[Localized purpura revealing vascular prosthetic graft infection]. / Purpura localisé révélateur d'une infection tardive de prothèse vasculaire.

Prosthetic graft infection after vascular reconstruction is a rare but serious complication. We report a case of infection occurring late after implantation of an iliofemoral prosthetic vascular graft. The Staphylococcus aureus infection was revealed by vascular purpura localized on the right leg 7 years after implantation of a vascular prosthesis. This case illustrates an uncommonly late clinical manifestation presenting as an acute infection 7 years after the primary operation. In this situation, the presentation differs from early infection, which generally occurs within the first four postoperative months. Diagnosis and treatment remain a difficult challenge because prosthetic graft infection is a potentially life-threatening complication. Morbidity and mortality rates are high. Here we detail specific aspects of the clinical and radiological presentation.

[Vascularization of the wall of the superficial veins. Anatomic study of the vasa vasorum]. / La vascularisation de la paroi des veines superficielles. Etude anatomique des vasa vasorum.

INTRODUCTION: The blood vessel wall is almost always nourished by two ways; from the blood stream itself and through the outer part of the wall by vasa vasorum. AIM OF THE STUDY: The aim of this study was to demonstrate that this kind of nutrition is also available for the venous wall and to define the distribution pattern in superficial venous walls. MATERIALS AND METHODS: 50 long saphenous veins and 20 short saphenous veins latex or barium injections, dissections with magnifying glasses and microradiographies. Topographical evaluation of the origin of vasa vasorum. RESULTS: The results showed that vasa vasorum originated from perforating arteries coming from several levels and getting a lot of anastomosis. We showed that the main sources for the long saphenous vein are the external pudendal artery and descending artery of the knee and for the short saphenous vein, the short saphenous vein artery. In thrombosis and varicose veins, the vasa were strongly altered. CONCLUSION: This study outlines the fact that superficial veins are supplied by arterial and venous vasa vasorum, and the role of vasa vasorum must be considered when questioning the pathogenesis of varicose and post thrombotic disease.

[Evaluation of a computer graphic representation of echo-Doppler (Echotrace) in the assessment of atherosclerosis of the legs]. / Evaluation d'une représentation graphique de l'écho-Doppler (Echotrace) dans le bilan de l'athérosclérose des membres inférieurs.

The problems generally encountered in interpreting written reports of echo-Doppler examinations led us to develop a graphic software system to visualize the vascular network: Echotrace. The objective of the present work was to evaluate the reliability of Echotrace in patients with atherosclerosis of the lower limbs using arteriography as the standard for assessing sonographic findings. This prospective study was conducted in 29 consecutive patients. Nineteen strategic sites of the arterial network were investigated with duplex-scan and arteriography: lesions scores were attributed for each examination and data for a given site were compared. On the 551 sites compared, we found 26 disagreements including 23 concerning lesion quantification and 3 on localizations. There were also 21 minor disagreements with a single variation in the pathology score. The statistical comparisons could not be made on these scores so the results were compared with the arteriography data on the basis of therapeutic decision taking into account all the arterial lesions and the patient's general status. We observed a perfect agreement between the two imaging techniques in 12 patients, one disagreement which would not change the treatment in 15 patients and, in 2 patients, a disagreement which would modify treatment. This study demonstrated that graphic visualization of arterial lesions with Echotrace is a reliable, easy-to-interpret method.

Popliteal arterial traumas: prognosis factors: multi-center prospective study apropos of 40 cases.

Forty cases of arterial popliteal traumas occurring in the course of 1992 were collected by 20 centers. The purpose of this prospective study was to evaluate a preoperative prognosis score suggested by Crolais from a retrospective study. Five clinical criteria are taken in account to establish the score: delay, degree of ischemia, contusion, general condition of the patient and wound apperture. Each of the criteria is affected by a progressive note according to the gravity. Analysis of our series confirms the seriousness of this pathology: one death, 8 major amputations and 50% of morbidity. The statistical analysis of pre-operative score and post-operative recovery confirms the existence of three groups at progressive risk: Low risk, score < 30 points. Revascularization must be done. Post-operative recovery is simple. Average risk, score is between 31 and 50 points. Revascularization must be done. Post-operative recovery is particularly simple as the delay before revascularisation will be short and systematic fasciotomies will be done. Major risk, score > 50 points. An amputation must be carried out.

In situ thrombolysis for late occlusion of suprafemoral prosthetic grafts.

Low-dose urokinase was used to obtain in situ thrombolysis in the treatment of 20 late occlusions of suprafemoral prosthetic grafts in 19 patients. Aortofemoral or aortobifemoral bypasses with occlusion of one limb had been performed in nine patients, direct iliofemoral bypasses in six, crossover iliofemoral bypasses in two, and axillofemoral bypasses in three. Sixteen of the grafts were polytetrafluoroethylene and four were Dacron. Vascular surgery had been performed on an average of 3 years earlier. Thrombolysis was inhibited on an average of 3 days after onset of occlusion. The protocol called for penetration of the thrombus with a 5 F catheter inserted through a brachial (12 cases) or femoral (eight cases) route. After initial injection of 2500 units of urokinase a continuous infusion of urokinase was begun at a dose of 2500 units/hr and heparin at 100 units/kg/12 hr. Clinical, biochemical (fibrinogen and activated cephalin time every 6 hours), and arteriographic surveillance was carried out every 12 hours with progressive mobilization of the catheter until complete clearance of the artery. Clearance was achieved in all cases. Anteroposterior and occasionally lateral arteriograms with the hip joint in flexion were obtained. An organic cause amenable to treatment was found in 16 cases, including distal or proximal lesions (two and 10 cases, respectively) and elongation/kinking (four cases). Endoluminal angioplasty, stenting, or endarterectomy (six cases) and conventional procedures (10 cases) were also performed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Paraplegia after surgery of the suprarenal aorta (26 cases reported during a national survey)]. / Paraplégies après chirurgie de l'aorte sous rénale (26 cas relevés lors d'une enquête nationale).

Although their frequency is probably underestimated, medullary complications of abdominal aorta surgery are rare but serious, and may be the cause of medico-legal actions. Referral of a patient allowed the collection of 26 unpublished cases: 18 with aneurysms, including 6 ruptured lesions and 12 undergoing cold surgery, and 8 with aorto-iliac occlusion, these 26 cases representing 0.16% of abdominal aorta interventions performed during the same period. Mortality (6 cases) was due principally to neurological complications, total in 4 cases, partial in 3 and persistent in 13. Risk factors were perioperative collapse (explaining the elevated frequency in ruptured aneurysms) and the occlusion of the internal iliac arteries. Duration of clamping was not significant. No certain method of prevention could be elucidated, either by a literature review or by analysis of the personal series.

Transthoracic endoscopy for upper thoracic chemical sympathectomy.

Beginning in April 1989, we have performed eight upper thoracic chemical sympathectomies by transthoracic endoscopy. The indications were occlusive arterial disease in four patients and Raynaud's syndrome and palmar hyperhidrosis in two patients each. Transthoracic endoscopy was performed under general anesthesia, through the third costal interspace on the anterior mid-clavicular line. Five ml of phenol were injected into the parietal pleura covering the three proximal thoracic ganglia. The duration of thoracic drainage was 24 hours. The postoperative course was uneventful except for one case of subcutaneous emphysema and transient Horner's syndrome in three instances. There were no initial failures. Because of its simplicity and the short hospitalization period, chemical sympathectomy by transthoracic endoscopy constitutes a valuable alternative to conventional surgery. This technique is, however, limited in the case of antecedent pleuropulmonary disorders.

Reconstruction of an abnormal artery observed in an 11 mm embryo: considerations on the embryologic origin of the subclavian artery.

The retro-oesophageal right subclavian a. is a classical variant. We report the first case recognised in the embryo (11 mm subject reconstructed by Born's method). Four other adult cases are analysed (1 dissection and 3 clinical cases) and compared with 250 clinical observations of the supraaortic trunks. In the modal state it arises from the 7th arterial segment. The origin of the subclavian and vertebral aa. and the arrangement of the supraaortic trunks allow the distinction of three types, whose embryologic origin is discussed.

[Angioscopy in peripheral vascular diseases]. / L'angioscopie en pathologie vasculaire périphérique.

Angioscopy is a useful investigation in patients referred for vascular surgery. The material has been improved over the last few years to make available angioscopes with external diameters ranging from 0.55 to 3.2 mm. The angioscopes are either rigid, composed of two groups of fibre optics (image and light transmission) or orientable and more complex. Both systems may carry operating channels. The angioscopy may be performed peroperatively or percutaneously. Other essential equipment includes catheter guides, balloon catheters, counterpulsation balloons or perfusion pumps. This investigation is used for diagnostic evaluation but when used peroperatively it may also help guide therapeutic intervention. Angioscopy is complementary to ultrasonic and radiological methods of vessel imaging.

[Efficacy of intra-arterial fibrinolysis in subacute atheromatous ischemia of the lower limbs]. / Efficacité de la fibrinolyse intra-artérielle dans l'ischémie subaiguë d'origine athéromateuse des membres inférieurs.

The study of 44 patients treated with intra-arterial fibrinolysis is reported. All these patients had an impending subacute ischemia of the lower limbs, a major complication of atheromatous disease. The criteria for patient selection were clinical, hemodynamic and radiological. The procedure of the treatment associating Urokinase, Heparin and Naphthidrofluril are defined, as well as its follow-up. The results have been evaluated according to the clinical and radiological improvement. 2 patients died when the treatment ceased and 10 were amputated, ie 27% of failures. The fibrinolytic treatment allowed identifying the patients who might quickly receive an additional treatment. In our experience, this treatment seems to improve the prognosis of impending subacute ischemia.

[Results of surgery in 144 cases for aneurysms of the infra-renal abdominal aorta in patients over 75 years of age]. / Résultats de 114 interventions pour des anévrysmes de l'aorte abdominale sous-rénale chez des patients âgés de 75 ans et plus.

114 patients aged over 75 underwent surgery for aneurysm of the infra-renal abdominal aorta in the University Teaching Hospitals in Nantes and Angers between 1979 and 1988. A retrospective study of these patients was performed to evaluate the immediate and long-term results. The mean age of the patients was 79 (+/- 4) years, the oldest being 94. 70% were men. Half of the patients underwent emergency or semi-emergency surgery (52 cases). Cardiovascular factors (in particular coronary insufficiency in 17% of cases) were the most common risk factors. In all cases grafting after laying open the aneurysm was performed, with an aorto-aortic graft in 32% of patients, an aorto-iliac graft in 37% or an aorto-bifemoral graft in 27% of patients. Combined intestinal revascularisation was performed in 10% of case either involving the inferior mesenteric artery or at least one internal iliac artery; renal revascularisation was performed in 3.5% of cases. 75% of patients underwent simple grafting. The mean duration of hospitalisation was 14 days (+/- 6), including a mean period of 7 days in ICU. 36 patients (31%) died in the first post-operative month. The mortality rate in patients who underwent emergency surgery for a complication of the aneurysm (essentially rupture) was 61% versus 6' for elective surgery. 96% of the patients who survived the first post-operative month were independent at the end of the study or at the time of their death.(ABSTRACT TRUNCATED AT 250 WORDS)

Topographic anatomy of the lumbar lateral vertebral groove. Anatomical basis of the surgical approach to extra foraminal herniated disc.

The study of numerous dissections, sections and X-rays of the lumbar spine has enabled us to clarify the connections of the lumbar spinal nerves at their emergence from the intervertebral foramen and in the lateral vertebral groove. This work naturally leads to the study of the extra foraminal herniated disc by an extra isthmian approach or to percutaneous surgery of thoracolumbar discs.

[Prognostic factors in vascular traumas of the popliteal region]. / Facteurs pronostiques dans les traumatismes vasculaires de la région poplitée.

Injuries of the popliteal region remain a serious problem as far as the outcome is concerned. The role and the risks of revascularization have yet to be properly evaluated. It's always difficult to decide on a major amputation. A retrospective study was applied to 37 cases referred to the CHRU d'Angers, between 1976 and 1987. We were then able to establish a prognostic scale with 120 ischaemia, the contusion, the clinical context and the open wound. The scale is used before any decision and allows us to decide whether revascularization or amputation have to be performed. In this series, 2 patients (5%) eventually died; 11 (33%) underwent a major amputation and 24 (65%) were successfully revascularized. The results are analyzed in relation to the prognostic scale and the literature.

The principal artery of the psoas major muscle.

The psoas major m. has a complex arterial supply, derived from the lumbar, iliolumbar, obturator, external iliac and common femoral a. The branches arising from the external iliac a., though quite often multiple and slender, are represented in 75% of cases by a single large-caliber vessel. This principal artery of the psoas m. is probably responsible for the curves of the external iliac a. in the aged and also in certain competitive athletes.

A rare embryologic variation: carotid-anterior cerebral artery anastomosis or infraoptic course of the anterior cerebral artery.

Carotid-anterior cerebral artery anastomosis constitutes an anomaly of the anterior part of the arterial circle of the brain. The anterior cerebral a. arises a few millimeters above the emergence of the internal carotid from the cavernous sinus, at the usual level of origin of the ophthalmic a. It travels medially, beneath the optic n., and then describes a curve with a superolateral concavity to arrive at the anterior part of the optic chiasma, where it anastomoses with the anterior communicating a. This asymptomatic variant of course is often associated with other cerebral vascular anomalies, especially arterial aneurysms. On the basis of 2 new cases discovered by chance, together with a review of the literature, various hypotheses capable of explaining the embryologic origin of these anomalies are discussed.

[Aortic sarcoma. A rare pathology]. / Le sarcome aortique. Une pathologie rare.

In the light of a case of endotheliosarcoma of the thoracic aorta, the authors found in the literature 33 cases of aortic sarcomas and 13 of sarcomas of peripheral arteries. The clinical diagnosis of this rare tumor is difficult. The diagnosis can be made before surgery only on the basis of angiographic and CT scan findings, whilst in most instances common arterial lesions are suspected whether of atheromatous or embolic origin. The positive diagnosis of arterial sarcoma remains histological. The diagnosis of an endothelial tumor can be made with the help of the techniques of factor VIII, antigen H and, more recently, lectins. Surgical treatment by excision and restoration of continuity has most often been used. Alone or in combination with chemo and/or radiotherapy, it would seem to be inadequate to prevent progression which involves the invasion of adjacent tissues, tumor emboli or generalized metastases. The prognosis of such a tumor remains gloomy with an average life expectancy of one year and 7 months, regardless of the histological type of arterial sarcoma.

Scanographic study of the calcaneus: normal anatomy and clinical applications.

To facilitate the interpretation of the scanographic findings in fractures of the calcaneus, the authors have achieved an anatomo-radiologic correlation in terms of the classical coronal, sagittal and horizontal planes. Clinically, the sagittal plane can be obtained only by reconstruction. The 2 other planes permit study of the sustentaculum tali and posterior talar surface only in different sections, without their respective relationships. The authors therefore suggest a new double-oblique view, practicable in the injured patient, with a forward tilt of 20 degrees and medial rotation of 35 degrees, perpendicular to the sinus tarsi. This serves for anatomo-radiologic correlation and shows both anatomic structures together. By itself, it provides as much information as the three classical views and appears adequate for the assessment of fractures.

[Primary aortoduodenal fistula of tuberculous origin]. / Fistule aorto-duodénale primaire d'origine tuberculeuse.

This case of aorto-duodenal fistula was due to fistulization of a tuberculous lymph node between an atheromatous aneurysm of the infra-renal aorta and the third part of the duodenum. CAT scan provided the diagnosis of an aorto-duodenal fistula. The tuberculous origin of the fistula was confirmed by bacteriological and histological examinations. The outcome was favourable after revascularisation "in situ" combined with epiplooplasty and prolonged antituberculous drug therapy.

[Distal reimplantation of the extremities]. / Les réimplantations distales des extrémités.

Over the last two years, 15 patients have undergone revascularization surgery to a total of 17 distal extremities at the level of or distal to the last phalangeal joint. Operations were performed by three surgeons trained in microsurgical techniques, making the series a homogeneous one. Results were analyzed using Tamai and Nakamura's scores. Determinant factors, social and economic costs and effects on occupation are emphasized. The mean success rate of 65% is influenced by the total or partial nature of the section, its localization to the thumb or long fingers and the mechanism of section. The good functional results obtained were due to distal forms of amputation, recognized despite the technical difficulties as being an indication of choice for this reimplantation surgery. All patients in this group were able to return to work, with or without adaptation, within a variable lapse of time.

[Isolated azygos continuation of the inferior vena cava. (Absence of the retrohepatic segment of the inferior vena cava)]. / La prolongation azygos isolée de la veine cave inférieure. (Absence du segment rétrohépatique de la V.C.I.).

The isolated azygos continuation of the inferior vena cave is a very rare variation of this organ. It is accompanied by the absence of the retrohepatic segment of the vena cava with two new observations, the literature is revised and the origin discussed.