[Value of Doppler ultrasonic studies in the diagnosis of deep venous thrombosis of the lower limbs]. / Valeur de l'écho-Doppler pour le diagnostic de thromboses veineuses profondes des membres inférieurs.

To compare the operating characteristics of the venous echo-doppler and that of venous phlebography in our setting, 90 consecutive patients admitted on suspicion of deep vein thrombosis of one leg underwent both examinations. Phlebography confirmed the diagnosis in 46 patients (51%). The sensitivity, specificity, and positive and negative predictive values of the echo-doppler were 91, 92, 94 and 90% respectively. For the subgroup of patients with proximal deep vein thrombosis, these values were 97, 97, 97 and 97%, respectively; for the subgroup with distal deep vein thrombosis, these values were 60, 95, 75 and 90%, respectively. This study confirms the excellent performance of the venous echo-doppler for the diagnosis of deep vein thrombosis of the leg in our hospital. However, in the subgroup of patients with distal deep vein thrombosis, only the sensitivity of the venous echo-doppler is relatively low and the diagnosis may still require color echo-doppler or phlebography.

Aorto-subclavian thromboembolism: a rare complication associated with moderate ovarian hyperstimulation syndrome.

The case of an arterial aorto-subclavian thromboembolism associated with a moderate ovarian hyperstimulation syndrome (OHSS) and following ovulation induction for in-vitro fertilization in a young woman is reported. Because of the lack of response to systemic thrombolysis, a left postero-lateral thoracotomy was performed on day 8 after embryo transfer. A fibrinocruoric embolus situated at the junction of the left subclavian artery from the aorta was removed through a left subclavian arteriotomy. The distal axillary embolus was removed by a retrograde balloon catheter embolectomy. A moderate OHSS was observed. The ovarian stimulation and OHSS-related risks of thromboembolism are discussed. We conclude that, in the absence of risk factors, counselling about possible complications resulting from stimulation must be emphasized.

Helical CT angiography for traumatic aortic rupture: correlation with aortography and surgery in five cases.

Dynamic computed tomography (CT) is frequently performed to assess the mediastinum in trauma patients with a suspected thoracic aortic rupture. Its usefulness lies in demonstrating a mediastinal hematoma. However, many patients still undergo conventional aortography despite a normal chest. CT, because of a perceived insensitivity of this technique for diagnosing aortic rupture. One application of helical CT is CT angiography, in which multiple thin sections are acquired through a blood vessel during the injection of iodinated contrast. Good demonstration of vascular pathology can be achieved, especially with 3-D reconstructions. This article reviews a series of four surgically proven thoracic aortic ruptures studied using helical CT, and one case proven to be false-positive by both helical CT angiography and conventional angiography. Correlation between conventional and helical CT angiography was excellent, with similar findings and the same interpretation pitfalls. Helical CT is fast and noninvasive. Combined examination of other anatomical areas can be performed in the same procedure in major trauma patients. Helical CT may potentially decrease the need for aortography in these acutely injured patients.

[Chronic obstructive bronchopneumopathy, mitral valvulopathy and global cardiac insufficiency]. / Bronchopneumopathie chronique obstructive, valvulopathie mitrale et insuffisance cardiaque globale.

The case of a 61 year-old man is presented. This patient had a rheumatoid arthritis and a cardiac failure. Echocardiography and catheterization revealed a mitral valvulopathy, biventricular dysfunction and conduction abnormalities. Pericardial disease was also present. Differential diagnosis lead to the clinical diagnosis of rheumatoid non constrictive pericarditis, rheumatoid myocarditis, rheumatoid endocarditis and idiopathic calcification of the mitral valve. Anatomo-pathologic findings consisted in rheumatoid pancarditis.

Comparison of results of intravenous infusion of anistreplase versus streptokinase in acute myocardial infarction.

This randomized study compares the coronary perfusion rate in patients with acute myocardial infarction (AMI) treated with 2 different intravenous thrombolytic agents: streptokinase 1.5 million U given over 60 minutes and anisoylated human plasminogen streptokinase activator complex (anistreplase) administrated as a bolus of 30 U over 5 minutes. One hundred seventy-five patients (149 men and 26 women, mean age 54 years) have been included in this study. Eighty-nine patients were treated with anistreplase and 86 patients with streptokinase. AMI was inferior in 54 patients (61%) in the anistreplase group and in 54 patients (63%) in the streptokinase group. It was anterior in 35 (40%) and 32 (37%) patients, respectively. Coronary angiography and ventriculography were performed at a mean time (+/- SEM) of 207 +/- 11 minutes after the beginning of thrombolysis in 170 patients. A perfusion score grade of 2 or 3 according to the Thrombolysis in Myocardial Infarction trial was found in 63 patients (72%) in the anistreplase group and in 56 patients (68%) in the streptokinase group (p = NS). Severe bleeding occurred in 7 patients (8%) after anistreplase and in 6 patients (7%) after streptokinase. No cerebral hemorrhage occurred. Nine patients (5%) died during their hospital stay: 6 after anistreplase and 3 after streptokinase. It is concluded that intravenous administration of anistreplase or streptokinase is efficient and safe. Coronary patency 207 minutes after fibrinolysis, incidence of adverse events and mortality are similar in both groups.

[Usefulness of perfusion balloon catheter in case of failure of coronary angioplasty: immediate and long-term results]. / Utilité du ballon de perfusion en cas d'échec d'une angioplastie coronaire: résultats immédiats et à long terme.

Coronary dissection and acute occlusion are serious complications of coronary angioplasty and may require emergency coronary bypass surgery or result in myocardial infarction or death of the patient. Recently, perfusion balloon catheters allowing prolonged inflations have been used to restore coronary flow after major dissection and occlusion of the artery. Forty-two consecutive patients requiring this procedure were evaluated at short and long term. A satisfactory angiographic result and clinical stabilisation were obtained in 37 cases (88%). Of the 5 immediate failures, 3 (7.1%) underwent coronary bypass surgery and 2 (4.8%) were treated conservatively. Reocclusion was observed in 4 patients (9.5%) during the hospital period; 2 underwent coronary stenting (4.8%) and the other 2 were treated medically. Myocardial infarction was observed in 11 patients (26.2%). Angiographic control was performed 6.2 +/- 3.6 months later in 20 of the 33 patients with no in-hospital complications. Coronary restenosis was observed in 12 of these cases (60%). This study shows the efficacy of perfusion balloon catheter in treating major coronary dissection and coronary occlusion during coronary angioplasty. In particular, the need for emergency coronary bypass surgery was limited. However, there was a high long-term restenosis rate which emphasises the need for careful follow-up of these patients.

Rectal leiomyosarcoma: acute presentation after local injury.

Rectal leiomyosarcoma is rare, often large and found in the distal third of the rectum. Most symptoms differ from those of an adenocarcinoma. Staging is difficult and should include tumour size, necrosis, cellularity, number of mitoses and anaplasia. Abdominoperineal excision (APE) remains the only effective treatment. A 66 year old asymptomatic female presented with painless rectal bleeding after a fall. Digital examination and proctoscopy revealed a mass on the posterior rectal wall. Pelvic ultrasonography, arteriography and CT-Scan showed a huge retro-rectal lesion. Following APE, histopathology confirmed a leiomyosarcoma. No adjuvant therapy was given; there is no recurrence 4 years later.

[Hypothenar hammer syndrome: little-known etiology of secondary Raynaud's phenomenon]. / Syndrome hypothénarien du marteau: étiologie peu connue de phénomène de Raynaud secondaire.

Hypothenar hammer syndrome is an uncommonly encountered cause of Raynaud's phenomenon associated with professional or recreational activities. We report 6 consecutive cases seen in our angiology unit between 1988 and 1990. Clinical findings include a history of repeated microtraumatisms of the dominant hand, male sex, unilaterality, sudden onset, and severe Raynaud's phenomenon of the last three fingers. Investigations reveal an aneurysm or thrombosis of the distal cubital artery or of the superficial palmar branch, associated with occlusion of digital arteries. Avoidance of the aggravating conditions or resection and/or plasty of the affected vascular segment usually leads to disappearance of the symptoms.

[Diagnostic and interventional radiology in pulmonary embolism]. / Radiologie diagnostique et interventionnelle dans l'embolie pulmonaire.

The clinical picture of pulmonary embolism (PE) ist remarkably unspecific and one has to rely mainly on imaging techniques to obtain a reliable diagnosis. PE is not a primary disease but the complication of deep venous thrombosis (DVT), and thus there is a strong correlation between pulmonary embolism and venous thrombosis. Radiologic screening of these diseases is based on invasive and noninvasive tests. Chest X-ray has a low predictive value of 63% and helps mainly in ruling out other diagnoses such as pneumothorax or pneumonia. Chest computed tomography scanning with contrast may occasionally be useful in detecting large central emboli. Magnetic resonance imaging in PE has not yet been shown to be of great clinical value. Digital subtraction angiography has the potential advantage of allowing injections of smaller contrast volumes and is particularly useful in pulmonary hypertension. Cardiac and respiratory motion blur images and render interpretation difficult. Conventional pulmonary angiography is required for definitive diagnosis in a significant number of patients, especially when V/Q scan is non-diagnostic. Its morbidity and mortality is nowadays negligible. If these facilities are not available, they can often be obviated by venous studies searching for the presence of venous thromboses. Alternative modalities include contrast phlebography and venous ultrasound imaging. This last, newly developed technique combined with compression Doppler is safe and accurate, at least in the femoral and popliteal veins. Contrast phlebography remains the standard imaging method, is widely available, and demonstrates floating clots or thromboses with minor complications using non-ionic contrast media.(ABSTRACT TRUNCATED AT 250 WORDS)

Iliac artery stenosis or obstruction after unsuccessful balloon angioplasty: treatment with a self-expandable stent.

Obstruction or stenosis of the iliac artery was treated by placement of a self-expandable stent in 91 patients. A total of 100 lesions was treated. All patients had had poor results of balloon angioplasty including residual stenosis, iliac occlusion, and dissection. The stent used in all cases was a self-expandable stainless steel endoprosthesis mounted on a 7- or 9-French catheter and covered by an invaginated tubular rolling membrane. The diameter of the expanded stent varied from 7 to 12 mm. A total of 129 stents was placed. Technical success was 97%. Thromboses occurred immediately after placement in two patients and within the first month in six; these were mainly due to residual obstruction. Eighty-two (93%) of 88 patients with a follow-up longer than 3 months had no recurrent symptoms. Restenosis caused by intimal hyperplasia inside the stent occurred in 10 patients; these required repeated intervention in only four cases. In the remaining six patients, no further complications occurred. Our results show that self-expanding endoprostheses are of value for improving the results of inadequate percutaneous transluminal angioplasty.

[Preoperative or palliative embolization of renal tumors]. / Embolisation préoperatoire ou palliative des tumeurs rénales.

This study evaluates our experience of renal preoperative or palliative embolization in 72 patients with a localized renal carcinoma or a metastatic disease. Angio-infarction of a renal malignant neoplasm is a helpful procedure to reduce the tumoral vascularization before an operation and to palliate symptoms and paraneoplastic syndromes of a metastatic disease with a very low morbidity.

Phospholipids and other lipids in angiographically assessed coronary artery disease.

Lipoprotein subclasses and their composition in cholesterol, triglycerides and in 5 types of phospholipid as well as apolipoproteins A-I and B were determined in blood of 114 patients undergoing coronary angiography for suspected or confirmed myocardial ischaemia. Lipid concentrations of lipoproteins were measured after preparative ultracentrifugation; high performance thin-layer chromatography was used to separate phospholipid subfractions. Patients with angiographically defined coronary artery disease (CAD) significantly differed from those without CAD in 25 different lipid or phospholipid parameters. Using discriminative analysis, apo A-I/apo B ratio was the only parameter with more than 70% success in reclassifying the patients in the CAD group. When correlated with a coronary atheromatous score reflecting either the number and degree of stenoses (Jenkins score) or the number of diseased vessels alone, only LDL-cholesterol was found to correlate with the Jenkins score. We conclude that serum phospholipid fractions may differ significantly in CAD group as compared with controls, but they are, however, no better predictors of CAD than other lipids.

[Cachexia, pain and muscle weakness in a 69-year-old woman]. / Cachexie, douleurs et faiblesse muscularies chez une femme de 69 ans.

The case is reported of a 69-year-old woman who for the last 2 years of her life had severe muscle weakness (with elevated muscular enzymes), thyroid abnormalities (autoantibodies and increase in TSH) and a slowly growing mass in the anterior mediastinum. She died in cardiogenic shock. The diagnosis of "nodular polymyositis" (painful nodules palpable in the muscles) with heart involvement was strongly suspected. The thyroid abnormalities were considered to be "biological thyroiditis" i.e. a "disease" frequent in normal females (5-10%) and, after differential diagnosis of anterior mediastinal masses, the diagnosis of thymoma was adopted in view of its frequent association with autoimmune diseases. Moreover, in rare cases of thymoma associated with polymyositis, histology has disclosed "giant cell polymyositis". Autopsy revealed giant cell polymyositis, a thymoma and lymphocytic infiltration of the thyroid.

Isolated phrenic nerve injury after apparently atraumatic puncture of the internal jugular vein.

Vascular lesions due to subclavian and internal jugular vein puncture may result in hematomas, which are usually clinically evident. While mostly benign, some of these hematomas can cause compression of the surrounding structures. When the hematoma is obvious, straightforward correlation can be made between the symptoms, for instance nerve compression, and the clinical signs. We present a case where we missed the diagnosis of phrenic nerve paralysis, which occurred after an unsuccessful, but apparently atraumatic attempt to puncture the internal jugular vein, prior to cardiac surgery. At the time the diagnosis was made (8 days post-op), the radiographic appearance of the neck was normal, and further investigation (i.e., CT-scan) had become pointless. A retrospective study of serial chest X-rays disclosed a space occupying lesion in the right lateral neck that displaced the nasogastric tube. This abnormality could only be seen on the first film and disappeared on the following. Since phrenic nerve paralysis is extremely rare in our institution, even after cardiac surgery, and as there was no clinical evidence of hematoma, our attention was not been drawn to the only definite sign that could have led to an early diagnosis.

[Incidence and treatment of coronary restenosis in spite of the implantation of an endoprosthesis]. / L'incidence et le traitement de la resténose coronarienne malgré l'implantation d'une endoprothèse.

Between April 1986 and February 1988, 72 endoprosthesis implantations were carried out in the coronary arteries of 65 patients. The indication for implantation was either abrupt closure post angioplasty or prevention of restenosis. The first 3 cases of restenosis within the stented segment are reported. Two were treated by repeat balloon angioplasty, with temporary improvement. The possible mechanisms underlying this particular form of restenosis are discussed.

Prevention of coronary restenosis by stenting.

Balloon angioplasty fails to provide acceptable long-term results for a significant proportion of patients. An intravascular mechanical support, developed with the aim of preventing restenosis and acute closure of diseased arteries after transluminal angioplasty, was implanted in 44 patients (39 male and five female), aged from 35 to 70 years (mean 56 years) with documented restenosis of native coronary artery (41 stents) and bypass grafts (12 stents). In the group of bypass graft patients there was no local restenosis and no major complication. In patients in whom stents were placed in native coronary arteries, the complication rate was higher (two patients died after coronary bypass surgery). One patient died suddenly at home. Except for one patient, in whom a new lesion developed proximally with extension into the stent, no case of restenosis could be observed. Despite the still relatively high complication rate, we feel that stenting may present a rational approach to the unresolved problem of restenosis after coronary angioplasty.