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.

Early carotid endarterectomy after intravenous thrombolysis for acute ischaemic stroke.

UNLABELLED: After intravenous thrombolysis (IVT) for acute ischaemic stroke (AIS), a severe cervical internal carotid artery (ICA) stenosis may remain and increase the risk of recurrent stroke. Carotid endarterectomy (CEA) has been shown to be effective in reducing the risk of stroke. However, it is not well known whether CEA can be performed safely after thrombolysis, and, if so, when. We report a prospective study of CEA for residual high-grade cervical ICA stenosis performed within 15 days after IVT for AIS. METHODS: All the patients had a brain magnetic resonance imaging (MRI) within 3h of the stroke onset. One day after IVT in neurovascular unit, computed tomography (CT) angiography was performed to assess the brain and the patency of cervical arteries. CEA was performed on neurologically stable patients after full cerebral artery re-canalisation. Blood pressure was controlled with particular caution before and after CEA. RESULTS: Between January 2005 and January 2008, we operated consecutively on 12 patients. Their median National Institutes of Health Stroke Scale (NIHSS) score was 12 (range: 5-21). Combined intracranial (ICA)-middle cerebral artery (MCA) occlusion was present in 58.3% of the patients. The median time between onset of symptoms until CEA was 8 days (range: 1-16 days). Stroke and death rate at 30 days was 8.3% (one nonfatal haemorrhagic stroke). At 90 days, nine patients had a Rankin score of 0-1, one had a score of 2 and two had a score of 3. CONCLUSION: In patients with residual cervical ICA stenosis after IVT, we achieved full patency of the occluded artery and good functional prognosis at 3 months in all cases. We advocate for an extremely close monitoring of the blood pressure in the pre-, peri- and post-operative course and a close collaboration between neurologist and surgeon to determine the best timing for CEA.

Prevalence of peripheral arterial disease in high-risk patients using ankle-brachial index in general practice: a cross-sectional study.

AIMS: The deleterious nature of peripheral arterial disease (PAD) is compounded by a status of underdiagnosed and undertreated disease. We evaluated the prevalence and predictive factors of PAD in high-risk patients using the ankle-brachial index (ABI). METHODS: The ABI was measured by general practitioners in France (May 2005-February 2006) in 5679 adults aged 55 years or older and considered at high risk. The primary outcome was prevalence of PAD (ABI strictly below 0.90). RESULTS: In all, 21.3% patients had signs or symptoms suggestive of PAD, 42.1% had previous history of atherothrombotic disease and 36.6% had two or more cardiovascular risk factors. Prevalence of PAD was 27.8% overall, ranging from 10.4% in patients with cardiovascular risk factors only to approximately 38% in each other subgroup. Prevalence differed depending on the localization of atherothrombotic events: it was 57.1-75.0% in patients with past history of symptomatic PAD; 24.6-31.1% in those who had experienced cerebrovascular and/or coronary events. Regarding the classical cardiovascular risk factors, PAD was more frequent when smoking and hypercholesterolemia history were reported. PAD prevalence was also higher in patients with history of abdominal aortic aneurysm, renal hypertension or atherothrombotic event. Intermittent claudication, lack of one pulse in the lower limbs, smoking, diabetes and renovascular hypertension were the main factors predictive of low ABI. CONCLUSIONS: Given the elevated prevalence of PAD in high-risk patients and easiness of diagnosis using ABI in primary care, undoubtedly better awareness would help preserve individual cardiovascular health and achieve public health goals.

[Endovascular aneurysm repair follow-up by unenhanced and contrast-enhanced duplex ultrasound]. / Surveillance des endoprothèses aortiques abdominales : intérêt de l'échographie-doppler standard et avec contraste.

OBJECTIVE: Long-term surveillance is needed after endovascular aneurysm repair to monitor the aneurysm and search for persistent endoleaks. Our aim was to compare follow-up with duplex ultrasound, with and without a new contrast agent to track endoleaks, versus computed tomography angiography taken as the gold standard. MATERIAL AND METHOD: Patients treated with endograft were included prospectively from December 2005 to July 2006. Aortic duplex ultrasound and computed tomography were used to measure maximal aneurysm diameter and detect endoleaks. Patients with a high risk of endoleaks had a contrast-enhanced ultrasound with Sonovue (Bracco, Milan, Italy). We compared echographic and tomographic diameter and studied the sensitivity of ultrasound endoleak diagnosis. RESULTS: Sixty-seven patients were included. There was a good correlation between maximum anteroposterior diameters (CCI=0.98) measured by ultrasound and tomography, as well as mean maximum cross section diameters (CCI=0.96). Compared to tomography, the sensitivity of ultrasound endoleaks diagnosis was 44% (kappa=0.58). Contrast injection improved this sensitivity significantly (p<0.001) (sensitivity=88%; kappa=0.72). CONCLUSION: These findings confirmed the performance of our ultrasound method for endograft surveillance. Contrast-enhanced ultrasound significantly improves the sensitivity of detection of endoleaks. We suggest alternating ultrasound and tomographic exams. A unique report chart for use nationwide would be useful for standardizing follow-up.

Homocysteine induces synthesis of a serine elastase in arterial smooth muscle cells from multi-organ donors.

OBJECTIVES: In heart transplant recipients with diffuse coronary arteriopathy, we have previously demonstrated the prevalence of elevated homocysteinemia, also known as an independent risk factor for myocardial infarction and stroke. In hyperhomocysteinemic mini-pigs we also observed early detectable pathologic changes in the elastic laminae. We hypothesized that homocysteine causes premature breakdown in the arterial elastic fibers by activation of the elastolytic activities. METHODS: We examined the effect of homocysteine on elastase-like production by smooth muscle cells from sub-inguinal arteries of multi-organ donors (23.4 +/- 3.4 yr, n = 8). The freshly isolated cells were incubated for 0-72 h with homocysteine (0-250 microM), in the presence or absence of specific protease inhibitors. RESULTS: Homocysteine was devoid of a direct effect, but after 18 h incubation the elastase-like activities increased by 5-6-fold in the extracellular medium. The enzymes were characterized as serine proteases. Incubation of cells with a nucleic acid synthesis inhibitor (actinomycin D) or a protein synthesis inhibitor (cycloheximide) suppressed the enzyme induction. CONCLUSIONS: This is the first report of serine protease induction by homocysteine in vascular smooth muscle cells. The process may require protein synthesis and account for the early alterations of the arterial elastic structures in heart transplant recipients, and in other hyperhomocysteinemic patients, as well.

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.

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.

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.

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)

Cannabis arteritis revisited--ten new case reports.

The purpose of this paper was to revisit the old concept of cannabis arteritis first described in the 1960s and report 10 new cases. Ten male patients, with a median age of 23.7 years developed subacute distal ischemia of lower or upper limbs, leading to necrosis in the toes and/or fingers and sometimes to distal limb gangrene. Two of the patients also presented with venous thrombosis and three patients were suffering from a recent Raynaud's phenomenon. Biological test results did not show evidence of the classical vascular risk factors for thrombosis. Arteriographic evaluation in all cases revealed distal abnormalities in the arteries of feet, legs, forearms, and hands resembling those of Buerger's disease. A collateral circulation sometimes with opacification of the vasa nervorum was noted. In some cases, arterial proximal atherosclerotic lesions and venous thrombosis were observed. All patients were moderate tobacco smokers and regular cannabis users. Despite treatment with ilomedine and heparin in all cases, five amputations were necessary in four patients. The vasoconstrictor effect of cannabis on the vascular system has been known for a long time. It has been shown that delta-8- and delta-9-tetrahydrocanabinols may induce peripheral vasoconstrictor activity. Cannabis arteritis resembles Buerger's disease, but patients were moderate tobacco smokers and regular cannabis users. These cases show that prolonged use of cannabis could be an additive risk factor for juvenile and young adult arteritis. Cannabis arteritis is a forgotten and severe occlusive vascular disease occurring in young adults. Search for cannabis use may be an important tool for a better knowledge of arteritis in young smokers.

[Detection of arterial thrombi using blood platelets labeled with indium-111]. / Détection des thrombus artériels par les plaquettes marquées à l'indium 111.

Scintigraphy with Indium 111-labelled platelets was carried out in 62 patients (37 transient cerebral ischaemic accidents, 21 lower limb ischaemic episodes and 4 aortic aneurysms) to detect arterial thrombi. The results of this investigation were compared with the surgical findings and showed this to be a satisfactory method of detecting haematologically active thrombi.

[Double-blind randomized controlled trial of ifenprodil tartrate versus placebo in chronic arterial occlusive disease of the legs at stage II of the Leriche and Fontaine classification]. / Essai comparatif randomisé en double-aveugle du tartrate d'ifenprodil versus placebo dans l'artériopathie oblitérante chronique des membres inférieurs au stade II de la classification de Leriche et Fontaine.

Authors report results on a comparative multicenter double blind trial carried out to assess the efficacy of Ifenprodil tartrate (*) (60 mg a.d.) versus placebo in symptomatic treatment of stable peripheral arterial occlusive disease (Fontaine stage II). Ninety four patients were included in this six months, two parallel group study (2 homogeneous groups) which shows a statistically significant functional improvement in the treatment group versus the placebo group. After six months of treatment, the maximum walking distance (MWD)--main assessment criteria--was 126.0 +/- 18.5 meters in the Ifenprodil group versus 46.4 +/- 20.2 meters in the placebo group (p = 0.005). This represents an improvement of 62.1% in the Ifenprodil group versus 21.0% in the placebo group. An improvement of at least 50% in MWD was observed in 41.3% of patients treated by Ifenprodil and in only 12.5% of patients receiving placebo (p = 0.002). The evolution of ankle/brachial systolic post exercise index from JO to J180 was not significantly different in the two groups. Clinical and biological tolerance of Ifenprodil tartrate was excellent.

[Emboli-forming arteriopathies of the limbs]. / Les artériopathies emboligènes des membres.

Atheromatous embolism disease is a recently defined entity of still to be determined prevalence. This complication can develop during the course of any arterial disease by overload or dystrophy in lower limbs, and is certainly responsible for many cases of worsening of subacute ischemias occurring during arterial disease for which it is not always possible to affirm the embolic origin. It is in no way a rare syndrome and the true frequency of this affection can only be underestimated. If arterial dystrophies are excluded, the primum movens is ulceration of an atherosclerotic plaque. Two types of emboli have been described as originating in these plaques. First, small cholesterol crystal emboli containing fibrino-platelet material that are the cause of very distal arterial occlusion, notably in the foot: the most typical corresponding clinical condition is the so-called blue toe syndrome. Second, larger emboli due to formation and migration of a fibrino-platelet thrombus in contact with the atheromatous ulcer. They consist mainly of fibrino-platelet material with variable quantities of atheromatous debris. They may be of moderate size, occluding a collateral of the deep femoral artery or a leg artery usually in an asymptomatic manner, or larger and provoking occlusion of main trunks. Diagnostic difficulties emphasize the importance of referring all embolectomy products for histopathology. One of the essential problems of this disease is that of diagnostic criteria. When confronted with the previously evoked picture of peripheral ischemia and/or a peripheral arterial occlusive lesion, how can this distal accident be related to a subjacent arterial lesion suspected of possessing an emboli-forming nature?(ABSTRACT TRUNCATED AT 250 WORDS)

[Simultaneous one- or two-stage restoration of the vertebral and carotid arteries]. / Restauration des artères vertébrales et carotides simultanée ou en deux temps.

Surgery of the vertebral artery is controversial. Few teams performed this procedure routinely. The usefulness of the vertebral artery surgery is even more questionable when carotid artery lesions are associated. In such cases many surgeons claim that carotid artery surgery alone can relieve symptoms of vertebrobasilar insufficiency. In deciding whether or not to perform vertebral artery surgery three questions are essential. First, is a restauration of one or both vertebral artery necessary in this situation? Second, will combined surgery increase the risk of mortality and morbidity? Third what technique should be used and in what order?

[Intra-arterial thrombolysis using rt-PA for the treatment of occluded infra-inguinal bypasses]. / Thrombolyse intra-artérielle avec le rt-PA pour le traitement des occlusions des pontages sous-inguinaux.

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)

[Our experience with carotid restenoses. Value of digital angiography using the arterial approach]. / Notre expérience des resténoses carotidiennes. Intérêt de l'angiographie numérisée par voie artérielle.

Between January 1980 and December 1985, 721 operations on the internal carotid artery were performed in the Department of Vascular Surgery, Hôpital de la Timone, Marseilles. During this 6-year period, carotid artery restenosis was detected in eleven patients. All had been operated upon initially in the department: carotid thromboendarterectomy (10 cases), internal saphenous vein graft (1 case). All but one patient were asymptomatic at time of diagnosis of restenosis, the mean a period of which was 20.5 months. Identification was by cervical murmur (5 cases), routine review Doppler examination (2 cases), digital subtraction angiography by arterial approach (2 cases); this examination being conducted on contralateral carotid artery during preoperative investigations, and conventional arteriography of supra-aortic trunks to determine permeability of a contralateral temporo-sylvian anastomosis in one patient. Digital subtraction angiography by the arterial approach was carried out in 8 of the 11 patients. Apart from the simplicity of repeated examinations (16 times in these 8 patients) this procedure permitted medical treatment to be instituted for 2 cases of restenosis and was sufficient to indicate the need for 5 repeat operations. A total of 6 recovery operations were performed, one in a symptomatic patient and five in asymptomatic patients: rapid surgery was necessary in 4 of these because of an immediate critical restenosis. Surgery was carried out in the last case due to progressive worsening of repeated stenotic lesions on serial angiographic examinations. Operations included venous grafts (crural internal saphenous vein) in 4 cases and angioplasty with venous patch grafts in 2 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Paralysis of the right arm caused by vertebral arteriovenous fistula]. / Paralysie du membre supérieur droit par fistule artérioveineuse vertébrale.

Traumatic vertebral arteriovenous fistulas rarely result in neurological disorders. We report a case of upper limb paralysis caused by a C5-C6-C7 radiculopathy, 44 years after a trauma and successfully treated by surgery and embolization.

[Costo-clavicular syndromes (thoracic outlet syndrome) (author's transl)]. / Les syndromes de compression costo-claviculaire (thoracic outlet syndrome).

During a 5-year period, 156 patients were followed with symptoms representative of costo-clavicular compression. Surgical treatment has been rejected in 80 patients. One hundred and five (20 bilateral) resections of the first rib were performed according to the technique as described by Roos. The surgical indication depends mainly on the severity of symptoms, clinical signs and the presence of complications (45 major complications). In 88% of the cases, a satisfactory result was obtained at the expense of a small incision, a hospital stay averaging 7 days and a few reversible complications of no significance.