodynamic disorders. Ninety patients had vertebro-basilar insufficiency (VBI) and 7 had hemispheric manifestations or upper limb ischemia. Of the 105 lesions of the subclavian artery, we observed 76 stenoses greater than 50% and 29 complete occlusions. Thirty seven patients presented a unilateral subclavian lesion and 63 multiple lesions. Doppler examination of the vertebral artery including an upper limb hyperaemic test allowed classification of the patients into three stages: stage 1 "pre-subclavian steal" (35 patients): sudden decrease in the systolic vertebral flow with complete interruption during hyperaemia; stage 2 "intermittent subclavian steal" (18 patients): transient inversion of vertebral during systole with permanent inversion for 1 or 2 minutes after hyperaemia; stage 3 "permanent subclavian steal" (33 patients): complete inversion of the vertebral flow without diastolic flow and increase of flow during hyperaemia. The clinical, hemodynamic and angiographic findings were compared. In stage 1, 65.7% of the patients presented severe VBI (at least two signs) and 66% had a 50 to 70% stenosis of the subclavian artery. In stage 2, 66.6% of the patients presented severe VBI and 78% had a 75 to 95% stenosis. In stage 3, 72.7% of the patients had severe VBI and 73% had either subtotal or complete occlusion of the subclavian artery. There was no correlation between the severity of VBI and the hemodynamic stages but a strong correlation between the hemodynamic grades and the anatomical lesions.(ABSTRACT TRUNCATED AT 250 WORDS)

Descending thoracic aorta as an inflow source for late occlusive failures following aortoiliac reconstruction

From November 1984 to March 1990, 10 descending thoracic aorta-to-femoral artery bypass procedures were performed after failure of one or several aortoiliofemoral reconstructions. All patients were men, mean age 60 years. Indications included noninfected false aneurysm of an infrarenal end-to-side aortoprosthetic anastomosis in one case; one occlusion of an axillofemoral bypass; degradation of an aortobifemoral prosthetic graft; two occlusions of aortofemoral bypass; and five occlusions of aortobiliac or aortobifemoral bypasses. Eight bifurcated grafts, one aortoprosthetic tube graft, and one aortopopliteal tube graft were inserted. One patient died 23 days postoperatively of multiple organ failure. Three patients underwent a successful seconary lower limb reconstruction procedure (prosthetic limb thrombectomy, embolectomy, femoral bifurcation angioplasty in one case each). Mean survival time was 14 months (range 3-48 months). Two patients were lost to follow-up, and one died of myocardial infarction six months postoperatively with a patent bypass. Graft thrombosis occurred in two patients. One was treated by thrombectomy at five months, the other was treated by in-situ thrombolysis at 15 months. Both of these patients had patent grafts at 12 and 21 months, respectively. The four other patients had patent grafts at 48 months. Primary patency was 55.5% (5/9 survivors) and secondary patency was 100% (9/9). This is a relatively simple method for constructing an extraanatomic aortofemoral or aortobifemoral bypass in late failures of aortoiliofemoral reconstructive surgery without having to re-enter the abdomen.

Results of vertebral artery reconstruction

We summarize here the immediate and long term results of 191 vertebral artery reconstructions. Patient selection criteria included vertebrobasilar insufficiency, appropriate angiographic work up, lack of contraindications, and the availability of a suitable technique. Of the 179 patients who underwent these operations, 170 presented with vertebrobasilar insufficiency that in turn was associated with hemispheric manifestations in 29 cases. Five patients had hemispheric manifestations only, and four were asymptomatic. The operation involved the proximal segment of the vertebral artery in 148 instances and its distal segment in 43 instances. Of the eight deaths recorded in this series (4.2%), one occurred in a group of 118 patients who underwent isolated vertebral artery reconstruction and seven in a group of 72 patients who underwent combined vertebral and carotid surgery. This difference was statistically significant (p less than 0.01). The overall survival rate at seven years was 88.8%, and was higher in the group undergoing isolated vertebral repair. Patency at seven years was 90.4% with better results for proximal vertebral artery repair than for distal repair (94.3% versus 77.3%). With a mean follow-up of 34.6 +/- 19 months, 118 patients are asymptomatic, and 15 are improved, for a success rate of 80.1%. Patients with hemispheric manifestations and associated carotid lesions constitute a high risk population for this type of surgery.

Multiple aneurysms in a seven-year-old child

Arterial aneurysms, rarely encountered in childhood, pose difficult etiologic and therapeutic problems. We report the case of a seven-year-old Algerian girl with aortoiliac, visceral, and limb aneurysms revealed by a tumefaction in the left popliteal fossa. Aortic rupture subsequently occurred. The aneurysms were resected with subsequent prosthetic or vein graft replacement. Three years later, clinical and functional results of the grafts were satisfactory. Possible etiologies include inflammatory arteritis, dysplasia, or idiopathic primary aneurysms.

[Budd-Chiari syndrome and Behçet's disease. A case treated by mesenterico-atrial prosthesis]

A 36 year-old North African man, with Behçet's syndrome complicated by an inferior vena caval thrombosis, developed a chronic Budd-Chiari syndrome associated with bleeding esophageal varices. He was treated by an emergency mesoatrial shunt. Results at 2 years were good. Analysis of this case and the 13 other similar cases with associated Budd-Chiari syndrome and Behçet's syndrome found in the literature showed that hepatic veins thrombosis: a) is often due to inferior vena caval thrombosis or membranous obstruction; b) has a high spontaneous mortality rate by acute liver failure; c) remains a potential indication for porto-systemic shunt, as are other causes of Budd-Chiari syndrome.

[Composite arterial prosthesis for aortofemoral reconstruction with preservation of hypogastric flow]

The technique described uses a composite prosthesis to combine infrarenal aortic resection with aorto-bifemoral bypass while preserving pelvic circulation. Its short-term objective is to prevent colic ischemia and its long-term objective to avoid impotence and gluteal claudication. This technique has the advantages of being simple, rapid and less aggressive than other procedures. It was applied in 6 cases over the last 2 years and was successful in all of them.