Naftidrofuryl in chronic arterial disease. Results of a six month controlled multicenter study using Naftidrofuryl tablets 200 mg.

The study was carried out on patients with intermittent claudication (Fontaine's stage II). The arterial and atheromatous origin of the disease was confirmed and localized by angiography or Doppler velocimetry examination. One hundred eighty-six patients were selected initially. Their pain-free walking distance on a treadmill (at a speed of 3 km/hour and an inclination of 10%) had to be 150-300 m. During the first month all patients received 3 placebo tablets daily. At the end of this run-in period (D-30; D 0) and after checking walking distance stability (allowed variation: +/- 20% between the two measurements) the patients were included in the study. One hundred fifty-four patients were selected and 118 remained during the whole study. The study was designed as a double-blind, using two parallel randomly selected groups. Sixty-four patients received for six months Naftidrofuryl (3 X 200 mg tablets daily with meals); 54 patients received placebo under the same conditions. During this period, clinical and paraclinical examinations were carried out every quarter (D 90 and D 180). After checking the initial homogeneity of the Naftidrofuryl and placebo-groups, the comparison between groups indicates a significant improvement in Naftidrofuryl group after 3 and 6 months of treatment. At the end of the study the observed differences in walking distance with Naftidrofuryl are approximately twice the difference in the reference group (D 90: p less than 0.05; D 180: p less than 0.02). The results of this study indicate that Naftidrofuryl is an efficient pharmacological tool for treatment of patients with chronic arterial disease (Fontaine's stage II).

[Ruptured hypogastric aneurysm presenting as a sciatic paralysis. Case report and review of the literature]. / Anévrysme rompu de l'artère hypogastrique révélé par une paralysie sciatique. Un cas et revue de la littérature.

A rupture of a hypogastric aneurysm presenting as a sciatic nerve compression is reported. The diagnosis was delayed as the lumbar spine CT Scan was normal. The aneurysm was visualized with a CT Scan of the pelvis, it was located in the front of the sacrum and continued through the greater sciatic foramen. After aneurysmorrhaphy the pain disappeared but the paralysis wasn't improved. 28 cases of ruptured hypogastric aneurysm have been collected by reviewing the literature, eight of them have simulated nerve compression.

[Compression of the left renal artery by the diaphragm]. / Compression de l'artère rénale gauche par le diaphragme.

Investigation of hypertension in a 21 year old man detected the presence of stenosis of the left renal artery. The arteriographic appearance of this stenosis, associated with the presence of stenosis of the celiac trunk of identical morphology, was suggestive of extrinsic pressure by the diaphragm and excluded endoluminal dilatation. Section of the left diaphragmatic crus released the renal artery and celiac trunk with complete recovery from the hypertension.

[Distal mesenteric arteritis: a rare complication of D. methylsergide treatment (author's transl)]. / Une artérite mésentérique distale. Complication rare du traitement par le D. méthylsergide.

A patient developed typical abdominal angina due to mesenteric arteritis secondary to D. methylsergide (Desernil) treatment. Multiple regular distal stenoses were revealed by arteriography, but these had completely disappeared 5 months after discontinuing treatment. Histology demonstrated fibrosis of the three tunicae with hyperelastosis. Six analogous cases due to D. methylsergide or ergotamine tartrate have been reported in the published literature, rapid regression occurring in all of them after interruption of treatment.

[Aorto-enteric fistulas]. / Fistules aorto-digestives.

Aorto-enteric fistulae are either primary or spontaneous, resulting from aneurysms of the aorta, or secondary to aortic surgery. Four symptoms are common to these two types, but every patient known to have an aortic aneurysm or a history of aortic graft surgery who presents with gastrointestinal bleeding or unexplained infection must be regarded as having an aorto-enteric fistula until proved otherwise. The fistula may be detected by duodenoscopy, but it is most often diagnosed at laparotomy, which is indicated when all paraclinical investigations are negative. While primary aorto-enteric fistulae can be treated by insertion of a prosthesis into the aortic aneurysm, secondary fistulae frequently require " extraanatomical " bypasses. In view of the poor prognosis of secondary aorto-enteric fistulae, prophylactic measures in aortic surgery are of paramount importance.

[Associated compression of the celiac trunk, superior mesenteric artery and aorta by the arcuate ligament of the diaphragm]. / Compression associée du tronc coeliaque, de l'artère mésentérique supérieure et de l'aorte par le ligament arqué du diaphragme.

Simultaneous compression of the coeliac axis, superior mesenteric artery and aorta by the arcuate ligament of the diaphragm is a very rare condition. The pathogenesis of the abdominal pain observed is debatable, but the simplicity and effectiveness of vascular release fully justify surgery in such cases.

[Thoracic outlet syndrome. Value of non-invasive arterial studies]. / Syndrome de la traversée thoraco-brachiale. Valeur des explorations artérielles non vulnérantes.

The value of non-invasive clinical evaluation of arterial compression at thoracic outlet was evaluated in 150 normal subjects and in 103 patients operated upon (127 sides). The specificity of arm abduction manoeuvres was good for angles of 90 degrees or less. Their sensitivity was poor in forms with neurological symptoms and better in forms with vascular symptoms. In these two forms, their predictive value was excellent (congruent 90%) with angles of less than 90 degrees. Their negative predictive value was mediocre in forms with neurological symptoms. It is concluded that a positive response to manoeuvres at an angle of less than 90 degrees is a strong argument in favour of arterial compression in the thoracic outlet, but that a negative response should not rule out a diagnosis of thoracic outlet syndrome, especially when neurological symptoms are present.

[Prevalence of gastric or duodenal ulcer in patients with arteritis. 100 systematic fibroscopies]. / Prévalence de l'ulcère gastrique ou duodénal chez l'artéritique. Cent fibroscopies systématiques.

A 19% prevalence rate of gastric or duodenal ulcer was found by systematic fibroscopy in a population of 100 patients with lower limb arteritis hospitalized in a vascular surgery unit. This morbid association raises pathogenic problems which remain unsolved, but peptic ulcers were unevenly distributed throughout this population. Their prevalence was higher in patients under 50 years of age (P less than 0.05) and in those who had trophic disorders and occlusive lesions of digestive tract arteries or progressive coronary disease. Systematic fibroscopy may be justified in these categories of patients, since 7% of those with ulcer were asymptomatic.

[Coarctation of the abdominal aorta: diagnosis, pathogenesis, medical or surgical treatment. 7 cases]. / Coarctations de l'aorte abdominale: diagnostic, pathogénie, traitement médical ou chirurgical. Sept observations.

Seven cases of coarctation of the abdominal aorta are reported. The diagnosis, suggested by the presence of arterial hypertension associated with nonperception of the arterial pulse in the lower limbs and/or systolic murmur in the abdomen, is supported by non-invasive investigations, such as Döppler flowmetry of lower limb arteries and ultrasonography of the abdominal aorta. Arteriography, however, is mandatory because of frequently associated lesions of other arteries, notably renal and/or intestinal arteries. The type and location of these lesions are of prime importance to therapeutic decision. According to the results of the present study, surgery may not be required in all cases and may be replaced, in some very specific circumstances, by medical treatment. There is still disagreement concerning the congenital or acquired origin of this type of aortic coarctation and the mechanism of hypertension. The various theories put forward are discussed.

[Parathyroid adenoma disclosed by a massive subcapsular hemorrhage]. / Adénome parathyroïdien révélé par une hémorragie sous-capsulaire massive.

In the case reported here a parathyroid gland adenoma was revealed by the sudden occurrence of a large subcapsular haematoma compressing cervical structures and causing recurrent nerve paralysis; spontaneously regressive hypercalcaemia was present. The place of these haemorrhages among other manifestations of a hitherto silent parathyroid gland adenoma is discussed, together with the diagnostic value of thyroid gland scintigraphy and cervical ultrasonography. In view of their potentially somber prognosis, emergency surgery is mandatory in such cases.

[Paradoxical embolism through a patent foramen ovale. 4 cases]. / Embolies paradoxales à travers un foramen ovale perméable. Quatre observations.

Four cases of paradoxical embolism through a patent foramen ovale associated with massive pulmonary embolism are reported. In two cases, patency of the foramen ovale was demonstrated by a new technique: cross-sectional contrast echocardiography potentiated by coughing. The conventional surgical treatment included arterial embolectomy followed by insertion of a caval filter. Embolism recurred on three occasions under mechanical ventilation prior to insertion of the filter. A new sequence of investigations to facilitate detection of paradoxical embolism in patients with unexplained arterial embolism is suggested: (1) blood gas measurements, which reveal associated pulmonary embolism; (2) cough-potentiated cross-sectional contrast echocardiography, which demonstrates a patent foramen ovale and excludes emboligenic cardiopathies; (3) phlebography and pulmonary angiography which complete the diagnosis. To reduce the risk of recurrent embolism, it is recommended to begin treatment by blocking the vena cava without mechanical ventilation. This can be done by inserting a filter through the jugular vein under local anaesthesia. Arterial embolism can then be treated at lesser risk under mechanical ventilation.

[Malignant pheochromocytoma. A case]. / Les phéochromocytomes malins. Une observation.

A case of malignant phaeochromocytoma is reported. The primary tumour was removed in 1970. Metastases were diagnosed in 1979 and management of the condition included antihypertensive treatment with alphamethylparatyrosine, antitumoral chemotherapy and surgical reduction of secreting tissue. In these rare tumours malignancy can only be confirmed by metastases, i.e. presence of chromaffin cells in loci where they are not usually found. Histology is of little value. High levels of catecholamine precursors or their metabolites in the urine may be a sign of malignancy, but some asymptomatic tumours are only revealed by metastases. Computerized tomography and radioisotope scanning with I131 metaiodobenzylguanidine are the best available methods to locate the lesions. In view of the small number of cases and of the unpredictable course (sometimes spread over many years) of malignant phaeochromocytomas, the effectiveness of treatments with alphamethylparatyrosine, chemotherapy and radiotherapy is difficult to evaluate.

[Carotid surgery under locoregional anesthesia]. / Chirurgie carotidienne sous anesthésie loco-régionale.

Eight-five carotid endarterectomies were performed in 77 patients, under regional anaesthesia using 2 different techniques: cervical epidural anaesthesia (35 cases) and cervical plexus block (50 cases). The patients' mean age was 71 years; 80 per cent had arterial hypertension and 41 per cent coronary disease. Transoperative cerebral ischaemia was detected by a 5-minute carotid clamping test, the occurrence of a neurological event indicating that shunting was required. In 62 patients this test was combined with measurement of carotid back pressure. None of the patients needed general anaesthesia. Intraoperative neurological events occurred more frequently (P less than 0.01) when the carotid back pressure was 25 mmHg or less, and 12 temporary shunts were installed for that reason (14.1 per cent). Three neurological events occurred at the end of endarterectomy: no shunt was installed and complete recovery was observed immediately after declamping. No complications ascribable to the anesthetic techniques were recorded. Mortality was nil, and the only neurological morbidity was a brachio-facial deficit which left few sequelae. The frequency of intra- or postoperative arterial hypertension was similar in both groups. Intraoperative hypotension, frequent under epidural anaesthesia, was observed in only one patient who had brachial plexus block (P less than 0.01). The analgesia obtained was equally good with both anaesthetic techniques, but cervical plexus block anaesthesia is easier to perform, had less haemodynamic repercussions and therefore tends to be preferred to cervical epidural anaesthesia. The lack of mortality, low morbidity and absence of systemic complications in this series despite the high number of patients at risk are in favour of this type of anaesthesia, notably for such patients. Moreover, because vigilance is preserved attention can be paid to the quality rather than the rapidity of endarterectomy, which is the best way of preventing embolism.

[Thirty years of axillofemoral bypass]. / Le pontage axillo-fémoral trente ans après.

Improvement in axillary-femoral bypass (AFB) surgery thirty years after its first use results mainly from progress in prosthetic material, particularly external reinforcement cuffs. Indications for use remain those of aorto-iliac surgery in patients at high general or local risk. However, since the primary permeability rate was fairly poor prior to the appearance of non reinforced prostheses, the use of AFB was replaced by other techniques, notably endoluminal procedures. At the same time, contraindications to aorto-iliac surgery were reduced because of the improved global care of these patients and the possibility of treatment in situ of aortic infections. However, the excellent results of the most recent series using only strengthened prosthesis have stimulated renewed interest in AFB, which should always be evoked as a possibility in patients at risk for aorto-iliac surgery.

[Revascularization of the limbs and visceral arteries from the thoracic aorta via the abdomen. New technic]. / Revascularisation des membres et des artères viscérales à partir de l'aorte thoracique par voie abdominale. Nouvelle technique.

An abdominal transdiaphragmatic approach of the lower part of descending aorta allows the insertion of a synthetic graft for revascularisation of the limbs and visceral arteries. The technique is described. The indications of the procedure are obstruction, coartation or aneurysms when infra renal anastomosis is impossible.

[Transdiaphragmatic approach to the supraceliac aorta. Surgical anatomy and operative technic]. / L'abord trans-diaphragmatique de l'aorte sus-coeliaque. Anatomie chirurgicale et technique opératoire.

The surgical anatomy and the practical modalities of the trans-peritoneal-diaphragmatic approach of the low thoracic aorta have been studied on the basis of 40 consecutive dissections. The trans-diaphragmatic approach of the supra-celiac aorta can be performed: either through a restrictive way, by dissociation of the muscular fibers of the posterior angle of the oesophagal hiatus, thus allowing the access to a mean 30 mm long part of supra-celiac aorta, large enough to perform a complete aortic clamping; either through an extensive way, by medial sagittal section, in front of the aorta of the muscular fibers of the posterior angle of the oesophagal hiatus and of the arcate ligament, thus permetting this exposure of a longer aortic part (60 mm on a average) and the realization of more important aortic procedures. These may be performed with a lateral aortic clamp, on account of the large diameter of the aorta at this level (30 mm on an average).

[Surgical treatment of cavernomas of the portal vein. 56 cases, including 42 operated cases]. / Traitement chirurgical des cavernomes de la veine porte. 56 cas dont 42 opérés

The difficulty of surgical treatment of cavernomas of the portal vein results from the anatomical conditions created by this type of portal hypertension, in spite of favourable physiological conditions due to the integrity of the hepatic parenchyma. The latter is, in fact, relative after a certain length of history. This erratic course renders difficult assessment of the efficacy of methods of treatment. In the light of 56 cases, including 42 operated cases, the authors present the indications for surgery which depend on the severity and frequency of hemorrhage and also on the patient's age. When repeated bleeding occurs, a by-pass should be attempted whenever possible, if the bleeding impedes social life or growth, or if it threatens life. Mesenterico-caval anastomosis is preferable before the age of 7 years. Spleno-renal anastomosis requires a sufficient size of splenic vein. Ligature of aesophageal varices or disconnection of the oesophagus from the stomach, may be considered in cases of moderate hemorrhage. The varices may be treated by sclerosing injections after failure of a by-pass operation or in inoperable patients. Oesophago-gastrectomy is useful but should be a last resort.

[Isolated proximal revascularization for double aorto-iliac and femoral lesions]. / Revascularisation proximale isolée dans les lésions à double étage aorto-iliaque et fémoral.

From 1980 to 1990, 101 limbs were revascularized at the upper level only in 67 patients, while they presented with associated aortoiliac and femoral obstructive lesions. The symptoms disappeared after aortofemoral revascularization in 94% of the limbs operated on for claudication and 80% of those operated on for critic ischemia. Surgery of the deep femoral artery was associated in 51% of all cases. The average time lapse is 58 months. No complementary revascularization was needed in the cases of claudication. Out of the patients operated on for critic ischemia, upper revascularization was insufficient in 8 cases. Two of the operated patients were cured after secondary downstream revascularization (4%). Three operated patients still presented with intermittent claudication (6%), and 3 were amputed due to acute iliac obstruction seen at an advanced stage. As no reliable predictive test is available, we find it justified to carry out only upper revascularisation in most cases and to decide on the need for secondary downstream extension according to the clinical outcome. However, simultaneous revascularization at both levels is required in case of extensive involvement of the deep femoral artery, such as observed in only 5 of the patients operated during the same period.

[Indications of the trans-diaphragmatic approach to the supra-celiac aorta]. / Indications de l'abord trans-diaphragmatique de l'aorte sus-coeliaque.

The trans-diaphragmatic approach of the supra-celiac aorta can be performed in two different ways, according to the indications of this approach: The approach through a restrictive way, by simple dissociation of the muscular fibers of the posterior angle of the oesophagal hiatus allows an high and fast aortic clamping, especially helpful when a serious sub-diaphragmatic bleeding is encountered. It can also be used at the time of reintervention on the sub-renal aorta, in case of juxta-renal aortic thrombosis or in case of abdominal aortic aneurysm involving renal arteries. The approach through an extensive way, by saggital section of the muscular fibers of the posterior angle of the oesophagal hiatus and of the arcate ligament increases considerably the length of the exposed aortic segment and allows the implant of a by-pass graft on the lower thoracic aorta; this graft can be used to revascularize the underlying aortic step; it can also be used to shunt a lesion of the thoracic aorta.

[Venous fistulization of an iliac aneurysm (author's transl)]. / Fistulisation veineuse d'un anévrysme iliaque.

The first reported case of a left iliac arteriovenous fistula from rupture of an aseptic atheromatous aneurysm is described. The fistula occurred proximally to a primary iliac vein thrombosis which explains the clinical picture observed of very severe "blue" phlebitis and the absence of any cardiac complications. The fistula was treated by the endo-aneurysmal approach and arterial continuity re-established with a prosthesis. The postoperative result was excellent.