P-705 Influence of ovulation induction strategy in oocyte meiotic maturation: hCG versus agonist

Study question

What is the influence of the ovulation induction strategy on the meiotic status of collected oocytes?

Summary answer

Non-invasive imaging of meiotic spindles during ICSI showed that ovulation induction with a hCG improved meiotic maturation and subsequent blastocyst formation rate.

What is known already

Owing to the shorter half-life of GnRH, this strategy has gained attention by significantly reducing risk of ovarian hyperstimulation syndrome. Reduced exposure to LH often requires luteal support and has been associated with a lower live birth rate, a lower ongoing pregnancy rate (pregnancy beyond 12 weeks) and a higher rate of early miscarriage (less than 12 weeks) in fresh autologous cycles, nevertheless. Mid-cycle LH surge triggers molecular activity in follicle cells initiating resumption of meiosis I for competition of the first meiotic division and formation of a MII oocyte inferring competence for subsequent fertilization and further development.

Study design, size, duration

A retrospective observational study was carried in a cohort of 25 - > 36 years old women including 85 patients. Analysis was carried in two groups: 1: GnRHa trigger and 2: hCG trigger and later stratified for patient age.

Participants/materials, setting, methods

Women between 25 and > 36 years old, non PCOS, with an AMH > 1.2 ng/ml and stimulated under a short scheme GnRH-antagonist for downregulation, FSH and ovulation induction with GnRHa or hCG. Oocytes allocated to (intracytoplasmic sperm injection) ICSI treatment were cultured for 3-4 hours striped from cumulus cells 2 hours after retrieval and placed in G-MOPS PLUS in aglass bottom dish and with an Octax PolarAide system.

Main results and the role of chance

A spindle was present in 39.3% (218/554) of all morphologically mature (MII) oocytes alone. Group 1 (GnRHa trigger) and group 2 (hCG trigger) had 56% (309/554) and 44% (245/554) of oocytes at MII stage from which 38% (120/309) and 39% (96/245) showed spindles. A better meiotic maturation stage (scores 3, 4) at ICSI was found when ovulation induction was performed with hCG (group 2) (81% (98/120) versus 88% (85/96), p = 0,0031), nevertheless. Fertilization rate was no different between groups (60% and 58%, respectively), while significantly more blastocysts (at culture day 4 and 5) were generated from group 2 MII oocytes presenting a spindle and a good score (36% (35/98) versus 62% (53/85), p = 0.039). Good blastocyst quality (≥3BB) did not differ between groups. When stratifying for age, women between 25 – 30 presented no differences in presence or meiotic maturation (score 2, 3) in MII oocytes, while fertilization (42% versus 77%, p = 0.022) and blastocyst formation (32% versus 45%, p = 0.012) were better in group 2. Women between > 36 years old presented no differences in presence of meiotic maturation, however, fertilization (40% versus 54%, p = 0.042) and blastocyst formation (25% versus 57%, p = 0.007) were best in group 2.

Limitations, reasons for caution

Thorough multivariable analysis in a larger patient cohort is required to endorse these results, nevertheless.

Wider implications of the findings

Prediction of ovulation induction efficacy in different patient cohorts could help fine tuning cycle management.

Trial registration number

not applicable

[Heart transplantation, indications and results at the University Hospital of Liege]

Heart transplantation remains undoubtedly the most effective treatment for end-stage heart failure, whatever its cause. Last decade has witnessed significant improvements in terms of morbidity and mortality following heart transplant. The 5-year survival rate is now beyond 70 %. However, the shortage of potential donors limits its use and requires strict criteria before listing a candidate for heart transplantation. Herein, we present a review of current indications and results of the heart transplantation program at the University hospital of Liège.

[Budd-Chiari syndrome: a case report and review of the literature]

We report the history of a 20-year-old woman admitted for thrombosis of the sus-hepatic veins and of the inferior vena cava (IVC) with extension of the thrombus into the right atrium. The etiological research was negative and a diagnosis of idiopathic Budd-Chiari syndrome was retained. In view of the absence of vein repermeabilisation under adequate anticoagulant therapy, a venous thrombectomiy was performed under cardiopulmonary bypass, which improved the hepatic venous drainage. Budd-Chiari syndrome is a very serious disorder. Its treatment implies a step by step procedure. An effective anticoagulation must first be established. The complications of portal hypertension then require attention. For a symptomatic patient, one should assess the possibility of restoring the venous permeability, improving the hepatic drainage and decompressing the liver by radiological interventional or surgical procedures. Finally, an hepatic transplantation should be considered in case of treatment ineffectiveness, of fulminant hepatic failure, or of an evolution towards cirrhosis.

Artificial insemination with donor sperm (AID): heterogeneity in sperm banking facilities in a single country (Belgium)

Due to the high inflow of foreign patients seeking cross-border reproductive care in Belgium and the increased number of lesbian couples and single women who call for artificial insemination with donor sperm (AID), Belgian sperm banks nowadays face a shortage in donor sperm. However, since there is no central registration system for sperm donors in Belgium, no figures are currently available supporting this statement. Therefore a study was performed to obtain a detailed overview of the sperm banking facilities in Belgium. Questionnaires were sent to all Belgian centres for assisted reproduction with laboratory facilities (n = 18) to report on their sperm banking methods. The results showed that 82% of the centres rely partially or completely on foreign donor sperm. Moreover, four of the thirteen centres that have their own sperm bank use imported donor sperm in > 95% AID cycles. Our results show that in 63% of the Belgian AID cycles imported Danish donor sperm is being used. Donor recruitment is mainly performed through the centre's website (61%) or by distributing flyers in the centre (46%) and 9 to 180 potential donors have been recruited per centre in 2013. Eventually, 15 to 50% of these candidate donors were accepted. Different criteria for donor acceptance are handled by the centres: donor age limits range from 18-25 to 36-46 years old, and thresholds for sperm normality differ considerably. We can conclude that a wide variation in methods associated with sperm banking is observed in Belgian centres.

Surgical treatment of cardiovascular complications in patients with Marfan syndrome: a report of two cases and literature review

Cardiovascular disease is the main cause of morbidity and mortality in patients with Marfan syndrome. The most life threatening complication is aortic root aneurysms leading to aortic dissection or rupture. It can be prevented by regular aortic follow-up and prophylactic aortic surgery. Modern aortic surgery has led to a substantial increase in the life expectancy of these patients. We report two cases of Marfan syndrome with cardiovascular complications. Their management is discussed according to the most recent literature.

[Structured differential diagnosis of a transient impairment of consciousness]

Transient impairment of consciousness frequently prompts the patient to consult a neurologist or a cardiologist. Detailed medical history and physical examination allow to distinguish fainting from epileptic seizure, metabolic or psychogenic events. We report the history of an 83-year-old woman who presented a transient loss of consciousness.The vascular, investigation demonstrated a subocclusive stenosis of one of the internal carotid arteries. We shall consider the differential diagnosis of transient impairment of consciousness and discuss the relationship between fainting and carotid artery disease.

[Endoleak, a specific complication of the endovascular treatment of aortic aneurysms]

Endoleaks represent the most common complication of endovascular aortic aneurysm repair. With the increasing use of endovascular techniques for aortic aneurysm repair, the prevalence of endoleaks has risen. While maintaining pressurization of the aneurysm sac, endoleaks expose to persistent risks of an evolution towards rupture. Long-term surveillance with imaging studies is necessary to reduce the incidence of these specific complications that may require intervention. The objective of this article is to draw the attention to the possible occurrence of these complications and to report the elements of diagnosis and treatment.

Endovascular aneurysm repair (EVAR): does it fulfil all its promises?

In the trend of the endovascular revolution for occlusive arterial disease, management of aneurysmal disease has known an analogous change in the nineties. Elective endo-aneurysmal stentgrafting (EVAR or endovascular aneurysm repair) is nowadays of widespread application in contemporary practice all over the world, sometimes by over-enthusiast proponents. There is a burden of recent publications on that topic. Critical analysis of relevant data reveal compelling evidence that elective EVAR is a safe procedure with a threefold reduced 30-day morbidity-mortality, when compared to conventional open aneurysm repair. EVAR also deemed efficace in terms of AAA rupture prevention. At the other hand, mid-term follow-up revealed that EVAR does not endure at the long-term in any late survival benefit, compared to open AAA repair. The major concern and drawback of EVAR is its higher cost and the need for indefinite, life-long surveillance, with a 20% reintervention rate (almost catheter-based endovascularly) at 5-year follow-up. In this review-paper, short-term gains of EVAR are balanced against the inherent disadvantages and long-term losses. According best available evidence, EVAR should not longer be the first choice for high-risk patients, judged unfit for open aneurysm repair. There also exist doubt on the use of EVAR in young fit patients with an anticipated long life expectancy. In approximately half of the AAA patients, EVAR can be considered as the appropriate treatment option.

[Aortic pseudo-aneurysm after coarctation repair]

Aortic pseudo-aneurysm is a well-known late complication after surgical repair of aortic coarctation. We report two cases of pseudo-aneurysm of the aortic isthmus evidenced after previous surgical repair of congenital aortic coarctation. These clinical observations give us the opportunity to underline the importance of a specific lifelong medical follow-up for patients who have undergone such surgery.

Cerebral subarachnoid blood migration consecutive to a lumbar haematoma after spinal anaesthesia

We report the case of a woman who received spinal anaesthesia for peripheral vascular surgery of the lower limbs and subsequently developed a spinal subarachnoid haematoma. Interestingly, low back pain was the only symptom of this spinal subarachnoid haemorrhage. During the following days, blood migrated from the spinal haematoma towards the cerebral subarachnoid spaces. The patient presented with stupor, nausea and vomiting that resolved within 2 weeks with conservative treatment.

Open surgery for abdominal aortic aneurysm or aorto-iliac occlusive disease--clinical and ultrasonographic long-term results

OBJECTIVE

To determine postoperative and long-term outcome and assess the relevance of abdominal ultrasound (US) after surgery for abdominal aortic aneurysm (AAA) or aortoiliac occlusive disease (AIOD).

METHODS

Records of 1704 consecutive patients having graft implantation from 1988 to 2000, either for AAA (n = 1144) or for AIOD (n = 560), were reviewed. In 2006, follow-up was 9180 patients-years for the AAA group and 5450 patients-years for the AIOD group. Among 1006 alive patients, 377 were invited randomly for US and clinical examination.

RESULTS

Hospital death occurred in 99 patients (8.6%) of the AAA group (53% in ruptured and 2% in elective AAA), and in 18 patients of the AIOD group (3.2%). There were 581 late deaths, including eight due to prosthesis infection, one to pseudo-aneurysm rupture, and one to graft thrombosis (0.6% graft-related mortality). Prosthesis thrombosis occurred in 32 patients (26 in AIOD group, p < 0.001), and graft infection in 26 (17 in AAA group, p < 0.01). Pseudoaneurysms developed in 90 patients (68 in AIOD group, p < 0.001), including eight at the proximal aortic, one at the distal aortic, two at the iliac and 79 at the femoral anastomosis. In the AAA group only, surgery was required for a new thoraco-abdominal and pararenal aneurysm in eight and four patients, respectively, while US evidenced a 26-35 and a 36-50 mm supraanastomotic aortic dilatation in 65 (32%) and in 14 (7%) patients, at a mean follow-up of 10.5 and 9.3 years, respectively.

CONCLUSION

Long-term results are good after open surgery for AAA or AIOD. Prosthesis infection and anastomotic pseudo-aneurysm are the main causes of graft-related mortality and morbidity, respectively. Because of high incidence of asymptomatic supraanastomotic aortic dilatation, all patients with a history of AAA repair should have regular abdominal US.

[Isolated spontaneous dissection of the superior mesenteric artery: a case report]

We report the case of a 38-year-old man admitted at the emergency department for abdominal pain of abrupt onset. Computed tomographic examination revealed a spontaneous isolated dissection of the superior mesenteric artery and an anevrysm of the coeliac artery caused by the arcuate ligament. Outcome was favorable under conservative medical treatment and a three months follow-up was uneventful. This observation offers the opportunity to present recent insights concerning this pathology.

Surgical treatment of thoraco-abdominal and low thoracic aneurysms of the aorta. One single center experience over ten years

This work presents the results of surgery in thoraco-abdominal aortic aneurysms (TAA) and thoracic descending aortic aneurysms (TDA) in one single center between January 1rst, 1996 and December 31, 2005. It concerns open surgery in 42 and endovascular procedures in ten patients. Forty two patients (11 TDA and 31 TAA (4 type I, 12 type II , 6 type III and 9 type IV)) define the open surgery series. Twenty six patients were operated on elective basis and 16 patients in emergency condition. Surgical correction was made under partial cardio-pulmonary bypass (PCPB) in 70% of cases via femoral vessels; most significant intercostal arteries were reimplanted and cerebro-spinal fluid (CSF) drainage used in half of the cases. Operative mortality was zero in the elective group (0/26) and attained 19% in the emergent group (3/16). Mortality was linked to cerebrovascular accidents (CVA) in two cases and post-pump left lung hemorrhagic infarction in one case. The paraplegia accounts 2/26 in the elective group and one in the emergent group (1/16). That is 7.1% in both groups. At the end of five years, survival is 66% in elective group and 74% in the emergency group. Ten patients (5 TDA and 5 TAA (2 type I, 3 type III)) were treated endovascularly. Operative mortality and postoperative paraplegia were nil.

[Aortoaesophageal fistula caused by a thoracic aortic aneurysm]

Primary aorto-oesophageal fistula, secondary to an aneurysm of the thoracic aorta, are almost fatal. In the literature, only twenty six successfully operated cases have been reported. We report the case of a 78-year-old man with a thoracic aortic aneurysm eroded into the mid oesophagus. Prompt diagnosis of an aorto-oesophageal fistula resulted from clinical history, CT-imaging and oesophagoscopy. The patient was successfully operated by exclusion of the thoracic aneurysm (insertion of a straight cryopreserved arterial allograft), oesophagectomy and cervical oesophagostomy and jejunostomy. The continuity of the digestive tube was later restored after preliminary aortic valve remplacement (stenosis of 0.8 cm2). This case report is the second in which a cryopreserved allograft was successfully implanted in the management of a primary aorto-oesophageal fistula.

Outlook of non operated type B aortic dissection with special reference to the incidence of degenerative abdominal aortic aneurysm (AAA). One center study

OBJECTIVES

to determine the value of pharmacological treatment of type B aortic dissection (B AD) in face of new forms of treatment.

DESIGN

this is a retrospective study of the period from 1990 to 2000. Files of 81 patients have been reviewed and completed by questionnaires.

RESULTS

Two B AD died after admission without any treatment, 10 were operated on with 7 discharged alive (group I); 69 received hypotensive agents and beta-blockers, 65 were discharged alive (group II). Late mortality of the group I is 3/7, not related with B AD. Late mortality after mean follow-up of 56.8 months is 27/65 with 4/27 related to B AD (4 ruptures, 2 operated on). Non fatal secondary surgery amounts 5 in 4 patients. Total B AD aortic events comprise 8/65 patients. Type A AD were operated on successfully (8 : 4 before B AD, and 4 after B AD). Degenerative abdominal aortic aneurysms were present, operated (9) or not (3), in the history of patients and 3 more appear subsequently. At 10 years, actuarial survival is 40% +/- 18.

CONCLUSION

in non-complicated cases of B AD, medical treatment is a reasonable choice, provided that a strict follow-up of the thoracic abdominal aorta is performed.

Intrinsic structural failure of polyester (Dacron) vascular grafts. A general review

Intrinsic structural failure of Dacron prostheses is a late exceptional complication, resulting from a loss of structural integrity of the graft. The authors report six cases of non-anastomotic false aneurysms in the mid-portion of a vascular Dacron graft, observed at a mean of 12 years after insertion. It concerns four femoro-popliteal bypass grafts, one cross-over graft and a branch of a bifurcated aorto-bifemoral graft, implanted between 1980 and 1990. This represents 0.2% of all vascular Dacron grafts implanted in authors' department since 1980. The degenerated prosthesis was excised, and a new bypass graft was inserted. In three cases, histological analysis revealed a foreign body giant cell reaction against fragmented Dacron fibers. In none of the cases there was evidence of graft infection. The authors discuss the evidence and etiopathogeny of this late, unusual complication, inherent to the Dacron graft material. The most probable causative factor is material fatigue, leading to gradual breakdown and fragmentation of individual fibers, and subsequent biodegradation of the basic material. Such an intrinsic weakness of prosthetic fabric has only be observed in first and second generation Dacron grafts.

[Clinical case of the month. Lower limb revascularization from descending thoracic aorta in occluded axillobifemoral bypass]

We report the case of a patient who had lower limb revascularization by a bypass graft originating from the decending thoracic aorta, after total thrombosis of an axillobifemoral bypass graft. The latter had been performed for surgical repair of a secondary aorto-enteric fistula. We successively discuss the three particular apects of this observation: the secondary aortodigestive fistula, the axillobifemoral bypass and the bypass between the descending thoracic aorta and the femoral arteries.

[Stepping-table MR angiography of the upper limb arteries]

Stepping-table MR angiography of the upper limb arteries is reported in a patient with clinical and sonographic signs of ischemia. Advantages and limitations of the technique are discussed.

Crural Artery Bypass with the Autogenous Greater Saphenous Vein

OBJECTIVE

To evaluate the long-term outcome of greater saphenous vein (GSV) infrapopliteal revascularisation in a single centre over a 10 year period.

MATERIAL AND METHODS

Fourty-one variables relating to a consecutive series of 90 crural artery GSV(76% in situ) bypasses in 81 patients (1990-2000) were analysed. The mean age of the 47 men and 34 women was 70 years. Limb-threatening ischaemia was present in 96% of cases, claudication in four patients. In 18 patients, surgery was 'redo'.

RESULTS

The perioperative mortality was 3% (n=3). Patient survival was 54% at 4 years. Independent risk factors affecting survival were chronic renal insufficiency (p=0.04), hypertension (p=0.02), and ischaemic heart disease (p=0.01). Four bypasses thrombosed within 30 days. Three of them could be successfully reopened. Mean follow-up was 39 months. The primary patency rate at 4 years was 80%. Chronic renal insufficiency revealed to be the single independent risk factor for graft thrombosis (p=0.03, RR=12.4). The 4-year limb salvage rate was 88%. No independent risk factor affecting the limb salvage could be identified.

CONCLUSION

Crural artery revascularisation is a valuable option for the management of limb threatening infrapopliteal arterial occlusive disease.

[Prevention of secondary mortality after type B aortic dissection]

Only few dissecting aneurysms type A survive without surgery. Opposingly, the dissecting aneurysms type B are successfully managed by the medical treatment "anti-impulsion". A personal series is reported, that evidence important cardiovascular mortality in the follow-up in chronic dissecting aneurysms type B; one part of this late mortality is linked to rupture of the thoracic descending aorta. Thus, the prevention of this late mortality depends on a strict follow-up of the characters and dimensions of descending aortic thoracic aorta.

[Prevention of lower limb necrosis and amputation by femoro-crural bypass: indications, techniques and results]

Limb threatening ischemia is a challenge for the vascular surgeon. Recent progress in revascularization procedures allow to minimize the primary amputation rate in the management of chronic critical limb ischemia. The authors discuss the prevalence and causes of chronic critical limb ischemia, with a special interest for diabetic arteriopathy. The technique of crural and pedal vessel revascularization is described, as well as the innovative tourniquet technique for distal bypass surgery. A review of published series of infrapopliteal bypass surgery is made. The experience of the authors during last decade with crural and pedal bypass surgery is analyzed.

Dynamics of cardiac wound healing following myocardial infarction: observations in genetically altered mice

Recent improvements in the clinical management of acute myocardial infarction (MI) have resulted in a dramatic decrease in mortality because of this condition. This implies that more patients enter the process of infarct healing. This is a highly complex cascade of events which, although studied for decades, is still not completely understood. An increasing number of genetically altered mice can now be studied in a mouse model of MI, to investigate the contribution of the product of the targeted gene to the infarct healing process. In this review, we will discuss the defects in infarct healing that have been observed in null mutants for plasminogen, urokinase-type plasminogen activator (u-PA), matrix metalloproteinases (MMPS), thrombospondin-2 and dishevelled-1. These studies provide new insights in the infarct healing process itself, but may also help to define new diagnostic and therapeutic targets in humans suffering from MI.

Disruption of the plasminogen gene in mice abolishes wound healing after myocardial infarction

The plasminogen system plays an important role in the proteolytic degradation of extracellular matrices during wound healing. In the present study we investigated the impact of the plasminogen system on cardiac wound healing and function after myocardial infarction. Myocardial infarction was induced in plasminogen-deficient mice (Plg-/-) and in wild-type controls (Plg+/+). Structural analysis 1, 2, and 5 weeks after infarction revealed that infarct healing was virtually abolished in Plg-/- mice, indicating that the plasminogen system is required for the repair process of the heart after infarction. In the absence of plasminogen, inflammatory cells did not migrate into the infarcted myocardium. Necrotic cardiomyocytes were not removed and the formation of granulation tissue and fibrous tissue did not occur. In these non-healing infarcted hearts, LV dilatation was not altered. In addition, gelatinolytic activity of MMP-2 and MMP-9 was depressed in the Plg-/- infarcted hearts, suggesting that the plasmin effect on infarct healing may be mediated by MMPs. Surprisingly, cardiac function was only attenuated to a rather small extent in the Plg-/- infarcted mice when compared to the wild-types. This study provides direct prove that plasmin-mediated proteolysis plays a central role in cardiac wound healing after myocardial infarction in mice.

Rupture of a thoracic aneurysm in the left bronchus

Aortobronchic fistula is a very unusual complication of thoracic aneurysm. We report the case of a 71-year old man with rupture of a thoracic aortic aneurysm in the left main bronchus. The patient had suffered a car crash fifteen years ago, without any evidence of aortic rupture at the time. Thereafter, he developed an aortic isthmic dilation (36 mm in diameter). The patient suffered from long standing pulmonary insufficiency and emphysema and was admitted several times on an urgent basis for acute dyspnea. During an hospitalization for respiratory distress, he presented haemoptysis and left lung hyperinflation secondary to partial fistulization and extrinsic compression of the main left bronchus. Isthmic aortic resection and prosthetic grafting was performed and the left main bronchus was closed by an autologous pericardial patch. Ten days later, following an air-leak from the bronchial closure, a transposed latissimus dorsi flap was used by the plastic surgeon to repair the defect. Nevertheless, the patient died from multisystemic failure six weeks later.

Ischaemic colitis following aortoiliac surgery

Ischaemic colitis following aortoiliac surgery is a feared complication. Its frequency varies from 7% after repair of ruptured abdominal aortic aneurysm (AAA) to 0.6% after bypass for aortoiliac occlusive disease (AOD). In order to analyse predisposing factors and outcome of ischaemic colitis, the authors reviewed their clinical experience from 1988 to 1998. It concerns 28 cases (16 ruptured AAA, 7 elective AAA, 5 OAD) of clinically evident colonic ischaemia. This means an incidence of 7% after repair of ruptured AAA, 0.6% after elective AAA repair, and 0.8% after bypass for AOD. Transmural necrosis (grade 3) was observed in 21 patients, grade 2 ischaemia in 5 patients, and grade 1 ischaemia in 2 patients. Fifteen patients with grade 3 ischaemia underwent colectomy (Hartmann's procedure) with a mortality rate of 66%. All non operated grade 3 patients died. Overall, 16 of the 28 patients died at hospital (57% mortality rate). None of the patients with mild (grade 2 or 1) colonic ischaemia died. Profound hypovolaemic shock and inflammatory AAA were the only significant predisposing factors leading to colonic ischaemia. Associated colon revascularization could not avoid the evolution to colon necrosis in four patients. Reimplantation of a patent inferior mesenteric artery or an internal iliac artery was performed in only 4.8% of all aortoiliac reconstructions, and did not influence the development of ischaemic colitis. The authors conclude that a more liberal use of postoperative sigmoidoscopy could allow detecting colonic ischaemia at an earlier stage and reduce ensuing mortality. A reinforced effort to restore or preserve colonic vascularization could lower the incidence of colonic ischaemia following aortoiliac surgery.

Inhibition of plasminogen activators or matrix metalloproteinases prevents cardiac rupture but impairs therapeutic angiogenesis and causes cardiac failure

Cardiac rupture is a fatal complication of acute myocardial infarction lacking treatment. Here, acute myocardial infarction resulted in rupture in wild-type mice and in mice lacking tissue-type plasminogen activator, urokinase receptor, matrix metalloproteinase stromelysin-1 or metalloelastase. Instead, deficiency of urokinase-type plasminogen activator (u-PA-/-) completely protected against rupture, whereas lack of gelatinase-B partially protected against rupture. However, u-PA-/- mice showed impaired scar formation and infarct revascularization, even after treatment with vascular endothelial growth factor, and died of cardiac failure due to depressed contractility, arrhythmias and ischemia. Temporary administration of PA inhibitor-1 or the matrix metalloproteinase-inhibitor TIMP-1 completely protected wild-type mice against rupture but did not abort infarct healing, thus constituting a new approach to prevent cardiac rupture after acute myocardial infarction.

[Clinical case of the month. Metastatic endocarditis: clinical observation and review of the literature]

The authors describe a case of metastatic endocarditis associated with a gastric carcinoma. The diagnosis was made early and the treatment by surgery and chemotherapy allowed a survival of 18 months, which is unusually long. The differential diagnosis is discussed and includes nonbacterial thrombotic endocarditis, infectious endocarditis and primary tumors of the heart.

[The clinical case of the month. Apropos of a case of unexplained fever]

An episode of fever of prolonged duration and undetermined origin always remains a difficult clinical problem. Several etiologies can indeed be responsible. If one wishes to obtain a diagnosis of the origin of the fever, one should adopt a well-structured strategy in which the various investigations are carried out in a strictly determined hierarchical order. This is badly needed if one wishes to reach a clue to the diagnosis and be able to implement an adequate therapy. In spite of all this, some cases will remain without precise diagnosis. The treatment of those cases will primary be empirical.

Thrombangiitis obliterans (Buerger's disease): still a limb threatening disease

A series of 29 well-documented and properly analysed patients with thrombangiitis obliterans (Buerger's disease) is presented. The diagnosis of Buerger's disease was based on following criteria: smoking history, onset before the age of 50 years, infrapopliteal arterial occlusive disease, either upper limb involvement or phlebitis migrans, absence of atherosclerotic risk factors other than smoking. In the last 10 years (1986-1996), we identified 29 patients who met these rigid criteria. There were 24 men and 5 women, aged 32.4 years at the moment of the disease first clinical symptom. The cumulative tobacco use averaged 16 pack-years for each patient. The initial symptom was limited gangrene of a toe (n = 9) or a finger (n = 2), foot claudication (n = 6), calf claudication (n = 3), rest pain (n = 3), migratory superficial phlebitis (n = 4), and Raynaud phenomenon (n = 2). Angiography and/or Doppler ultrasound revealed digital, pedal and calf artery involvement in all patients, with proximal extension in ten patients (femoropopliteal in ten, including three cases with external iliac artery involvement). Seven patients had also evidence of upper limb involvement. Histologic proof was available in only seven patients. Only nine patients completely stopped smoking. Treatment was exclusively medical in five cases. Twenty-four underwent sympathectomy (20 at lumbar, and four at thoracic level), with good immediate result in 16. In 11 patients a vascular reconstruction was done (eight femorocrural and three iliofemoral bypasses), with a patency rate of only 36% at two years. Amputation was required in 16 patients (a mean of 2.7 amputations per patient) at one or more levels: toe (n = 19), forefoot (n = 5), below knee (n = 8), above knee (n = 2), finger (n = 3). Two patients ended up with bilateral leg amputation. Overall, 23% (7/30) of the patients required major leg amputation during the course of the disease. Disease progression was moderately related to continued tobacco use. Buerger's disease still entails considerable risk of major amputation. Complete abstinence from tobacco use is crucial to expect stabilization of the process. However, in advanced stages of the disease and despite cessation of smoking recurrent episodes of ischaemia or tissue loss are not excluded.

Comparison of results of carotid artery surgery after either direct closure or use of a vein patch

In order to assess the benefit of vein patching versus direct closure after carotid endarterectomy, a series of 2271 carotid operations were analysed retrospectively. Apart from 114 procedures consisting of saphenous vein bypass (n = 29) and eversion endarterectomy (n = 85), 2157 open endarterectomies were performed. They were closed either directly (n = 837) or using a vein patch (n = 1320). The combined mortality-major neurological morbidity rate was 1.7%, i.e. 1% mortality (0.2% neurological) and 0.7% permanent neurological morbidity (0.5% ipsilateral to the operated artery). Early symptomatic internal carotid thrombosis was documented in six cases (four following direct closure and two after vein patching). A total of 827 carotid arteries were followed up by duplex scanning on an annual basis (244 direct closure and 583 vein patching). The mean follow-up was 44 months; 69 months for direct closure and 35 months for vein patching. In direct closure, there were 21 stenoses (9%) and 10 occult thromboses (4%); in vein patching carotids, there were 17 stenoses (3%), nine thromboses (1.8%) [corrected] and six pseudoaneurysms (1%). Annual incidence of poor results was 2.4% in direct closure, and 0.87% in vein patching. The only other factor responsible for a significant difference was gender (3.4% in women versus 2.1% in men). In this retrospective study, vein patching appears to be beneficial for the prevention of acute postoperative thrombosis and late stenosis or thrombosis.

The impact of renal revascularisation on renal dysfunction

AIM

To determine the value of kidney revascularisation in patients with impaired renal function and correctable renal artery stenosis, the authors reviewed their surgical experience from 1978 to 1990.

PATIENTS AND METHODS

The study population included 23 patients with ischaemic nephropathy whose preoperative baseline creatinine level exceeded 20 mg/l (range 21-65 mg/l). This represents 20% of all patients operated on for renal artery disease during the same time interval. Preoperative risk profile, operative mortality, impact on hypertension and on renal function, and late survival were analysed. Renal function response to kidney revascularisation was defined as favourable (20% or more reduction of serum creatinine), moderate (stabilised serum creatinine values) or bad (further deterioration of renal function). All patients had atherosclerotic renal artery disease, involving a solitary kidney in five, both kidneys in 15 and one of the two kidneys in three patients. Hypertension was present in 74%. Revascularisation was unilateral in 10, bilateral in nine and associated with controlateral nephrectomy in four patients.

RESULTS

Four patients died postoperatively (three myocardial infarctions, one stroke). Four patients needed postoperative short-term dialysis. After operation, renal function improved in 13, stabilised in six and deteriorated in four patients (of whom two died). Follow-up among the survivors averaged 46 months. The mean serum creatinine value at last follow-up visit was 26.2 mg/l, a decrease of 7.7 mg/l compared to preoperative values (p < 0.05). Overall, 69% of azotemic patients submitted to renal revascularisation manifested a favourable response (45% improved and 24% stabilised). Three patients required long-term dialysis. The 5-year survival rate was 48%.

CONCLUSION

These data suggest that kidney revascularisation in patients with ischaemic nephropathy can restore or stabilise renal function, preventing evolution and end-stage renal disease and dialysis dependency.

Results of an exclusion technique for treatment of abdominal aortic aneurysm

An exclusion technique for the treatment of abdominal aortic aneurysm was used in six patients considered to be at high operative risk mainly because of chronic pulmonary disease. There were no deaths or immediate major complications. Thrombosis of the aneurysm was achieved in four of the six patients. However, in three cases, repeated percutaneous embolization was required to produce thrombosis. One patient developed a secondary rupture of a persisting infrarenal sac resulting from a patent inferior mesenteric artery. This patient was successfully managed by ligature of the infrarenal portion of the abdominal aorta through a median laparotomy. This study emphasizes the limits and the risks of the exclusion technique.

Venous allografts for critical limb ischaemia

In as many as 25% of the patients with critical lower limb ischaemia, a suitable autogenous vein graft is not available. Patency rate of prosthetic grafts is disappointing at the infrageniculate level. Recently, there is renewed interest in the use of preserved venous allografts as an alternate conduit in patients with threatened ischaemic limbs. From 1991 to 1993, the authors revascularized 12 ischaemic limbs with venous allografts (10 preserved at 4 degrees C, 2 Varivas grafts). The indication for operation was rest pain in five patients and tissue necrosis in seven. Nine patients had one or more previous ipsilateral revascularizations. The at 4 degrees C preserved venous allografts were conserved for a near period of 2 months. In only half (5/10) of the cases ABO isocompatibility could be respected. Distal anastomosis was always below the knee. In 6 patients, the anastomosis was at tibial level. There was one rupture of a Varivas graft on the fifth postoperative day, necessitating ligation of the graft and subsequent amputation. All other grafts remained patent for a mean period of 10.6 months. Actually, 6 grafts are still open. Most patients were given aspirin. Only three patients were under oral coumarin anticoagulation in an effort to prevent early graft failure. The limb salvage rate is 67% (8/12) (mean follow-up of 13 months). The authors discuss the clinical experience with venous allografts as published in recent literature. Use of venous allografts for arterial reconstruction in humans was met with limited success so far. The one year patency approximates 50%. Venous allografts progress in an ineluctable way to a fibrous conduit.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery for occlusive renal artery disease: immediate and long-term results

A retrospective study is presented concerning 115 patients submitted to renal artery surgery from 1978 to 1990, and observed during 2 to 15 years. Included are 69 men and 46 women, aged 14 to 84 years (mean: 58.8 years). The underlying occlusive arterial disease was atherosclerosis in 87 patients, fibromuscular dysplasia in 21, and miscellaneous causes in 7 cases. One hundred and one patients (88%) were hypertensive. Some degree of impaired renal excretory function (serum creatinine level above 16 mg/l) was present in 30% (n = 42) of the patients, whereas 11 patients had severe renal insufficiency (creatinemia above 30 mg/l). Primary nephrectomy was performed in 11 patients as sole procedure and was associated with contralateral revascularization in another 9 patients. A variety of types of arterial reconstruction was performed, although more than half of the procedures were aortorenal bypass grafts. Bilateral procedures were performed in 19 cases. Simultaneous extrarenal operations included aortic reconstruction (n = 43), mesenteric arterial repair (n = 8), and carotid endarterectomy (n = 5). Operative mortality (9/115, 7.8%) varied considerably between the subgroups: 4% for group I (hypertension alone, n = 73), 15% for group II (renal impairment with or without hypertension, n = 34), and 12.5% for group III (acute renal failure, n = 8). There were 3 late non procedure-related in-hospital deaths. Preoperative renal insufficiency was the only independent predictive risk factor for operative death. The procedure was curative or led to improved blood pressure control in 79% (80/101) of hypertensive patients. The response rate was better for recent onset hypertension, compared to long-standing hypertension. Of the 42 azotemic patients, 78% had a benefit (improvement in 50%, stabilization in 28%) of renal revascularization. Associated longstanding hypertension had a negative prognostic value. Sequential clinical and functional follow-up evaluations are available on 99 of the 103 surviving patients. Cumulative 5-year survival is 87%. Cardiovascular causes account for most (11/15) of the late deaths.(ABSTRACT TRUNCATED AT 400 WORDS)

Chronic ischaemic gastritis: an unusual form of splanchnic vascular insufficiency

Three cases of erosive gastroduodenitis secondary to chronic splanchnic vascular insufficiency are reported. In all cases, pain failed to respond to conventional therapeutic measures for peptic ulcer disease. A patchy discolouration and erythematous mottling of the gastric mucosa, with scattered shallow aphthous ulcers, was seen on endoscopic examination. Angiography showed coeliac axis involvement in all patients, with insufficient mesenteric collateral pathways. Chronic gastritis resolved clinically and endoscopically after revascularization.

Pathological aspects of carotid plaques. Surgical and clinical significance

We examined 134 carotid plaques microscopically in 125 consecutive patients, and found 21 (15.7%) had simple fibrous plaques versus 113 (84.3%) complicated plaques. The following plaque characteristics were present: intraplaque hemorrhage (73 plaques), ulceration (83 plaques), fresh thrombus (93 plaques), and recanalized thrombus (22 plaques). An average of 2.4 characteristics were observed in each complicated plaque. The only significant (p less than 0.05) clinico-pathologic correlation was the presence of fresh thrombi, found in 80% of the plaques from patients with a previous transient ischemic attack, in 93% of those with nonfocal neurologic symptoms, and in 80% of those with amaurosis fugax. Analysing the localization of the fresh thrombus (mural or intraluminal), we found that fresh thrombus in symptomatic plaques was most frequently (NS) (71 to 77%) exposed to the vessel lumen. Ulceration without fresh thrombus, plaque hemorrhage and recanalized thrombus were also found in a considerable number of asymptomatic patients, of whom 85% (33/41) presented a form of complicated plaque.

Blowout of carotid venous patch angioplasty

Two cases of vein patch blowout were observed five and seven days after carotid bifurcation endarterectomy with patch angioplasty. Both patients died in spite of emergency reoperation. One patient developed respiratory failure with subsequent fatal cardiac arrest seven days after reoperation; the other died of extensive hemispheric infarction on the fifth postoperative day. At reoperation both ruptures were found to be located in the middle of the patch whereas the suture lines were intact. Both patients were hypertensive. In the first case, an accessory saphenous vein retrieved from the calf had been the only venous material available for the patch, while the other patient had varicose veins in the contralateral leg. Pathology revealed central transmural tissue necrosis in one of the disrupted patches. A review of the literature regarding morphologic alterations of free vein grafts placed within the arterial circulation as well as hemodynamics in patched arterial segments may provide additional insight as to the inherent benefits and risks of vein patch angioplasty after carotid endarterectomy. When considering vein patch angioplasty, particular attention should be directed to the gross aspect of the vein to be used as well as to any antecedent history of phlebitis.

Axillounifemoral and axillobifemoral bypasses. Retrospective study of 85 cases

From 1983 to 1990, 65 axillobifemoral and 20 axillofemoral bypasses have been performed in 85 patients (77 men and 8 women), with a mean age of 69 +/- 9 years. Indications for surgery were: severe aortoiliac occlusive disease (87%), sepsis of previous aortoiliac prosthesis, abdominal aorta aneurysm. Anatomic bypass was precluded for general (81%) or local (19%) conditions. In the last group, 9 patients have had previous laparotomy. Four patients presented with aortoenteric fistulas. Eighteen patients were operated on in emergency. The operative mortality was 12%, with 50% cardiac related deaths. Early primary patency was 98%. Early secondary patency was 100%. The mean follow-up is 28 +/- 15 months. The 3 years survival is 77%. The cumulative patency rates at 1 and 3 years are 89% and 76% respectively. Although axillobifemoral bypasses achieve poor long-term results when compared with aortoiliac bypasses, they can be considered in high risk patients. In this group of patients, the cumulative patency rate and the survival curves tend to be parallel.