[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.

Primary mechanical stapled anastomosis in surgery for colorectal emergencies.

From May 91 to March 99 a consecutive series of 100 acute obstructions or perforations of the left colon or rectum were treated by primary resection with mechanical anastomosis using a double or triple stapling technique without proximal colostomy. There were 8 postoperative deaths (8%) due to sepsis, acute respiratory distress syndrome, pulmonary embolism, stroke, and cachexy. Complications occurred in 29% of surviving patients. Clinical anastomotic leaks were observed in 7%, respiratory infection in 8%, wound infection in 8% and major cardiovascular problems in 4% of patients. The median hospital stay was 19 days. The morbidity and mortality of this series did not exceed the cumulative morbidity and mortality that can be expected after staged surgery. Compared with staged surgery, immediate resection and anastomosis using an entirely mechanical suture, thereby avoiding the problems of colostomy and reducing the length of hospital stay, has significant advantages for patients.

[Focal atherosclerotic abdominal aortic stenosis]. / Sténose médio-aortique d'origine athéroscléreuse.

We report a case of a 54-year-old woman presenting a symptomatic focal atherosclerotic abdominal aortic stenosis. Computed tomographic angiography allowed to study the lesion, the abdominal aorta and its main branches. The patient was treated via an endovascular approach using a covered stent. The postoperative course was uneventful and the patient was asymptomatic with a patent reconstruction after 18 months. Improvement in endovascular technology has totally modified the treatment of focal atherosclerotic abdominal aortic stenosis. However, many technical points remain to be determined including the necessity of systematic stenting, the type of stent to use, and the steps of the procedure.

'Pole test' measurements in critical leg ischaemia.

BACKGROUND: For the quantification of critical limb ischaemia (CLI) most vascular surgery units use sphygmo-manometric and transcutaneous oxygen pressure (TcPO2) measurements. However, measurements obtained by cuff-manometry can be overestimated especially in diabetic patients because of medial calcification that makes leg arteries less compressible. TcPO2 measurements present a considerable overlap in the values obtained for patients with different degrees of ischaemia and its reproducibility has been questioned. Arterial wall stiffness has less influence on the pole test, based on hydrostatic pressure derived by leg elevation, and this test seems to provide a reliable index of CLI. OBJECTIVE: The objective of this study was to evaluate the pole pressure test for detection of critical lower limb ischaemia, correlating results with cuff-manometry and transcutaneous oxygen pressure. DESIGN: University hospital-prospective study. MATERIALS AND METHODS: Seventy-four patients (83 legs) with rest pain or gangrene were evaluated by four methods: pole test, cuff-manometry, TcPO2 and arteriography. CLI was present if the following criteria were met: (a) important arteriographic lesions+rest pain with an ankle systolic pressure (ASP) < or = 40 mmHg and/or a TcPO2 < or = 30 mmHg, or (b) important arteriographic lesions+tissue loss with an ASP < or = 60 mmHg and/or a TcPO2 < or = 40 mmHg. Fifty-seven lower limbs met the criteria for CLI. RESULTS: Measurements obtained by cuff-manometry were significantly higher to those obtained by pole test (mean pressure difference: 40 mmHg, p<0.001). The difference between the two methods remained statistically significant for both diabetics (50.73, p<0.001) and non-diabetics (31.46, p<0.001). Mean TcPO2 value was 15.51 mmHg and there was no important difference between patients with and without diabetes. Overall, there was a correlation between sphygmomanometry and pole test (r = 0.481). The correlation persisted for patients without diabetes (r = 0.581), but was not evident in patients with diabetes. Correlation between pole test and TcPO2 was observed only for patients with diabetes (r = 0.444). There was no correlation between cuff-manometry and TcPO2. The pole test offered an accuracy of 88% for the detection of CLI. The sensitivity of this test was 95% and the specificity 73%.

Juxtarenal aneurysm. Comparative study with infrarenal abdominal aortic aneurysm and proposition of a new classification.

OBJECTIVE: to propose an anatomical classification of juxtarenal aortic aneurysm (JRA) that relates to their epidemiology and the result of surgical repair. MATERIAL AND METHODS: retrospective study of 53 JRA and 376 infrarenal aortic aneurysm (AAA) operated between January 1989 and August 1999. RESULTS: perioperative mortality after JRA repair was 19% for type A (interrenal), 13% for type B (aneurysm of one or two renal origins) and 4% for type C (no infrarenal neck). These differences were not significant. The overall perioperative mortality after JRA repair (11%) was significantly higher than mortality of AAA (3%p<0.01). Postoperative morbidity after JRA repair was 62% for type A, 75% for type B and 33% for type C. Postoperative morbidity after type B repair was significantly more frequent than after type C (p<0.001). The overall postoperative morbidity (51%) was significantly more frequent than after AAA repair (26%p<0.01). Preoperative ischaemic heart disease, aortic clamping above the coeliac axis and aortic proximal clamping longer than 30 min were significant risk factors for death after JRA repair. Survival by life-table analysis at five years after JRA repair and AAA repair were respectively 73%+/-7% and 76%+/-3%. CONCLUSION: there is a less favourable outcome after JRA repair as compared to AAA repair. The complexity of the surgical procedure requires accurate preoperative morphological assessment. The proposed classification of juxtarenal aneurysms may be helpful in guiding surgical access.