[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)

[Procedures in critical ischemia of the legs in non-emergency situations]. / Conduite à tenir dans les ischémies critiques des membres inférieurs en dehors de l'urgence.

Our experience with 91 operated cases in 84 patients (47 men, 37 women) relates essentially to arterial diseases resulting from overloading and diabetic arteriopathy. Diagnosis of critical ischemia is easy in clinical conditions, but it is advisable to rely on universally recognized hemodynamic standards to define this condition. Ankle pressure should be less than 400 mmHg and the Doppler trace flat or barely perceptible. Patients in our series had a mean ankle pressure of 32.4 mmHg. Local examination can determine the extent of gangrene, whereas general examination detects numerous, often associated defects diabetes, coronary artery disease, rhythm disorders, arterial hypertension, etc. As far as possible, these defects are to be corrected before surgery. X-ray examination (M. Kasbarian) is frequently done in conjunction with conventional aorto-arteriography and digital angiography. The later technique allows arteries to be visualized which are not seen with the conventional technique. The x-ray examination will indicate whether revascularization is feasible, although it cannot show whether it will be efficient. In our series, opacification of the plantar arches was predictive neither of success nor failure. But do tests exist which can predict the success of a revascularization attempt? It would be necessary to be able to estimate ankle pressure after the operation, and several methods have tried to do this. TcPO2 would seem to be a good examination. The possibilities of nuclear magnetic resonance are being studied, and the results thus far are promising. Preoperative explorations are carried out in a different situation. Arteriography performed in the operating room is a simple act which can reveal a usable downstream bed not indicated in preoperative X-rays, although it provides no hemodynamic data. Measurement of peripheral resistances would appear to be a very good predictive examination. Flow measurements by infusion or electronic flowmeter also seem to be predictive for bypass results. Unfortunately, these measurements are at present not widely performed and the critical threshold is assessed differently. Given the difficulty of correctly estimating the value of these numerous methods, many surgeons, ourselves included, have chosen to revascularize patients whenever the upstream bed as evaluated by X-ray indicates the presence of at least one viable artery.

Rupture of the external iliac artery during balloon angioplasty: endovascular treatment using a covered stent.

PURPOSE: To report the emergent endovascular management of an external iliac artery (EIA) rupture after standard guidewire recanalization and balloon angioplasty. METHOD AND RESULTS: A 54-year-old diabetic male presented with an occlusion of the EIA associated with severe stenotic lesions of the femoral bifurcation. Guidewire recanalization of the lumen was followed by balloon angioplasty, but evidence of EIA rupture was detected on the intraoperative arteriogram. Temporary homeostasis was achieved using the angioplasty balloon, and a Cragg EndoPro System 1 stent-graft was inserted transluminally to repair the injury. At 18 months poststenting, routine color Doppler confirmed continued patency of the vessel repair. CONCLUSIONS: While rupture of the EIA during angioplasty usually demands open surgical correction, an endovascular procedure can provide a fast, efficient, and less aggressive method of treating this serious complication.

Femorofemoral bypass through the perineum for infection complicating arterial revascularization of the lower limb.

Of 587 prosthetic arterial constructions performed between 1980 and 1984 on the aorta and lower limbs, 25 patients were operated on for sepsis. A total of 37 operations were performed, six of which were femorofemoral crossover bypasses through the perineum. Prosthetic material was used in one case and vein in five. The host vessel was the contralateral iliac or femoral artery, the contralateral limb of an aortobifemoral bypass, or the contralateral limb of an axillofemoral bypass in two cases each. The recipient vessel was the profunda femoris artery in four cases, the popliteal artery in one case, and the profunda femoris and popliteal arteries sequentially in one case. Indications for perineal bypass included an infected pseudoaneurysm in the femoral triangle following a femoropopliteal (one case) or aortofemoral bypass (five cases). In two instances, sepsis was bilateral and also required an axillofemoral bypass. Excepting one postoperative death, early results were satisfactory as infection disappeared and arterial reconstructions remained patent in all other cases. This technique should have its place in the armamentarium of extraanatomic bypasses along with other techniques such as the axillofemoral, prepublic femorofemoral crossover, and obturator bypasses. The best indication for perineal bypass is when vascularization of a lower limb from the contralateral side is necessary because of infection in the femoral triangle.

Indium-111 platelet scintigraphy in carotid disease.

Forty-five patients (35 men, 10 women) undergoing carotid surgery had Indium-111 platelet scintigraphy as part of their preoperative work-up. Imaging was performed within three hours after injection of the Indium-111. A second series of views was obtained 24 hours later and repeated at 24 hour intervals for two days. Of 54 scintigrams, 22 were positive and 32 negative. Positive results were defined as a twofold or more increase in local activity on a visualized carotid after 24 hours. The sensitivity of the method was 41%, intraoperatively, and the specificity, 100%. The low sensitivity places this method behind sonography and duplex-scanning for screening patients for surgery. We believe that indications for platelet scintigraphy are limited to: 1. Repeated transient ischemic attacks in the same territory with minimal lesions on arteriography and non-homogeneous plaque on duplex scan; 2. Symptomatic patients being treated medically as a possible argument for surgery; 3. Determining therapeutic policy for patients having experienced a transient ischemic attack with a coexisting intracardiac thrombus.