Curative treatment of pelvic arteriovenous malformation--an alternative strategy: transvenous intra-operative embolisation.

OBJECTIVES: Pelvic arteriovenous malformations (AVMs) are difficult to treat. Arterial embolisation is the most common strategy but often has poor results. We report an alternative surgical approach of controlled intra-operative transvenous embolisation with long-term results in seven cases. MATERIALS AND METHODS: Between 1980 and 2008, we treated seven patients (four men, three women, mean age 50 years). Indications were rectal bleeding (one case), urinary tract problems (four cases), oedema of lower limb (one case) and high-output cardiac failure (one case). Four of them had previous operations and three had previous attempts for embolisation. Embolisation of the malformation was performed through the internal iliac vein. This was done after clamping of all the feeding and draining vessels. The agent used was cyanocrylate (one case), Ethibloc (one case) and bone wax (five cases). RESULTS: Mortality was 0%. Complications occurred in two patients (28,5%), one pulmonary embolism and one regressive femoral paresis. Three patients were re-operated for various reasons. The mean follow-up period was 6 years (1-12 years). Symptoms resolved in all patients, while control by computed tomography (CT) angioscan revealed one residual shunt. CONCLUSION: Complete surgical excision of pelvic AVMs is not always possible. Embolisation does not offer a permanent cure. Intra-operative transvenous embolisation of persisting complex AVMs appears to be an alternative approach with good immediate and long-term results. Ethylene glycol appears to be the most suitable agent.

The psychological burden of an initially unexplained illness: patients with sternocostoclavicular hyperostosis before and after delayed diagnosis.

BACKGROUND: Sternocostoclavicular hyperostosis (SCCH) is a rare, debilitating, chronic inflammatory disorder of the anterior chest wall due to a chronic sterile osteomyelitis of unknown origin. SCCH is largely underdiagnosed and often misdiagnosed. In individual cases it can remain unrecognized for years. The purpose of this study is twofold. Firstly, to evaluate the psychological condition of SCCH patients, both in the sometimes quite extended pre-diagnostic period between first manifestations and confirmed diagnosis of the disease, and in the current situation. Secondly, to investigate the relationships between the pre-diagnostic and the current psychological conditions of confirmed SCCH patients. METHODS: Structured interviews were held with 52 confirmed SCCH patients. Questionnaires were included to assess posttraumatic stress symptoms, social support, aspects of pain, illness perceptions, self-reported health status, and quality of life. RESULTS: SCCH patients reported stronger posttraumatic stress symptoms, more unfavorable illness perceptions, lower health status, and poorer quality of life than healthy individuals and patients with other diseases or traumatic experiences. Psychological distress in the pre-diagnostic period was associated with unfavorable conditions in the current situation. CONCLUSION: SCCH is an illness with serious psychological consequences. Psychological monitoring of patients with unexplained complaints is recommended as long as a diagnosis has not been reached.

Delayed-iatrogenic injury of the thoracic aorta by an anterior spinal instrumentation.

We present a case of a 15-year-old girl who presented to us with an unusual low back pain. About 7 years ago, this patient had corrective surgery for her idiopathic left thoracolumbar scoliosis. Recent surgery revealed a laceration of the posterior wall of the thoracic aorta by an impending screw thread. This injury was repaired by the vascular surgeons and, subsequently, the patient had full recovery without any complications.

[Late occlusion of the subclavian artery proximal to mammary bypass]. / Occlusion tardive de l'artère sous-clavière en amont d'un pontage mammaire. 2 observations.

We report the cases of two patients with an occlusion of the left subclavian artery several years after left internal mammary bypass of the anterior interventricular artery. The effect on the myocardium was only apparent after scintigraphy in one case, and was clinical in the second with angina pain on exertion of the upper limb. Re-implantation of the subclavian artery in the common carotid relieved the signs of myocardial ischaemia. While the internal mammary artery is the conduit of choice for coronary revascularisation because it is not affected by atheromatous lesions, this does apply to the proximal subclavian artery. Stenosis or occlusion here can entail ischaemia in the revascularised myocardial territory. Regular clinical and ultrasound surveillance can detect these lesions.

Use of biological glue in acute aortic dissection. Preliminary clinical results with a new surgical technique.

Use of a biological glue (GRF) is common in certain fields such as hepatic or renal surgery, but its use in vascular surgery, especially in acute aortic dissection, has not yet been reported. Our experience has demonstrated many advantages: The glue is very simple and safe to use. The aortic tissues are firmly reinforced and the sutures tighten immediately. The proximal aortic stump is anatomically reconstructed, and generally the aortic valve can be preserved and coronary reimplantation avoided. The preoperative and postoperative bleeding rates are low and the postoperative course generally is simple. The risk of maintenance or recurrence of the dissection process is reduced. Consequently, the hospital mortality rate can be reduced to about 10 percent and the long-term survival rate greatly improved.

The cavaportal shunt in interruptions of the suprarenal inferior vena cava.

Abrupt interruption of the suprarenal inferior vena cava can have dramatic consequences and can be difficult to repair successfully. In the case reported, an excellent result was obtained by a cavaportal anastomosis, with minimal consequences on renal and hepatic functions.

Inadvertent arterial injury during saphenous vein stripping: three cases and therapeutic strategies.

We report 3 cases of iatrogenic arterial injuries in relation to saphenous vein stripping. In 2 cases the patients sustained acute severe ischemia and required prompt revascularization. The third patient was seen at a later stage with chronic ischemia and claudication. All 3 patients had their limbs salvaged without severe sequelae. The therapeutic strategies for different situations are discussed.

Long-term follow-up of positive cultures in 500 abdominal aortic aneurysms.

Routine aneurysm culture is frequently performed as it is thought that a positive culture could be a risk factor for secondary graft infection. Five hundred aneurysms, in a series of 796 patients, had microbiologic examination of the thrombus and/or aneurysm wall. Cultures were positive in 185 cases (37%), mostly due to normal skin flora microorganisms (80%), whereas 16 patients (3.2%) had infectious aortitis. Gram-stained smears were positive in nine of these 16 patients compared with two of the other 169. Of the 185 patients with positive culture, after a mean length of follow-up of 35 months, only one had a graft infection that occurred 6 years later and was not due to the same microorganism. Graft sepsis was diagnosed in six of the 296 patients who did not have a positive culture, and was related to clinically obvious locoregional or systemic foci. In this series, positive cultures from aneurysm without rupture or signs of infection were not a risk factor for secondary graft sepsis. Therefore, in cases of asymptomatic unruptured aneurysm, routine culturing is not necessary as a positive result has no pathogenic significance or therapeutic implication.

Aortocoronary bypass with homologous saphenous vein: long-term results.

Between February 1973, and February, 1979, 27 homologous saphenous veins were used in 20 patients (mean age, 54 years). Seven fresh grafts were used less than 24 hours after severance. They were kept at a temperature of 4 degrees C in saline solution containing penicillin. Twenty cryopreserved grafts were used within a period of eight days to 2 months from severance. They were preserved in glycerol at a temperature of -40 degrees C. One patient (5%) died postoperatively. A perioperative myocardial infarction developed in 3 patients (15%). Average follow-up is 27 months. No late mortality was registered. Fifteen patients are free from symptoms, and 3 patients have residual angina with exercise. Control angiograms were made in 13 patients 1 to 68 months after operation; 17 homografts were seen. Early occlusion of 1 graft and late occlusion of 8 grafts were registered. The poor late patency rate does not seem to be related to either histocompatibility or technical conditions. Conversely, microscopic examination of several cryopreserved grafts showed that the mode of preservation resulted in deterioration of intimal and medial tissues of the vein. Therefore, it appears to us that the use of homologous saphenous veins should be avoided for coronary bypass.

Embolized ischemic lesions of toes in an afibrinogenemic patient: possible relevance to in vivo circulating thrombin.

Fibrinogen plays a complex role in hemostasis, thrombosis, and vascular disease. Hyperfibrinogenemia is an independent vascular risk factor and dysfibrinogenemia can provoke thrombosis. Afibrinogenemia is usually responsible for hemorrhagic diathesis, and unexpected ischemic lesions are intriguing. We report the case of an afibrinogenemic patient, who at the age of 30 developed ischemic lesions of the feet related to severe stenosis of the iliac and hypogastric arteries. The biopsy of the iliac artery lesion showed an intense myointimal hyperplasia. We performed standard hemostatic analysis and analyzed the activation markers of platelets and coagulation factors and the kinetics of thrombin generation in the patient and in normal control plasmas treated or not with reptilase. Occlusive arterial lesions were attributed to a disruptive hematoma penetrating the vascular lumen. Thrombin concentration after calcium addition increase markedly in the afibrinogenemic patient and in defibrinated normal plasma, as compared to untreated normal plasma. Thrombin-antithrombin complexes (T-AT) were markedly enhanced while F1+2 prothrombin fragments stayed in the normal range. These results suggested activation of coagulation and in vivo circulating thrombin. Thrombin activates the platelets that secrete growth factors for smooth muscle cells and generate the intimal hyperplasia. Recurrent hemorrhage within the vessel wall might induce injury and local thrombin generation. Thrombin not trapped by the clot is available for platelet activation and smooth muscle cell migration and proliferation. The absence of a protective fibrin cap on the intima might account for intima vulnerability and embolization. Afibrinogenemia appears in this paradoxical situation as a vascular risk factor.

Impairment of vertebral artery flow caused by extrinsic lesions.

In a consecutive series of 71 cases of extrinsic lesions involving the vertebral artery (VA), 51 patients presented with external compression of this vessel. The compressive agents included 34 tumors, 4 osteophytes, 5 fibrous bands, 4 traumatic lesions, 2 neural elements, and 2 infectious processes. The main site was the second portion of the VA (C2-C6) (30 of 51 patients). Compression always induced at least significant stenosis, and in 8 patients caused complete occlusion. The compression was either permanent (44 patients) or intermittent (7 patients). Symptoms were observed in 11 patients, including 2 with permanent deficits. Surgical release of compression was performed each time symptoms could be explained by a reduction in VA flow and also when the compressing agent needed to be removed, as in the cases involving tumors. VA decompression was achieved by direct approach in 37 patients, by reduction and fixation of a traumatic dislocation in 2 patients, and by distal revascularization in 4 patients. Medical treatment or roentgenotherapy was used in the other patients. Results were excellent in all but 2 patients, who died from traumatic and ischemic lesions, respectively. Therefore, it seems important to identify external causes of compression of the VA for two reasons: 1) to suppress symptoms of vertebrobasilar insufficiency when their relation to VA compression is clearly established, and 2) to remove compressive agents like tumors safely while preserving the VA.

Extradural and hourglass cervical neurinomas: the vertebral artery problem.

Eleven cases of cervical neurinomas with an extradural component were operated on with control of the vertebral artery as the first step of the surgical procedure. The lateral anterior approach was used first in each case with excellent results. In the case of hourglass tumors (seven cases), a complementary posterior approach was performed to remove the intradural portion. Primary control of the vertebral artery in cases of extradural or hourglass neurinoma is a logical and safe procedure in the attempt to achieve complete and bloodless tumor removal.

Cervical osteochondroma (C2 level) with vertebral artery occlusion and second cervical nerve root irritation.

A case of osteochondroma arising from the C2 transverse process, responsible for vertebral artery compression with complete occlusion and C2 nerve root irritation with C2 neuralgia, is reported. Complete surgical removal was achieved via the lateral anterior approach.

Surgical management of vertebral-basilar insufficiency.

The authors report 251 cases of lesions of the major branches of the aortic arch and the vertebral artery in 172 patients. A detailed account is given of the observed lesions (34 lesions of the innominate artery, 93 of the subclavian artery and 119 of the vertebral arteries), the techniques used and the indications for surgery. The use of the cervical approach seems to be justified in order to adapt the extent of cure to the patient's condition and accounts for the low mortality rate of 1.5%.

Transient relief of abdominal angina by Wallstent placement into an occluded superior mesenteric artery.

A 56-year-old man presented with complete occlusion of the superior and inferior mesenteric arteries resulting in chronic mesenteric ischemia. After a minimal angioplasty a Wallstent was inserted across the superior mesenteric artery occlusion. This produced immediate clinical relief, with a successful angiographic result. Eight months later, an intrastent occlusion with acute bowel infarction was treated in emergency by saphenous vein bypass graft. Despite the death of the patient a few days later from a multivisceral failure syndrome, this method seemed to us feasible in treating a chronically occluded SMA in patients with high operative risk.

[Vascular complications after the treatment of carcinoma of the cervix (author's transl)]. / Complications vasculaires tronculaires après traitement du cancer du col utérin.

Vascular complications after this treatment are rare. Artery stenosis or occlusions, more often iliac, are well recognized complications of postoperative radiotherapy. These segmental lesions, sometimes, are pathological lesions similar to arteriosclerotic changes. These lesions may be corrected later on after the treatment of carcinoma of the cervix. The venous complications often present later and tall within the context of post thrombotic syndrome. Conservative treatment is indicated alone. A well recognized complication, lymphedema is usually mild; a superimposed iliofemoral thrombophlebitis often may be suspected.

Surgical management of vertebral-basilar insufficiency.

The authors report treatment of 251 lesions of the major branches of the aortic arch and the vertebral artery in 172 patients. A detailed account is given of the lesions observed (34 lesions of the innominate artery, 93 of the subclavian artery and 119 of the vertebral arteries), the technics used and the indications for surgery. Use of the cervical approach seems to be justified in order to adapt the extent of surgery to the patient's condition. This accounts for the low mortality rate of 1.5%.

[Effects of ultrasound energy on femoral artery occlusion. Angiographic and angioscopic results]. / Effets de l'énergie ultrasonore sur les occlusions artérielles fémorales. Résultats angiographiques et angioscopiques.

Ultrasonic energy has been shown to be able to disrupt atherosclerotic plaques and thrombi. The authors used an ultrasonic angioplastic technique developed by the group in 10 patients with a femoral arterial occlusion. The ultrasonic angioplasty was attempted before surgical bypass using a 130 cm long titanium guide wire with a 0.8 mm diameter and a round distal tip measuring 2 or 2.5 mm. Angiographic and angioscopic examinations were performed before and after the procedure in 9 patients. It was not possible to perform the angioplasty in 1 patient. Angioscopy showed that the proximal part of the occlusion consisted of atheromatous material in 3 cases and of thrombus in 6 cases. Angiography showed complete restoration of flow in 4 cases; distal flow was very slow in 4 cases and no distal run-off was observed in 1 case. Angioscopy showed residual stenosis at the site of entry in only 1 case. In 3 cases, the artery had no significant residual stenosis. In the other 5 patients residual stenosis was present and angioscopy showed persistence of strands of fibrin and small thrombi. These results show that ultrasonic angioplasty was capable of recanalising an occlusion in 9 out of 10 patients with partial or total disruption of thrombi. At the present stage of development of this system, balloon angioplasty would be an essential complement in most cases in order to obtain normal flow without significant residual stenosis. The manoeuverability of the guide wire and the relatively small size of the round distal tip explain why not all the thrombi could be treated.(ABSTRACT TRUNCATED AT 250 WORDS)

[Extratemporal Horton's disease: diagnosis using subclavian biopsy. 4 cases]. / Maladie de Horton à localisation extratemporale: diagnostic par la biopsie sous-clavière. 4 observations.

A histological diagnosis of Horton's disease was made in 4 patients with lesions of the axillary-subclavian arteries by biopsy of these vessels. Unilateral biopsy of the temporal artery, performed initially in 2 of these patients, during surgery in one and immediately after surgery in another, had been negative in 3 cases and insufficient for a diagnosis in 1 case. For temporal biopsy to be valuable, the arterial fragment resected must be long enough and serial histological sections must be performed to avoid false-negative results. It is only when these conditions are fulfilled that negative results may be considered. Horton's disease of the axillary-subclavian arteries is relatively frequent, and histological studies of these vessels have already been used to assert the diagnosis in case of negative or non-performed temporal biopsy, whether or not the arteriographic findings were suggestive of the disease. The indications for subclavian biopsy remain to be determined. It can be carried out for diagnostic purposes in case of clinically atypical suspected Horton's disease revealed by axillary-subclavian lesions and negative temporal biopsy, particularly when revascularization proves necessary.

[4-year clinical experience with gelatin-resorcinol-formol glue in acute dissections of the ascending aorta]. / Quatre ans d'expérience clinique de la colle gélatine-résorcine-formol dans les dissections aiguës de l'aorte ascendante.

The gelatine-resorcine-formol glue (GRF) was used to reinforce the tissues of 25 patients operated for acute dissection of the ascending aorta, between January 1977 and September 1980. The results were compared with those of a control group of 25 patients operated between 1970 and 1976 by "classical techniques". There were no significant differences between the two groups as regards age, anatomical and preoperative clinical states. The ascending aorta was replaced in all patients; the aortic valve was replaced three times (12 p. 100) in the GRF group and twelve times (48 p. 100) in the control group: the coronary arteries were bypassed or reimplanted in 20 p. 100 of patients in both groups. The average peroperative blood loss was 5,800 ml in the control group and 2,100 ml in the GRF group (p less than 0,01). There were four peroperative deaths (16 p. 100) in the control group and no peroperative deaths in the GRF group. Postoperative complications (renal failure, cerebral ischemia, persistent peripheral ischemia or infection) were much more common in the control group. They were responsible for eight hospital deaths in the control group and two hospital deaths in the GRF group (p less than 0,01). Therefore, global hospital mortality was reduced from 48 p. 100 (control group) to 8 p. 100 (GRF group) (p less than 0,01). Two late deaths occurred in the control group, but there were none in the GRF one, all survivors being in good clinical condition. Sixteen patients in the GRF group underwent 19 angiographic controls, 2 to 36 months after surgery. These investigations showed two moderate aortic regurgitations (8 p. 100), three persistent dissections of the descending aorta but a stable, good quality repair in the other patients. In conclusion, the use of GRF glue significantly reduced: 1) the number of aortic valve replacements, 2) per- and postoperative blood loss, 3) the incidence and severity of postoperative complications. The long-term survival rate (4 years) has improved from 40 to 91 p. 100.