The recurrent cervical swelling syndrome.

The objective of this study is to report an overlooked cause of cervical swelling linked to a thoracic duct (TD) intraluminal obstruction. Four consecutive patients underwent supraclavicular fossa echo-colour-Doppler assessment (ECD) because of recurrent spontaneous cervical swelling. In all patients, during the swelling period we documented a TD dilation with hyperechogenic content, resulting undetectable during asymptomatic periods; ECD also allowed an effective differential diagnosis with TD cysts, obstructive malignancy or other causes of cervical swelling. In conclusion, ECD is to be considered an effective tool in cervical swelling and TD anomalies investigation.

[Actinomyces odontolyticus isolation during prosthetic aortic graft infection with paraprosthetic duodenal fistula]. / Isolement d'Actinomyces odontolyticus au cours d'une infection de prothèse aortique avec fistule duodénoparaprothétique.

INTRODUCTION: Prosthetic vascular graft infection is a rare complication of vascular surgery. We report a case with graft enteric fistula and Actinomyces odontolyticus bacteremia. EXEGESIS: A 73 year-old man with a prosthetic aortic graft and who had a parodontal disease, has been hospitalised for fever of unknown origin. Blood cultures grew with Escherichia coli and Actinomyces odontolyticus. The imaging studies indicated graft infection. Laparotomy has confirmed the diagnosis and highlighted a polymicrobial infection and a paraprosthetic duodenal fistula. A review of the literature's data concerning prosthetic vascular graft infections is made. The role of Actinomyces odontolyticus in that case is discussed. CONCLUSION: Prosthetic aortic graft infection due to graft enteric fistula is usually a polymicrobial infection and is a late complication of aortic surgery. Imaging is essential for the diagnosis of prosthetic aortic graft infection. It is possible that Actinomyces odontolyticus has contributed to prosthesis infection in this case.

Aneurysms of the innominate artery: surgical treatment of 27 patients.

PURPOSE: Aneurysms of the innominate artery (AIA) are widely considered to be a rare entity. We describe our experience with AIAs in the last three decades. METHODS: From October 1973 to October 2000, we operated on 27 patients with an AIA. The underlying cause of aneurysm was Takayasu's disease in 7 patients, degenerative disease in 6 patients, syphilis in 5 patients, chronic dissection in 3 patients, trauma in 2 patients, infection in 2 patients, a postoperative complication in 1 patient, and Marfan syndrome in 1 patient. AIA was associated with an aortic aneurysm in 17 patients. Fourteen patients had no symptoms. The remaining patients had symptoms, with thromboembolic complications in 7 patients, pain without rupture in 3 patients, and a ruptured aneurysm in 3 patients. In two patients at high risk for surgery who had a small AIA with embolic complications, a cervical approach was used as a means of performing distal exclusion and crossover bypass. In the remaining 25 patients, a midline sternotomy was used. One patient with a ruptured AIA exsanguinated during sternotomy. Ten patients underwent a prosthetic replacement of the ascending aorta and/or aortic arch with a separate prosthetic branch to the innominate artery (IA). Thirteen patients underwent ascending aorta-to-IA prosthetic bypass in association with lateral suture (8 patients) or prosthetic patching (5 patients) of the aorta. One patient with an infected aneurysm was treated by means of resection of the aneurysm, proximal ligation of the IA, and transposition of the right into the left common carotid artery. Cardiopulmonary bypass with deep hypothermic circulatory arrest was used in 10 patients. RESULTS: Three perioperative deaths occurred (2 of 4 in association with emergency treatment and 1 of 23 with elective treatment). Respiratory complications requiring prolonged artificial ventilation developed in five patients. Two patients had transient worsening of preoperative neurologic deficits. Late results, with a mean follow-up of 85 months, were good. CONCLUSION: The etiology and presentation of AIAs are variable. Surgical management with current cardiovascular techniques achieves excellent results.

A new study demonstrates the efficacy of naftidrofuryl in the treatment of intermittent claudication. Findings of the Naftidrofuryl Clinical Ischemia Study (NCIS).

BACKGROUND: The efficacy and safety of naftidrofuryl were assessed in a double blind, placebo controlled, parallel group study, in patients presenting with intermittent claudication, according to the latest European guidelines. METHODS: The outpatients selected were of both sexes, aged 35 to 85, with moderately severe chronic, stable intermittent claudication and a pain-free (PFWD) and maximum walking distance (MWD) on the treadmill of between 100 and 300 metres. They received naftidrofuryl 200 mg tid or placebo for six months and were then assessed during a six-month follow-up period without treatment. The primary outcome measures were the pain-free walking distance and maximum walking distance. RESULTS: Of the 221 selected patients, 196 were randomised and 181 entered the intention-to-treat analysis. The two groups were well matched for demographic variables, risk factors and history of vascular disease. After six months of treatment, patients who received naftidrofuryl had a 92% im-provement of geometric pain-free walking distance versus 17% in the placebo group (p < 0.001) and an 83% improvement of geometric maximum walking distance versus 14% in the placebo group (p < 0.001). During the follow-up period without treatment, the walking distances of the patients in the naftidrofuryl group significantly decreased. The incidence of adverse events was similar in the two groups. CONCLUSIONS: This study demonstrated the efficacy of naftidrofuryl versus placebo in patients with intermittent claudication with a highly significant and clinically relevant difference and confirmed its good safety profile.

Treatment of aortic arch dissection using the elephant trunk technique.

The elephant trunk technique was developed to facilitate multiple-stage treatment of extensive aneurysm of the thoracic aorta. However, little information is available concerning its usefulness for aortic dissection. From April 1992 to July 1998, we used the elephant trunk technique for treatment of aortic arch dissection in 22 patients (including 19 men) with a mean age of 58.5 years (range 21 to 85 years). Twelve patients presented with type A dissection (acute in 3 and chronic in 9), 3 with type B acute dissection, and 7 with "non A/non B" dissections with retrograde extension to the aortic arch or entry site located in the aortic arch without involvement of the ascending aorta. All patients had aneurysms of the descending (n = 7) or thoracoabdominal (n = 15) aorta. Procedures were performed under hypothermic circulatory arrest at between 15 degrees and 20 degrees C. Antegrade cerebral perfusion was used in three cases. The procedure was associated with aortic valve replacement and/or coronary bypass in 6 cases and bypass of one or more supraaortic vessels in 13. In two patients the distal end of the elephant trunk was attached with an endovascular prosthesis during the same procedure. The ensuing results in these patients indicate that the elephant trunk technique can be highly effective for treatment of complex aortic arch dissection.

Ambulatory conservative hemodynamic management of varicose veins: critical analysis of results at 3 years.

This report describes the results of our 3-year experience using ambulatory conservative hemodynamic management (ACHM) for lower extremity venous insufficiency involving the greater saphenous vein (GSV), with specific analysis of recurrence due to neoformation of vessels. We performed 289 ACHM procedures in 259 consecutive patients with GSV-related varicose veins. Follow-up clinical examination and Doppler ultrasound imaging was carried out at 3, 6, 12, 24, and 36 months in all cases to assess formation of neovessels supplied either by the superficial (A) or deep (B) venous system. Our data showed that ACHM achieved excellent improvement, with complete disappearance of varicose veins in 41.2% of cases, good improvement in 43%, fair improvement in 14.1%, and no improvement in 1.7%. The only predictor of outcome was the quality of drainage from the GSV vein. Poor drainage leads to neoformation of vessels supplied by the superficial (A) venous system. In about 50% of cases, drainage appeared spontaneously within 1 year, with a subsequent reduction in formation of neovessels. Neoformation of vessels supplied by the deep (B) venous system (10%) was independent of the quality drainage. This finding suggests that formation of these neovesseis is unrelated to the surgical method used to treat varicose veins. In patients with poor drainage of the saphenous network, neoformation of vessels supplied by the superficial (A) venous system is predictable with regard to both topography and delay. ACHM is a good tool for treatment of varicose veins, as reliable statistical prediction of mid-term results is possible using available models.

Progress in the management of type I thoracoabdominal and descending thoracic aortic aneurysms.

We reviewed our categorization of patients at high risk for neurologic complications in the repair of descending thoracic and thoracoabdominal aortic aneurysm in which we used cerebrospinal fluid drainage and distal aortic perfusion (adjuncts). A total of 409 patients were operated on by one surgeon for descending thoracic or thoracoabdominal aortic aneurysm between 1992 and 1997. Of these patients, 232 had total descending thoracic or type I thoracoabdominal aortic aneurysm, 131 (56%) of whom were operated on with adjuncts. These patients were compared to 101 nonadjunct patients for demographic variables, intraoperative variables, blood product consumption, and neurologic status. In 131 consecutive patients with adjuncts, all but one awoke from anesthesia without neurologic deficit. In nonadjunct patients, however, neurologic deficit occurred in 6 of 101 (6%) (p < 0.003). The adjunct group had more preoperative renal insufficiency (p < 0.05), an established risk factor for neurologic deficit (odds ratio = 2.2 in published studies). All other risk factors for neurologic deficit occurred with comparable frequency in both groups. We conclude that the introduction of adjuncts has dramatically reduced the neurologic risk associated with type I thoracoabdominal or total descending thoracic aortic repair. Previously considered high risk for neurologic complications, these aneurysms can now be reclassified as low risk in surgery accompanied by adjuncts. Future investigations will focus on type II thoracoabdominal aortic aneurysm as the major source of neurologic morbidity.

Occlusive fibromuscular disease of arteries supplying the brain: results of surgical treatment.

Occlusive fibromuscular disease (FMD) of arteries supplying the brain is a documented cause of neurologic complications. From September 1976 to December 1994, 70 patients underwent surgery for occlusive FMD involving arteries supplying the brain. Isolated dysplastic aneurysms and coilings or kinkings were not included in this series. Twenty-two patients had experienced previous nonlethal ischemic stroke, 25 patients had experienced transient ischemic attacks, and 32 patients had vertebrobasilar insufficiency with or without associated carotid symptoms. Lesions involved one (n = 36) or two (n = 29) internal carotid arteries, and one (n = 18) or two (n = 14) vertebral arteries. Twenty-seven patients had simultaneous involvement of both carotid and vertebral arteries. Ten patients had FMD at another site, four had intracranial aneurysm, and four had an aberrant right subclavian artery. Seventy-seven carotid procedures including 67 graduated intraluminal dilatations were performed and 18 vertebral arteries were revascularized. One patient (1.4%) died postoperatively from hemorrhagic stroke and two patients (2.8%) presented nonlethal stroke. Sixty-two patients were followed postoperatively from 2 to 184 months (mean 86.2 +/- 54.4). Actuarial survival rates at 5 and 10 years were 96.4 +/- 5.0% and 82.1 +/- 14.9%, respectively. Actuarial primary patency rate at 5 and 10 years was 94.3 +/- 5.5%. Actuarial probability of stroke-free survival rates at 5 and 10 years were 94.2 +/- 5.6% and 88.6% +/- 10.3%, respectively. We conclude that improvement of symptoms, prevention of stroke, and stable long-term results justify surgical treatment in symptomatic patients with FMD of arteries supplying the brain.

[Ambulatory conservative hemodynamic correction of venous insufficiency. Technique, results]. / La cure conservatrice hémodynamique de l'insuffisance veineuse en ambulatoire. Technique, résultats.

Ambulatory conservative haemodynamic correction of venous insufficiency (CHIVA) is a surgical treatment of superficial venous insufficiency designed to correct the pathological haemodynamic effects of superficial venous insufficiency apparent on standing. Surgical treatment is based on precise preoperative anatomical and haemodynamic mapping performed by duplex ultrasound, providing preoperative ultrasound-guided marking. Surgical treatment consists of dividing the hydrostatic pressure column and disconnecting venovenous shunts by ligation-section of the superficial venous network at precise points determined by the preoperative ultrasound-guided marking. This strategy should achieve a superficial venous circuit draining perfectly into the competent deep venous network. The operation is performed under local anaesthesia as an outpatient procedure and allows immediate resumption of walking, which promotes a good result due to activation of the calf muscle pump. The results of the technique are very good provided a reliable preoperative ultrasound-guided marking and a precise surgical procedure are performed. Failures are due to poor haemodynamic assessment or inappropriate surgical procedure.

[Inflammatory aneurysms of the thoracic aorta. Surgical aspects]. / Anévrysmes inflammatoires de l'aorte thoracique. Aspects chirurgicaux.

In the Western world, inflammatory aneurysms account for only 1 to 5%, of all operated thoracic aorta aneurysms. Takayasu's disease is by far the commonest cause although all forms of aortitis may result in aneurysm formation. Usually observed in young patients, these aneurysms are suitable for often major surgery with results that are globally better than in degenerative or dissecting aneurysms. However, they pose, two specific problems: the progression of the inflammatory disease which may require pre- and/or post-operative steroid therapy and that of the risk, at least in theory, of a late pseudo-aneurysm, which justifies regular long-term follow-up after surgery.

Popliteal aneurysm due to fibromuscular dysplasia.

We report herein the case of an asymptomatic popliteal aneurysm due to fibromuscular dysplasia in a 39-year-old woman. The aneurysm was resected and arterial continuity restored by direct end-to-end anastomosis. Pathologic findings were consistent with fibromuscular dysplasia of the media. To the best of our knowledge, this is the fourth case documented by pathologic findings in the literature.

[Technical advances in the surgical management of thoracoabdominal aortic aneurysms]. / Progrès techniques dans la chirurgie des anévrysmes de l'aorte thoraco-abdominale.

Thoracoabdominal aortic aneurysmectomy ranks among the major cardiovascular surgical procedures. During the last two decades perioperative results have improved to the point that surgery should be discussed in the vast majority of patients seen with a thoracoabdominal aortic aneurysm. This progress is largely attributable to a variety of technical improvements including: aortic reconstruction using the graft inclusion technique, usually with direct reattachment of aortic branches to the prosthetic graft; distal aortic perfusion; selective use of deep hypothermic circulatory arrest in anatomically complex situations; preoperative visualization of arterial blood supply to the spinal cord using selective arteriography of intercostal and lumbar arteries. Current perioperative mortality is around 10% whereas the spinal cord complication rate is between 5% and 20% according to clinical and anatomical conditions. Future efforts should concentrate on the prevention of spinal cord complications.

In situ arterial allografting for aortoiliac graft infection: a 6-year experience.

Between October 1988 and May 1994, all aortoiliac graft infections seen in the authors' service were treated by in situ arterial allografting after resection of any infected graft or tissue. Some 83 consecutive cases were treated; there were 68 isolated primary prosthetic infections (82%) and 15 aortoenteric fistulae (18%). Emergency arterial allografting was performed in five cases (6%), elective allografting in 64 cases (77%) and elective allografting after emergency palliative revascularization using a temporary prosthetic graft in 14 cases (17%). Arterial allografts were harvested from cadavers as part of a programme to retrieve multiorgan transplant tissue. Fifteen patients (18%) died either intra- or postoperatively. Three died during the operation, one from septic shock and two from uncontrollable coagulopathy. Twelve patients died in the early postoperative period, from from septic shock, two from myocardial infarction, two from pneumonia, one from a pulmonary embolism, one from an intestinal infarction, one from recurrence of a duodenal fistula and one from disruption of the native aorta at the suture line. Three patients presented with an early complication directly related to the use of the allograft. Eleven early survivors of the series died during follow-up. Among these late deaths, only one could likely be allograft-related. In four patients, the aortic segment of the allograft was mildly dilated on late computed tomography scan; three were reoperated on for disruption of the extra-abdominal segment of their allograft. All four cases were managed with simple suture of the allograft or with the use of a new allograft. Fifteen patients exhibited 19 late occlusive lesions of their allograft; 17 of these lesions had to be treated either with transluminal angioplasty or with surgery using autogenous or allograft material. In all but one case, secondary patency could be achieved through these additional procedures. Late occlusive disease was more prevalent in the femoral segment of the allograft than in the iliac or, moreover, the aortic segment. There were no late amputations in this series.

[Variations in the origin of the artery of Adamkiewicz]. / Variazioni di origine dell'arteria di Adamkiewicz.

Variations of the origin of the medullary artery. The purpose of this study was to define the origin of the medullary artery through medullary angiography in order to prevent paraplegia during surgery of the thoraco-abdominal aorta. Twenty-eight patients, candidate to thoracoabdominal aorta operations, have been studied for the study of the origin of the medullary artery and its eventual reimplantation during surgery. The artery has been localized in 24 of the 28 patients. In 22 cases (78.6%) it originated from an intercostal artery between D8 and D12, while in 6 cases (21.4%) it originated from a lumbar artery between L1 and L2. In 23 (82.1%) cases it originated from the left side, while only in 5 (17.9) from the right side. Although medullary artery originates more frequently at the thoracic level, particularly from the left D9 and D10, its variability is important, and its localization before thoraco-abdominal aortic surgery is often desirable.

[Treatment of prostheto-digestive using arterial allograft]. / Traitement des fistules prothéto-digestives par allogreffe artérielle.

From October 1988 to March 1995, we operated 22 patients for fistulization between the prosthesis and the digestive tract to remove the in situ allograft. The delay between the initial operation and treatment for fistulization was 7.3 +/- 4 years. In these patients who had undergone multiple operations (2.5 +/- 1.9 operations per patient), the infected prosthesis was made of Dacron in 21 cases and polytetrafluoroethylene in one. The procedure was planned beforehand in 21 cases who benefited from a complete preoperative work-up and was required in an emergency situation in 6 for digestive bleeding (5 cases) or an abscess of the Scarpa (1 case). Among the patients with an emergency operation, three of the procedures were conducted within a single operative time and three with two separate procedures. The allografts were aorto-aortic tubes (n = 3), aortobifemoral bypasses (n = 14), aorto-iliac bypasses (n = 4) and one aorto-femoral-iliac bypass. Organ revascularization was associated in 8 patients. Seven patients (32%) died post-operatively. Five of them had undergone an emergency procedure. An amputation was required in 2 patients, one at the time the allograft was implanted and the second due to ischaemia despite a permeable allograft. None of the patients had to be amputated due to failure of the allograft. Mean follow-up was 36.6 +/- 20 months. There were 4 deaths post-operatively due to digestive bleeding in 2. The aortic allograft was dilated in 4 patients without re-operation. Thrombosis of the allograft branch occurred in 4 patients, including 3 who had been re-operated successfully. Despite these still perfectable results, treatment of secondary digestive-prosthesis fistulae with an in situ allograft constitutes a real progress in terms of patient survival and preservation of the limb in high-risk patients.