Place of intravenous arteriography with non-numerized processing in vascular pathology and surgery. Results of 424 investigations.

424 intra-venous arteriographies with non-numerized photographic subtraction have been carried out in 304 patients. Exploration concerned supra-aortic trunks in 204 cases, abdominal aorta in 107 cases, arteries of the lower limbs in 89 cases, thoracic aorta in 19 cases and arteries of the upper limbs in 5 cases. Technique is described, indications, results, complications and limits of the method are discussed for each explored area. This method is an interesting contribution as a morphological, slightly invasive evaluation of arterial lesions when computerized systems are not available.

Iatrogenic vascular injuries. A review of 125 cases (excluding angiographic injuries).

From the files of an insurance company and from a number of our own files as expert medical witness to the court we have been able to collect 125 cases of malpractice suits following a iatrogenic vascular injury. An analytic study has revealed the following: --12 vascular injuries occurred after stripping of varicose veins of the lower extremities; --4 accidents occurred during arterial surgery; --35 lesions followed orthopedic surgery; and --2 general surgery. Besides these 53 injuries following surgical procedures, 72 injuries are described following non-surgical diagnostic or therapeutic procedures: --sclerotherapy of varicose veins or angiomas: 34 cases; --injection of anesthesic agents: 20 cases; --injections, infusions, catheterisms: 16 cases; and --endoscopic procedures: 2 cases. Vascular risk exists in almost all medico-surgical procedures and requires constant and careful attention since professional responsibility is easily involved. Early recognition and early correction of the vascular lesion reduce the incidence and the gravity of the complications.

Resection and reconstruction of the carotid bifurcation with polytetrafluoroethylene grafts; operative technique. Preliminary results in 25 procedures and indications.

Although carotid endarterectomy is the standard procedure, the purpose of this paper is to describe a new surgical technique and indicate its role in the surgery of cervical cerebrovascular disease. The technique consists of resection of the pathologic carotid artery bifurcation followed by its total replacement with a bifurcated thin-wall polytetrafluoroethylene (PTFE) graft constructed by the surgeon. Prosthetic graft reconstruction of the carotid bifurcation (PGRCB) was performed in 21 patients (25 procedures) from November 1984 to May 1987. Many patients were over 70 years old. The indications for surgery were transient ischemic attacks (TIA)'s in 10 patients (high-grade stenosis), established stroke with mild deficit in 3 patients (high-grade stenosis). Eight patients (high-grade stenosis) were asymptomatic and 4 had vertebro-basilar symptoms. In 11 procedures the indications were the same as for standard carotid endarterectomy (significant stenosis and/or ulcerated plaque). In 14 cases, the procedure was justified by extensive lesions involving a long segment of the internal carotid artery (2 restenoses, 12 calcified lesions). In the perioperative period, there were no deaths and no TIA's. The 25 procedures were assessed one month postoperatively by ultrasonic imaging and venous substraction angiography. All the grafts were patent with perfect restoration of the carotid bifurcation anatomy. Systematic follow-up study was carried out in 1987. Three patients had died of non-neurologic causes and one was lost to study. The remaining 19 procedures were evaluated with an average follow-up of 19 months (range 7 to 32 months). The patients were asymptomatic and all the grafts remained patent including one stenosis (greater than 50%) at the common carotid artery anastomosis. Because recent studies have documented a much higher rate of technical defects or recurrent stenosis after carotid endarterectomy, we believe that PGRCB merits consideration, particularly in difficult endarterectomies, and in recurrent carotid stenosis. Furthermore it seems acceptable to advocate PGRCB in aneurysms of the internal carotid artery and in post-irradiation arteritis.

"Redo" surgery for late aorto-femoral graft occlusive failures.

Experience of late failures of Dacron aortofemoral grafts is presented; about 70 cases observed during the past eight years on whom 105 subsequent operations were performed. One third of these patients were first operated upon by another surgical team. During the same period, 850 patients were submitted to reconstructive surgery of the abdominal aorta and iliac arteries either for atherosclerotic or for aneurysmal disease. It appears that conservative procedures like thrombectomy of the occluded limb are often insufficient, impossible, inappropriate or dangerous, even after restoration of a good deep femoral outflow. On the other hand, aggressive restoration of limbflow is generally necessary, with other various and ingenious direct or indirect reconstructive techniques for restitution of a good inflow and outflow. These techniques are usually successful (85%) and gain time against the major etiology of these late failures viz the development of atherosclerotic disease.

Doppler spectrum analysis and vascular imaging in the diagnosis of extracranial carotid artery disease.

Ultrasound methods are well suited for the exploration of the carotid system. High resolution echography can visualize atheromatous defects on the vessels walls with a resolution better than one mm, whereas Doppler examination detects haemodynamic disturbances due to these plaques. Conventional Doppler examination can reveal moderate or severe stenosis (greater than 60%); the recent development of frequency analysis of the Doppler audio signal makes now possible the detection of very light haemodynamic disturbances due to low grade stenosis even as small as 15%. Spectral distribution abnormalities have been classified in four grades according to their amplitude. The combination of the morphological and functional data provided by echography and Doppler spectrum analysis has drastically increased the diagnostic possibilities of the ultrasound methods in the field of the extracranial vascular pathology. With a new duplex system which combines echography and C.W. Doppler examination (duplex probe) it is possible to detect, and quantify carotid stenosis (in percentage of the lumen reduction), and to evaluate blood flow volume in ml/mn.

The white clot syndrome or heparin associated thrombocytopenia and thrombosis (WCS or HATT) (26 cases).

The Authors report a new iatrogenic complication of preventive or curative standard heparinotherapy. This so called "white clot syndrome" or "Heparin associated thrombocytopenia and thrombosis" is an anatomico-clinical entity characterized by severe, multiple, recurrent, arterial and/or venous thromboembolic accidents which are sometimes fatal. They appear, paradoxically, under heparin treatment and are concomitant with thrombocytopenia (generally less than 100 10(9)/l). Antiplatelet immunoallergic phenomena, via type IgG antibodies, induced by heparin, are the most commonly admitted in physiopathology; however they remain controversial. Treatment of "WCS" includes urgent suppression of standard heparin, administration of antivitamin K, or the new generation of low molecular weight heparin. This series presents 26 cases of HATT treated by LMWH (CY 216 CHOAY). Severe complications must be surgically cured. Prevention of WCS or HATT is mandatory by the systematic survey of platelet count during heparinotherapy.

Carotid artery surgery in patients over 70 years of age.

Between 1965 and 1979, 934 patients underwent 1,057 operations for extracranial carotid stenosis at this institute, and over a recent 30-month period 463 patients underwent 511 operations of this type. This number is equal to the total of operations performed during the years 1965-1976. The increase in the frequency of carotid artery surgery has been more marked in patients of over 70 years. The percentage of elderly patients has increased from 17.5% to 27% in the recent period. In the latter group of 511 operations, results were good in 93.17% of cases, while there was a mortality rate of 1.95% (1% of which were directly related to the surgery), in 1.95% the neurologic condition deteriorated and in 3.13% there was no change. In the first period the mortality rate for patients over 70 years of age was 7.69%. In the second it was 3.27% (1.63% of which were due to non-neurologic causes), 4.09% deteriorated, in 2.18% there was no change and good results were obtained in 90.46%.

[Evaluation of the degree of carotid stenosis by spectral analysis of the Doppler signal. Comparison of the results of spectral analysis, angiography and anatomo-pathology]. / Evaluation du degré des sténoses carotidiennes par l'analyse spectrale du signal Doppler. Confrontation des résultats de l'analyse spectrale, de l'angiographie et de l'anatomo-pathologie.

With the single Doppler spectrum analysis, one can appreciate the degree of the carotid stenosis according to the importance of the haemodynamic disturbances induced by the stenosis. The purpose of our study is to show the possibilities and the limitations of this method. Spectrum disturbances were classified in 5 grades, each of them being related to the importance of the stenosis. The degree of stenosis has been evaluated by the C.W. Doppler spectrum analysis, the angiographies and the anatomical study of the endarteriectomies. We considered that we had a perfect concordance between the results of the different methods when the degree of stenosis measured on the angiographies or on the endarteriectomies was compatible with the spectrum analysis classification: grade I: stenosis inferior to 40% (in area), 23% (in diameter); grade II: stenosis ranging between 40 and 60% in area (23 and 40 in diameter); grade III: stenosis of 60 to 75% in area (40 to 50% in diameter) and of particular shape (extended plaque); grade IV: stenosis ranging between 60 and 90% in area (40 to 70% in diameter); grade V: stenosis higher than 90% in area (70% in diameter). The confrontation of spectrum analysis and angiographic date concerns 58 bifurcations. We got a perfect correlation in 93% of the cases. The confrontation of the spectrum analysis method and the anatomical study of the endarteriectomies concerns 38 bifurcations. We got a perfect correlation in 92% of the cases. The appreciation of the carotid stenosis degree is now performed in routine at the Hospital. For some patients, the endarteriectomy has been decided from the clinical and the spectrum analysis data, and an electro-encephalogram with compression. However these date are generally completed with an angiography with venous punction.

[Myocardial ischemia and carotid surgery. Holter study of 21 severe coronary patients. Preventive effect of intravenous trinitrin]. / Ischémie myocardique et chirurgie carotidienne. Etude par la méthode de Holter chez 21 coronariens sévères. Effet préventif de la trinitrine intraveineuse.

Cervical carotid artery surgery is increasingly being performed in elderly, polyvascular, high risk patients, some of whom have severe coronary artery disease. Is this right? The effects of this almost routine surgical procedure from the technical point of view were analysed with respect to the coronary lesions. 1. A retrospective study of coronary events occurring in the peroperative or immediate postoperative period and at short term was carried out in 367 patients aged over 70 years old (average 73,4 years) undergoing 424 cervical carotid artery procedures with a particularly high coronary risk. 2. A prospective study of ischemic ECG changes occurring in the period between induction of anaesthesia and the 4th postoperative day was performed by Holter monitoring in 21 patients with severe coronary artery disease. The mortality and morbidity observed were very low and could be further reduced by certain anaesthetic and pre-and postoperative techniques. In particular, prophylactic intravenous trinitrin (0,5 to 1,5 gamma kg/min) was most effective in protecting the myocardium in 15 patients with severe angina (classes III and IV of the NYHA classification). The authors conclude that the surgical result depends mainly on the neurological status of the patients, the best results being obtained in asymptomatic patients (stage 0) or those having suffered transient ischemic attacks (stage 1). The global mortality and morbidity rate was less than 2 p. 100 in those groups. On the other hand, long-term survival depends mainly on the severity of the coronary artery disease.

[What key zones should be monitored as a function of the assessment of the initial lesion? Collateral pathways?]. / Quelles sont les zones clés á surveiller en fonction du bilan lésionnel initial? Les voies de suppléance?

Key zones to be kept under surveillance are defined as a function of initial lesion features of operated or unoperated arteriopathy of lower limbs. Knowledge of these key zones resides in the anatomical knowledge of the supply network and of the physiopathology involved and its coming into play. Collateral circulations of infrarenal aortic obstructions are studied in detail, and then those that develop after femoral and tibial artery occlusions. Valid prediction of the ischemic risk can only be made after obtaining precise data on the re-entry effectiveness through this collateral circulation, allowing a prognosis to be established and a reasoned choice of therapy to be made.

[Anatomy and surveillance of key sites and collateral pathways in arteriopathies of the lower extermities]. / Anatomie et surveillance des zones clés et des voies de suppléance dans les artériopathies des membres inférieurs.

Key sites to be followed up are defined as a function of initial explorations of lesions in operated or unoperated arterial disease of the lower limb. Details of these key sites were obtained from pathologic examination of collateral vessel networks. Precise studies were conducted of the collateral circulation after infrarenal aortic obliterations, and femoral and tibial artery occlusions. Prediction of the ischemic risk and therefore of prognosis, and choice of therapy, can be obtained only by a detailed study of the reentry value through the bias of this collateral circulation.

[Resection graft prosthesis (PTFE) of the carotid bifurcation (RGPCB). A new alternative to endarterectomy or to venous bypasses for the treatment of cervical carotid atheromatous stenoses. Technique and indications]. / La résection greffe prothétique (PTFE) de la bifurcation carotidienne (RGPBC). Une nouvelle alternative à l'endartériectomie ou au pontage veineux pour le traitement des sténoses carotidiennes athéromateuses cervicales. Technique et indications.

Carotid endarterectomy, possibly followed by an enlarging angioplasty using a venous patch or a prosthesis, is standard treatment for cervical atheromatous lesions. However, this technique may be impossible to apply and a bypass operation may be necessary. J.M. Cormier has proposed the use of a venous by-pass by autologous internal saphenous graft as an alternative to endarterectomy, and reported very favorable results. The usual procedure is lateral implantation into common carotid artery followed by end-to-end implantation into internal carotid artery. The object of this paper is to demonstrate the interest of total resection of the pathologic carotid artery bifurcation followed by total replacement with a prosthesis in PTFE (Goretex) with bifurcated thin walls (new bifurcation constructed by the surgeon) and 3 end-to-end anastomoses (common carotid proximally and internal and external carotids distally). This repair procedure is simple, orthoanatomic, and complete, ensuring permeability of the two axes, internal and external, and is logical. It avoids the thrombo-embolic risk related to the walls after endarterectomy which are often imperfectly smooth leaving a distal intimal projection difficult to prevent or to fix. This thrombotic in situ risk of the endarterectomized wall is shown by isotopic studies with Indium 111-labelled platelets, and most secondary neurologic accidents, definitive, sometimes fatal, or transient, are due to this phenomenon. The three anastomoses in healthy zones considerably reduces this risk. The use of PTFE in femorodistal bypass surgery has been shown to give a good level of long-term permeability even for poor distal beds, and to present a low septic risk compared with Dacron prosthesis. This material was therefore considered a good alternative to a venous graft for the carotid vessels. The technique was used 12 times in 11 patients, between 1984 and 1985, without occlusion, or mortality. One patient developed a transient ischemic accident related to a low output and with multiple pedicles lesions, but there were no sequelae. All shunts were seen to be permeable on follow up venous angiography. Wider experience and a longer review period are necessary before proposing this method, but initial results of its use have been encouraging.

[Development of a standardized form for mercury gauge plethysmography of veins and arteries]. / Mise au point d'une fiche de compte rendu standardisé pour les examens pléthysmographiques à jauge de mercure veineux et artériels.

Mercury strain gauge plethysmography will play an increasingly important role in vascular function exploration, participating in the detection of deep vein thrombosis and replacing arteriopathy in its arterio-capillary context. This required the development of a standardized reporting form for entering results of venous and arterial examinations and providing simple, clear evaluations of vascular function to assist therapeutic decisions. A standardized sheet in the form of rapidly scanned graphs and tables was established, this simplified representation facilitating decision making. Wider use of this type of form is proposed, with the aim of providing uniformity of data from mercury strain gauge plethysmography and statistical and computerized analysis of results of multicentre studies.

[Peroperative endoluminal dilatation or recanalization (DELPO or RCPO) in arteriopathies of the lower extremities. A new therapeutic weapon for the vascular surgeon. Apropos of 42 cases]. / La dilatation ou recanalisation endoluminale peropératoire (DELPO ou RCPO) dans les artériopathies des membres inférieurs. Une nouvelle arme thérapeutique pour le chirurgien vasculaire. A propos de 42 cas.

Forty-two DELPO or RCPO were performed using coaxial balloon catheters through surgical vascular approach for 35 cases of advanced lower limb arterial disease (stages: pronounced II: 6, III: 13, IV: 12, subacute ischemic: 4). The DELPO involved the following arteries: iliac: 12, deep femoral: 3, superficial femoral: 12, popliteal: 5, leg artery: 8, stenosis of popliteal anastomosis: 2, and was combined with a reconstructive arterial operation in 26 cases (proximal: 11 times, distal: 14 times or intersegmental: twice in relation to the surgical procedure). The DELPO was conducted alone in 9 cases and the RCPO alone in 6 cases, the surgical approach being preferred to the percutaneous route. Early results were rated as good in 89%, with clinical failures requiring amputation in 4% and failure of the method in 7%. The DELPO allows two objectives to be reached. First, when combined with a surgical procedure it reduces the extent and therefore the degree of surgical aggression while creating improved hemodynamic conditions for vascular reconstruction (improved proximal or distal beds or both). Second, when performed alone DELPO or RCPO enable safe, reliable treatment of lesions usually approached by a percutaneous endoluminal dilatation procedure.

[Severe ischemic accidents from ergotism. A report on 3 cases. Value of a new antidote : sodium nitropruside (author's transl)]. / Accidents ischémiques graves par ergotisme. A propos de 3 cas. Intérêt d'un nouvel antidote : le nitroprussiate de sodium.

The autors describe 3 recent cases of severe ischemic accidents from ergotism affecting different regions. Two of the cases resulted from taking Gynergene (ergotamine tartrate) for a short period, while the other case followed continuous administration of Desernil (Methysergide) for 3 years. The third case was treated at a late stage by continuous peridural anesthesia and various vasodilators without success and led to very severe mutilations in two young women. The third case was treated by continuous infusions of sodium nitropruside (SNP) under hemodynamic control, and recovery was rapid and complete. The value of SNP as an antidote for severe ergotism is discussed, together with its mode of administration, and precautions necessary when prescribing this extremely powerful vasodilator treatment for this indication.

[Echotomography and spectral analysis of the Doppler signal in the assessment of carotid lesions]. / L'échotomographie et l'analyse spectrale du signal Doppler dans le bilan des lésions carotidiennes.

Real-time echography and C.W. Doppler examination with spectrum analysis are the two methods most widely used for the study of the circulation. Echography allows the detection and the localization of the atheromatous defects whereas Doppler examination provides information on the blood flow. With the help of the frequency analysis of the Doppler signal it is possible to study much more accurately the local haemodynamic conditions. Spectrum analysis is one of the possible display mode for the Doppler signal. It provides in comparison with the zero crossing mode, much more haemodynamic parameters on the blood flow, such as velocity spectrum, density of red cells on each velocity... In this study, we tried to demonstrate that a relationship exists between the amplitude of the spectrum disturbances, recorded just after a stenosis and the degree of this stenosis. For that we propose a classification of the spectrum disturbances in five grades, each of them being related to an interval of possible values for the stenosis degree (grade I----stenosis less than 40% in area, grade II----40-60% stenosis, grade III----60-75% stenosis (extended defects) grade IV----70-90% (extended defects) and 60-90% short stenosis. Grade V: stenosis greater than 90%. The results provided by this classification were compared to those obtained by measurements of the stenosis degree on the piece of endarterectomy (72 cases). The results were in agreement in 94% of the cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[White clot syndrome. Arterial and venous thromboses during heparin therapy with thrombopenia after bone surgery]. / Le syndrome du caillot blanc. Thromboses artérielles et veineuses sous héparinothérapie avec thrombopénie après chirurgie osseuse.

The authors observed 9 patients submitted to prophylactic treatment with adequately doses subcutaneous heparin, for orthopaedic or traumatic surgery (chiefly total hip arthroplasty) who presented between the 7 and 9 day after starting heparin therapy, thrombotic complications including recurrent arterial occlusions and venous thrombosis associated with a profound thrombocytopenia, with a maximum platelet count below 30,000 per cubic millimeter. A rapid increase of platelet count after heparin withdrawal is observed, and the profound thrombocytopenia seems to be immune mediated with heparin dependent platelet antibodies, in most of the reported cases. We propose a platelet count for all surgical patients with heparin therapy, and if a thrombocytopenia appears, with a platelet count in the range of: 80,000 clinical inspection and platelet aggregation investigations, and immediate cessation of heparin therapy at 30,000 platelets/mm3.

[Validation of quantitative and qualitative data of real-time carotid echotomography in comparison with standard Doppler tests, arteriography and anatomopathology. On 59 carotid endarterectomies]. / Validation des données quantitatives et qualitatives de l'échotomographie carotidienne (en temps réel) par confrontation avec celles de l'examen Doppler standard. De l'artériographie et de l'anatomopathologie. Sur 59 endartériectomies carotidiennes.

Findings on ultrasound, arteriography and pathology examinations were compared in 49 patients undergoing 59 carotid endarterectomies between December 1981 and April 1983. Carotid artery lesions were investigated routinely by cervical Doppler, high resolution rapid ultrasound and either direct or more usually venous arteriography (with photographic subtractions). Postoperative endarterectomy specimens were examined to determine the exact degree of stenosis, and also qualitatively (gross pathology and histology of ulcerations and thromboses, the biochemical nature of the plaques, etc.). With respect to detection, that is demonstration of the existence or not of an atheromatous lesion, the ultrasonographic findings could always (100% of cases) be correlated with pathology data. Qualitative analysis of atheromatous lesions showed certain to be diagnosed with ease: calcified, fibrous or chondroid and lipidic plaques, while those complicated by hemorrhage, ulceration or mural thrombosis were less constantly diagnosed by ultrasound imaging. Occlusive plaques were easily detected, while recent intraluminal thrombosis was more difficult to diagnose by ultrasound alone. In this case the combined use of Doppler is a valuable aid, and is a routine procedure, in fact, in the department. Results of quantitative analysis showed good correlation between ultrasound and pathology findings in 79.7% of cases (insufficient in 20.3%). However, if ultrasonography is combined with other ultrasound methods of examination (standard Doppler and spectral analysis of Doppler) correlation is of the order of 95%, close to morphological data supplied by arteriography, with in addition a functional and qualitative approach not possible with arteriography alone.

[Ultrasonic, arteriographic and anatomopathological correlation in 59 cases of carotid atherosclerosis]. / Corrélations ultrasoniques, artériographiques et anatomopathologiques dans 59 cas d'athérosclérose carotidienne.

This study was carried out on 49 patients who underwent an ultrasound study by continuous Doppler and echotomography B real-time, an angiography of supra-aortic arteries, and a carotid endarterectomy. Thirteen had had transient ischemic attacks and 20 a stroke. A quantification of the carotid stenosis in 4 stages was established for each method. For detection of lesion an excellent correlation was observed between the results of echotomography and pathology. For the quantification of lesion the correlation between echotomography and pathology was excellent also in 79,7 p. 100 of the cases, discordant in 20,3 p. 100. It was similar to the correlation between arteriography and pathology (excellent in 83 p. 100 of the cases). The correlation with pathology enabled to distinguish for stages of atherosclerotic lesions, to clarify their type of complications, and to evaluate their functional significance, particularly those with a high risk of embolism.

[Splenic trauma complicating translumbar aortography : a report on 2 cases (author's transl)]. / Traumatismes spléniques compliquant l'aortographie translombaire. A propos de 2 cas.

Two very rare cases of splenic trauma following high translumbar aortography are described. Two types of clinical picture are observed : severe intraperitoneal hemorrhage, subcapsular and then intraperitoneal, from rupture of the spleen, and septic peritonitis following rupture of an intra- and perisplenic abscess. The authors review the frequency, mechanism, and prevention of complications following translumbar aortic puncture.