Elective popliteal aneurysms: does venous availability has an impact on indications?

AIM: The aim of this retrospective study was to evaluate the patency and limb salvage rates after prosthetics or venous bypasses for asymptomatic or mildly symptomatic popliteal aneurysms, in order to determine if small uncomplicated aneurysms (caliber <300%) should be operated or periodically controlled when a venous conduit is not available. METHODS: During a 18 years period, 100 popliteal aneurysms, including 85 asymptomatic and 15 associated with intermittent claudication, were operated on: group I consisted of 80 venous bypasses, and group II consisted of 20 prosthetic bypasses. RESULTS: Demographics and risks factors were similar in both groups. Local complications were more frequent in group I (17% vs 10% p=NS). Early vascular complications were rare in both groups. Late arterial complications were more frequent in group II. Primary patency, assisted primary patency, and secondary patency rates at 2 years were 94.3%, 97.3% and 98.7% in group I, and 61.5%, 89% and 88.4% in group II (p<0.05). In contrast, the limbs salvage rates were not significantly different for each type of graft (98.7% vs 100% p=NS). CONCLUSIONS: Our data shows that aneurysms treated with a prosthetic graft are at higher risk of late occlusion than those operated with a vein graft. This should be taken into account when facing a small uncomplicated aneurysm without available venous conduit. The presence of a suitable vein should be checked before deciding to operate a small uncomplicated popliteal aneurysm.

Primary hyperparathyroidism: is technetium 99m-Sestamibi/iodine-123 subtraction scanning the best procedure to locate enlarged glands before surgery?

Technetium99m (99mTc)-Sestamibi/123I subtraction scanning was prospectively performed in 30 patients with primary hyperparathyroidism in an attempt to locate enlarged glands before first surgery. Imaging results were compared to surgical findings; the surgeon tried to identify all parathyroid glands. Twenty-seven patients were found to have a solitary adenoma during surgery, and 3 had multiglandular parathyroid hyperplasia. Twenty-six parathyroid adenomas (96%) were accurately located before surgery. The smallest gland detected weighted 125 mg. Preoperative detection of two mediastinal adenomas allowed them to be excised by median sternotomy during the initial operation. 99mTc-Sestamibi/123I subtraction scanning predicted multiglandular involvement in two patients with parathyroid hyperplasia, whereas it showed a solitary image in the third. Ten patients (33%) had associated nodular thyroid disease, hindering image analysis and leading to one false positive result. 99mTc-Sestamibi scanning seems to be better for locating enlarged parathyroid glands than other noninvasive imaging techniques. However, 1) difficulties associated with thyroid nodules call for complementary thyroid scanning; and 2) images showing a solitary enlarged parathyroid gland do not rule out multiglandular disease. This technique should help in detecting lesions, such as mediastinal glands, that are difficult to find at initial surgery.

Acute arterial obliteration: a new feature of the POEMS syndrome?

The POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammapathy, and skin changes) syndrome is a rare variant of plasma cell dyscrasia with multisystemic manifestations. We present 4 cases with arterial symptoms typical of acute arterial obliteration (AAO) and review 9 similar cases in the literature. The clinical course of AAO was unusual and particularly severe when affecting the lower limbs; recurrent events required amputations. As demonstrated by angiographic and histologic studies, thrombotic and atheromatous lesions were the main pathologic features of AAO. Atherosclerotic risk factors were absent or moderate in 3 of our cases, and no cause of thrombosis other than the POEMS syndrome was found. A high production of cytokines was found in all cases, with elevated serum levels of interleukin-1 beta (9/9 samples), interleukin-6 (7/9 samples), and tumor necrosis factor-alpha (6/9 samples). We suggest that arterial manifestations should be added to the spectrum of manifestations of the POEMS syndrome. Cytokines may mediate the POEMS syndrome-associated AAO, as previously proposed for the other systemic manifestations of this disorder.

Parathyroid imaging using simultaneous double-window recording of technetium-99m-sestamibi and iodine-123.

UNLABELLED: Technetium-99m-sestamibi represents an important advance in the scintigraphic location of parathyroid neoplasms. However, the optimal procedure for 99mTc-sestamibi parathyroid scanning has not been defined. The first objective of this work was to optimize the technical aspects of subtraction scanning, using simultaneous double-window recording of 99mTc-sestamibi and 1231 instead of successive image recording. The second objective was to compare two protocols for detecting abnormal parathyroid glands: subtraction scanning and single-tracer double-phase scanning. METHODS: Thirty patients referred for first surgery of primary hyperparathyroidism had both subtraction scanning and double-phase scanning in the same imaging session. Images of 99mTc-sestamibi and 123I were recorded simultaneously in nonoverlapping windows and then subtracted. For double-phase scanning, images of 99mTc-sestamibi, acquired 15 min and 120 min after tracer injection, were visually compared. Surgery disclosed a solitary adenoma in 27 patients, bilateral adenomata in 2 patients and 3 hyperplastic glands in the last patient. No patient had persistent hypercalcemia. RESULTS: Preoperative 99mTc-sestamibi/123I subtraction scanning located 25 of 27 solitary adenomas, the bilateral adenomata and 3 of 3 hyperplastic glands. The overall sensitivity for enlarged parathyroids was 94%, and the false-positive image rate was 3%. The 99mTc-sestamibi single-tracer technique located 22 of 27 solitary adenomas, the bilateral adenomata and 1 of 3 hyperplastic glands. Overall sensitivity was 79% and the false-positive image rate was 10%. The gamma camera imaging time was 30 min for the subtraction technique and 50 min for the single-tracer double-phase study. An ectopic adenoma in the sheath of the right carotid artery was detected by both techniques. CONCLUSION: These results, together with other data in the literature, indicate that 99mTc-sestamibi/123I subtraction imaging is accurate in locating enlarged parathyroids. Classical difficulties of this technique (motion artifacts and prolonged immobilization) were avoided by using simultaneous recording of the two isotopes. In this series subtraction imaging was more rapid and more sensitive (p < 0.04) than the single-tracer technique.

Arterial occlusive disease after radiotherapy: a report of fourteen cases.

Fourteen cases of arterial occlusion or severe narrowing following radiotherapy are studied in order to assess the possible etiological role of such therapy in arterial lesion. Surgical results are also discussed in terms of long-term efficacy. The average time of occurrence after radiotherapy was 8 years post-radiotherapy. This series includes 7 supra-aortic trunk stenoses and 7 abdominal aorta trunk stenoses. The doses received in the volumes irradiated ranged from 47 to 70 Gy with standard fractionation. Association of atherosclerotic risk factors (smoking, hyperlipidemia, diabetes, high blood pressure) was present in 12 patients, but stenoses were usually confined to irradiated areas, and at times occurred in uncommon sites. Surgical management included 11 by-passes, 2 endarterectomies and one percutaneous transluminal angioplasty. All patients experienced immediate and satisfactory functional improvements. Three patients were re-operated on because of the re-occlusion of the by-pass (2 cases) and graft infection (1 case). On the whole, stenoses in previously irradiated areas showed no particular difficulties for surgical treatment. It was concluded that radiotherapy seems to be a definite risk factor for arterial occlusion or narrowing, especially in association with atherosclerotic risk factors.

Goiter with severe respiratory compromise: evaluation and treatment.

Goiter with major respiratory compromise is uncommon but troublesome. Evaluation and treatment of this condition are controversial. Of a total of 2,908 goiters operated on over a 17-year period, 58 cases with this particular complication were studied retrospectively to define optimal management. Twenty-two patients had severe or acute dyspnea, and four of them required immediate tracheal intubation. Thirty-six patients had chronic dyspnea without cyanosis. Carcinoma was present in these two groups in 50% and 11% of patients, respectively. Results of our retrospective study are as follows: long-standing tolerance of goiter did not preclude the possibility of compressive respiratory distress or carcinoma. Optimal management of goiter with respiratory compression was obtained when surgery was delayed until satisfactory operating room conditions and adequate possibilities of interpretation of pathologic conditions were united. In case of respiratory distress, tracheal intubation allowed to abide without risks. In other patients preoperative investigations were kept to a minimum. Technical artifices facilitated the extraction of the goiter via cervicotomy without sternotomy in 92% of patients with minimal morbidity. Whenever necessary, endotracheal intubation obviated the need for tracheostomy. These data suggest preventive removal of all large or substernal goiters.

Aneurysm of persistent sciatic artery: report of a case treated by endovascular occlusion and femoropopliteal bypass.

Aneurysmal degeneration is the most serious complication of persistent sciatic artery. In the literature there have been only 16 surgically treated cases. We report one additional case to present an original and safe method of treatment: balloon endovascular occlusion and femoropopliteal bypass. Diagnosis and other methods of treatment are discussed.

Thyroid carcinoma with tracheal or esophageal involvement: limited or maximal surgery?

This retrospective study was undertaken to evaluate the prognosis of and to determine optimal therapy for thyroid carcinoma adhering to or invading the trachea or esophagus. In our series of 412 operated thyroid cancers, there were 45 patients including 20 with adherences to the trachea or esophagus that were dissected free by sharp dissection (group 1), six patients with invasion of the trachea or esophagus who underwent total resection followed by radioiodine and external-beam irradiation (group 2), and 19 patients with invasion of the trachea or esophagus that had been incompletely resected (group 3). There were no major complications. Survival or disease-free unrelated deaths were recorded in 80%, 100%, and 16% of patients in groups 1, 2, and 3, respectively. The three patients with anaplastic carcinoma in group 1 are free of disease 3, 6, and 7 years after operation, respectively. Combined with those in the literature, our data indicate that (1) adherences to the trachea or esophagus are not necessarily associated with poor prognosis and should be treated with aggressive surgery even in anaplastic carcinoma, (2) invasion of the trachea or esophagus must be treated whenever possible by total resection followed by radioiodine and external-beam irradiation, (3) a two-stage operation should be considered when optimal conditions are not available initially, and (4) cure may be obtained with complementary radioiodine and external-beam irradiation after incomplete resection of papillary carcinoma.

Pulmonary function after transverse or midline incision in patients with obstructive pulmonary disease.

Atelectasis and bronchopneumonia occur frequently in patients undergoing aorto-iliac reconstructive surgery. Transverse (T) incisions in upper abdominal surgery are thought to be followed by fewer pulmonary complications than midline incisions (M) but reports remain controversial. We studied the incidence of postoperative pulmonary complications and lung dysfunction after T and M incisions for aorto-iliac surgery in 13 patients with chronic obstructive pulmonary disease (COPD) and 13 control patients with normal lungs (C). For all subjects, we evaluated (1) postoperative clinical or radiological pulmonary events; (2) preoperatively and on postoperative days 2 (D2), 5 (D5), 9 (D9) and 12 (D12) - the forced expiratory volume in 1 s (FEV1), vital capacity (VC), alveolar-arterial oxygen difference (AaPO2), and (3) convenience for the surgeon. Operatively, aortic exposure was excellent with both incisions. Bronchopneumonia occurred only after M in five patients (1 C, 4 COPD). In contrast with the control patients in whom no difference was found between T and M incisions, the FEV1 of COPD patients was significantly less impaired with T than with M incisions (p less than 0.005 on D2 and p less than 0.05 on D5). VC decreased similarly with both incisions on D2 but on D5 the improvement was less with M (p less than 0.005). Changes in AaPO2 were more marked on D2 and D5 for the COPD patients with M incisions. We conclude that (1) in patients with chronic obstructive pulmonary disease, laparotomy with a transverse incision was associated with better postoperative lung function and fewer pulmonary complications; (2) in patients without pulmonary disease, midline and transverse incisions were equivalent.

Unilateral surgery for primary hyperparathyroidism on the basis of technetium Tc 99m sestamibi and iodine 123 subtraction scanning.

HYPOTHESIS: Parathyroid scanning, based on simultaneous recording of technetium Tc 99m sestamibi and iodine 123 images, is able to identify patients with multiple parathyroid gland disease and is a safe imaging technique for unilateral parathyroid surgery. DESIGN: Scintigraphic criteria of eligibility for unilateral surgery were prospectively tested against findings of conventional bilateral surgery. SETTING: Patients referred to an endocrine surgeon in a university hospital. PATIENTS: Seventy consecutive patients with primary hyperparathyroidism had dual-isotope scanning before conventional surgery. Forty-one patients had scan findings compatible with unilateral surgery, with a single focus of high intensity seen on the anterior and lateral views. The remaining 29 patients had 1 or more criteria of ineligibility: (1) scan findings pointing to multiple gland disease, (2) no well-identified focus, (3) contralateral thyroid nodule requiring surgical management, or (4) family history of hyperparathyroidism or multiple endocrine disease. MAIN OUTCOME MEASURES: Number of enlarged parathyroid glands at surgical inspection and calcemia follow-up. RESULTS: None of the 41 patients, with a single well-defined focus on the scan image, showed evidence of multiple parathyroid involvement. Each parathyroid adenoma was resected from the precise site predicted by the subtraction scan. Nine patients (13%) had surgical findings of multiple parathyroid gland disease. All 9 were ineligible based on preoperative image findings. CONCLUSIONS: Unilateral surgery can be safely offered to 60% of patients with primary hyperparathyroidism, on the basis of simultaneous (99m)Tc-sestamibi and (123)I scanning. This may reduce the length of the operation, anesthesia requirements, and hospital stay, and the risks of hypoparathyroidism and injury to the recurrent laryngeal nerve.

Operation for hyperthyroidism. Methods and rationale.

Five hundred patients with hyperthyroidism underwent operation between 1970 and 1984. Sixty-nine percent had Graves' disease, 19 percent had toxic thyroid adenoma, and 12 percent had multinodular toxic goiter. Good results were achieved in the 275 patients most recently treated. These results may be attributed to the following: good personal contact between the surgeon and the patient at the first meeting, 1 month of preoperative management with carbimazole and propranolol without interruption of work, operation adapted to the type of goiter, and treatment of postoperative tachycardia by propranolol. The mean duration of hospital stay was 5 days. Sequelae were rare. In the patients with Graves' disease, results at 2 years were as follows: 74 percent of operated patients were euthyroid, 23 percent required substitutive treatment, and surgical treatment failed or early relapse occurred in 3 percent. There were no recurrences after operation in patients with solitary or multinodular toxic goiter, but 30 percent of the former and 98 percent of the latter had to be treated with L-thyroxine. Seventy-two percent of the patients who presented with atrial fibrillation had return of normal cardiac rhythm after operation.

Fibromuscular dysplasia of the right subclavian artery.

The case of an uncommon form of arterial fibromuscular dysplasia is reported. The anomaly was located in the right subclavian artery. Claudication of the affected limb was the presenting symptom. Angiography was diagnostic in visualizing typical multifocal stenosis of the proximal portion of the right subclavian artery. Complete surgical correction was performed by establishing a carotido-subclavian by-pass graft.

Late occlusion of aorto-bifemoral grafts. Causes and management.

Late occlusion occurred in 52 limbs of 37 bifurcated aorto-femoral grafts (37 patients). These were analysed to determine causal factors and the efficacy of various surgical techniques of repair. There were two principle causes: intimal hyperplasia (n = 19) and progressive atherosclerosis (n = 18), and then miscellaneous causes (n = 15). Surgical techniques included: repair of inflow by thrombectomy (n = 30), new aorto-femoral graft (n = 6), cross-over femoro-femoral (n = 3), and axillo-bifemoral graft (n = 2); repair of out-flow by profundoplasty (n = 18), addition of a new length of graft (n = 10), and femoro-popliteal bypass (n = 13). There were no immediate post-operative deaths but four rethromboses (7.6%) occurred and there were five amputations (9.6%). During the follow-up period (mean 19 months), four patients died (11%), 5 limbs reoccluded (9.4%), and two were amputated (4.2%). Patency rate was 90% for thrombectomy and 83% for new aorto-bifemoral graft. It was 86% for repair of the profunda femoris artery and 77% for femoro-popliteal bypass. Although no statistical analysis can be applied on this small number of patients, the present study suggests that: intimal hyperplasia is a frequent and probably under-estimated cause of late thrombosis; whenever feasible thrombectomy and profundoplasty are the most simple and effective procedure of repair.

Wrapped autologous greater saphenous vein bypass for severe limb ischemia in patients with varicose veins. Preliminary report.

The greater saphenous veins in patients with varicose veins has been overlooked as a conduit for arterial bypass. Greater saphenous veins is often normal and when only parts of the greater saphenous veins are of normal size, a veno-venous or a graft composite bypass may be performed. The goal of this preliminary study was to asses if wrapped autologous greater saphenous veins could be suitable conduits for arterial bypass in patients presenting with critical ischemia. In three patients the greater saphenous veins had one to four dilatations which were wrapped with short segments of Polytetrafluoroethylene graft. In three other patients, the dilated area being longer, the greater saphenous veins were totally wrapped in a hand-made mesh of Dacron. No complications were due to the wrapping procedure and the unwrapped segments did not dilate during a mean three year follow-up. We conclude that wrapped autologous greater saphenous veins may help save limbs of patients with critical ischemia. As an underestimated proportion of patients presenting with varicose tributaries have normal or quite normal greater saphenous veins, the caliber of the greater saphenous veins should be carefully measured before treating the varicose veins. All greater saphenous veins suitable for an arterial bypass should be preserved remembering that one or several dilatations may be wrapped if the greater saphenous veins is used as an arterial substitute. Patients should be informed of the reasons for this choice.

Severe injuries resulting from operations for thoracic outlet syndrome: can they be avoided?

Surgery for thoracic outlet syndrome (TOS) is claimed to have a low risk of severe complications. To re-evaluate this, a questionnaire was sent out to the French vascular surgical community. There were 66 replies. While some surgeons had operated on several hundred patients without any severe complications, others had experienced rare but dramatic complications including wounds or thrombosis of the axillary artery, vein injuries or thrombosis, transient or definitive paralysis of the brachial plexus, long thoracic or phrenic nerves, hemothorax, and chylothorax. Two resulted in the death of young patients. The results of the present study, as well as rare reports in the literature, demonstrate that these complications may occur even with experienced surgeons using either the supraclavicular or transaxillary approaches. We conclude that: (1) operation for TOS should be considered only when the diagnosis is certain and when operative decompression is the sole solution; (2) the choice of an adequate approach, good vision during operation, and meticulous technique are all mandatory for full security. Surgical guidelines are suggested.

Carotid surgery. Is regional anesthesia always appropriate?

We retrospectively studied a series of 385 carotid endarterectomies performed either under general anesthesia (242) or under local anesthesia (145) to compare the peri-operative mortality and morbidity rate and to identify factors which may influence the choice of anesthesia. The rate of transient ischaemic attacks (TIA), stroke, death, combined mortality, severe neurological and cardiac morbidity were not statistically different. Under general anesthesia, more shunts were inserted (17% versus 7%, p less than 0.05) and more myocardial infarctions occurred (5% versus 0%, p less than 0.05). However, more strokes due to technical imperfection were seen under regional anesthesia. We concluded that regional anesthesia is more appropriate in patients with coronary artery disease and in patients at risk of intolerance to cross clamping. General anesthesia is more appropriate in poorly cooperative patients or in those with unfavorable operative conditions.

Should all spontaneous popliteal aneurysms be operated on?

Operative treatment of spontaneous popliteal aneurysms (S.P.As) is occasionally disappointing. In order to determine the criteria for operation we analyzed retrospectively the fate of 77 S.P.As in 52 patients (mean age, 66 +/- 10 years). S.P.As were divided into 3 groups according to initial symptoms: group I, asymptomatic or mild symptoms, group II, rest pain or toe gangrene, group III, severe ischemia or foot gangrene. Patency rate of arterial reconstruction in groups I, II, III were respectively 83%, 43%, 36%. The course of S.P.As of group I that were not initially operated was not significantly different compared to those operated on, as long as they were frequently reviewed and operated on expeditionaly in cases of complications. The nature of the arterial substitute was the second contributing factor. Quality of run-off had no influence in groups I and II, but was determinant in group III. A good general condition was essential for survival. Operative indications of S.P.As is considered according to classification into 3 groups. Group I: bypass is mandatory, except when the general condition of the patient is poor or when a bad run-off is associated with an unavailable vein. Group II: bypass should be attempted whenever a distal arterial segment seems suitable. Otherwise lumbar sympathectomy may sometimes save a limb. Group III: bypass should be attempted only when the run-off is sufficient and when the tissue damage seems reversible. In the other cases, primary amputation is safer.

Late arterial aneurysm proximal to corrected post-traumatic arteriovenous fistula.

A 60 year-old man presented with an extensive iliofemoral aneurysm discovered 11 years after the closure of a long-standing (28 years) post-traumatic arteriovenous fistula (AVF). Treatment by exclusion and bypass was successful. Fifteen other such cases have been reported in the literature in the last 15 years. While cardiomegaly is reversible once the AVF has been closed, arteriomegaly continues to increase or may begin only after closure. The mechanism for this phenomenon is debated. All arterial dilatations discovered during or after closure of AVF must be treated because of the risk of rupture. Prevention implies early treatment of all AVF. If the AVF is long-standing, the caliber of the artery proximal to the site of repair must be carefully measured and all dilated segments replaced. The patient should be warned of the possibility of late arteriomegaly proximal to the site of closure.

Management of radiation-induced occlusive arterial disease: a reassessment.

BACKGROUND: The goal of this study was to evaluate the operative hazards, therapeutic procedures, and late results of arterial reconstruction for radiation-induced occlusive disease. METHODS: Twenty-five patients were referred to our institution for radiation-induced occlusive arterial disease. Group 1: carotid artery stenosis or occlusion was encountered in seven patients. The nine procedures employed included percutaneous transluminal angioplasty (PTA) (n = 2), carotid endarterectomy (n = 3), vein or prosthetic bypass (n = 4). Group 2: four patients presenting with subclavian and axillary artery occlusion were treated with a common carotid to brachial artery vein bypass, one after unsuccessful PTA. Group 3: Thirteen patients had aorto-iliac occlusion. Initial management included medical treatment (n = 1), PTA (n = 2), aorto-bifemoral bypass (n = 4), aortofemoral and iliofemoral bypass (n = 1 each), axillofemoral bypass (n = 3), femorofemoral bypass (n = 1). Group 4: One patient had femoral artery occlusion treated with PTA. RESULTS: Group 1: One of two PTA was successful. Endarterectomy or bypass were successful in all cases. One late vein bypass stenosis was treated by venous patch angioplasty. Group 2: All vein bypasses were successful. Group 3: Limb salvage was achieved in all patients but eight required repeat operations for prosthetic sepsis (n = 3), restenosis (n = 3), or thrombosis (n = 12). Two patients died of late sepsis. Group 4: Outcome after PTA was successful. CONCLUSIONS: 1) Surgery for radiation-induced arterial lesions is difficult because of arterial, periarterial, and cutaneous sclerosis. Some patients, however, are amenable to PTA or endarterectomy. When bypass is necessary, anastomosis should be performed in healthy arteries, for instance, the thoracic aorta for the proximal anastomosis, or the brachial artery approached through a lateral mid-arm incision. 2) The risk of early or late graft infection is enhanced by the presence of tracheostomy, colostomy, or ureterostomy and by repeat operation for thrombosis. PTA, endarterectomy, or vein bypass should be preferred whenever feasible. When prosthetic material is unavoidable, prevention of infection should include the use of omentoplasty, remote bypass, antibiotic-bonded grafts or, in the case of major sepsis, allografts. 3) As restenosis remains a frequent complication, annual clinical and Duplex-scan surveillance is mandatory.

Proximal anastomosis in aortobifemoral bypass: end-to-end or end-to-side?

When performing an aortobifemoral bypass, the surgeon may choose between an end-to-end or end-to-side aortic anastomosis. Although several authors have claimed the superiority of the former, controversy still exists. The aim of this study was to compare the early and late results of these two techniques in patients for which both procedures were possible. Of 158 patients, aortic anastomosis was performed end-to-end in 47 (group I) and end-to-side in 111 (group II). Both groups were similar in all other aspects. The type of proximal anastomosis did not affect the rate of perioperative mortality or early thrombosis. There were no secondary aortic aneurysms or aortoenteric fistulae in either group. Actuarial primary (without reoperation) and secondary (after thrombectomy) five year patency rates were 90.2 and 98.9 per cent in group I, and 90.8 and 98.5 per cent in group II, respectively. Five-year limb survival was 95.3 and 95.7 per cent, respectively. As we could not find any difference between the results in the two groups, we suggest choosing the simplest procedure which maintains adequate pelvic and colonic blood supply, according to angiographic findings.