Relief of buttock claudication by percutaneous recanalization of an occluded superior gluteal artery.

We report a case of a woman presenting with right severe buttock claudication and normal neurological and osteoarticular examination, in whom a guidewire recanalization and percutaneous transluminal angioplasty (PTA) of an occluded right superior gluteal artery (SGA) has provided relief of her symptoms. To our knowledge, this is the first report of percutaneous recanalization of the SGA. PTA can be considered the treatment of choice for buttock claudication caused by SGA stenosis or occlusion.

Is transcranial Doppler a worthwhile examination for preoperative evaluation of the Circle of Willis? Evaluation of 137 carotid endarterectomies performed under regional anesthesia.

BACKGROUND: Transcranial Doppler is often proposed for evaluation of the Circle of Willis prior to carotid endarterectomy. The purpose of this study was to evaluate preoperative TCD before carotid surgery. METHODS: This is a retrospective report of 137 carotid endarterectomies performed under regional anesthesia operated between January 1992 on June 1996. All patients have a tight stenosis between 70% on 99%, and 49% were symptomatic. Forty-three patients of the 132 had a controlateral hemodynamically significant carotid stenosis with none occlusion. The TCD examinations were all performed with ADMS Doppler Spectradop with 3-MHz and 2-MHz probes. Clinical evaluation during cross-clamping was compared to the preoperative TCD. In 14% of the patients, the TCD could not be performed because there are not temporal bone windows. RESULTS: When the patients could be tested the positive predictive value of the TCD was 18% and the sensitivity was 33%. The negative predictive value was 94%. 8% of the patients were shunted. TCD had numerous difficulties. The most common is the lack of the temporal bone window (40% of the patients). The compression test is often difficult when the lesion is calcareous. Preoperative TCD is not according to our results, a reliable enough examination to modify operative strategy during carotid surgery. When coupled with arteriography it is a good way to study cerebral hemoynamics. CONCLUSIONS: Regional anesthesia with local supplication remains the method of choice to select those patients who require a shunt during carotid surgery. It can be used routinely and it is less complex than the various methods.

[Value of transcranial pulsed Doppler in artery carotid surgery. A comparison of clinical, paraclinical and peroperative data]. / Intérêt du Doppler pulsé transcrânien dans la chirurgie carotidienne. Confrontations cliniques et paracliniques des données peropératoires.

Blood flow in the middle cerebral artery was monitored during carotid artery surgery under loco-regional anaesthesia by plexus block in awake patients in order to assess the value of transcranial pulsed Doppler in understanding the embolic or haemodynamic mechanisms of peroperative cerebrovascular accidents. Blood flow changes in the middle cerebral artery ipsilateral to the operated carotid artery were compared with clinical, paraclinical and operative findings. Sixty-two patients were included in the study, 34 with symptomatic carotid artery lesions and 28 with very severe, progressive but asymptomatic stenosis. Thirteen patients (9 with symptomatic and 4 with asymptomatic lesions) suffered one or more neurological events during surgery. The blood flow velocities were studied at different stages during surgery and compared between the two groups-symptomatic and asymptomatic-to try and assess the mean systolic velocities predictive of cerebral hypoperfusion. Three events occurred during carotid artery dissection, 7 at clamping, 3 during clamping; 9 shunts were installed, one of which at the twelfth minute of clamping. A shunt was not installed in 4 cases: two events occurred at the end of the operation (muscle weakness, diplopia), one event occurred during an episode of hypotension, another at clamping which resulted in aborting the operation as transluminal pulsed Doppler suggested an embolism during dissection. Two events were attributed to an embolic phenomenon and 16 to cerebral hypoperfusion. Peroperative middle cerebral arterial flow recording enables detection of an embolism, monitoring of a shunt and the prediction of a neurological event should the mean systolic velocities fall to less than 15 cm/s and the reduction in velocity attain 70% (sensitivity 87.5%, specificity 91%).

[Percutaneous angioplasty of the renal arteries. Long-term results of 222 operations]. / Angioplastie percutanée des artères rénales. Résultats à long terme de 222 procédures.

OBJECTIVES: Determine the relative role of percutaneous angioplasty of the renal arteries in the treatment of renovascular hypertension. METHODS: From September 1984 to June 1993, we performed 222 angioplasties in 196 patients with renovascular hypertension. There were 186 atheromatous stenoses of the renal arteries and 36 fibromuscular dysplasias. Certain patients had associated moderate renal failure but variations in renal function were not considered in this study. RESULTS: The operation was hemodynamically successful in 180 cases (86%) including 165 cases with residual narrowing less than 30% and 27 between 30 and 50%. In 10 cases (4%), residual stenosis was greater than 50%. Complications at the site of angioplasty occurred in 13 cases (6%) including parietal damage (n = 10) due to hemodynamic pressure (n = 4), thrombosis (n = 2), and arterial rupture (n = 1). Mean follow-up in 131 patients was 2 years. Among these patients, clinical success was obtained in 93 (70%) including 12 complete cures (9%) and 81 improvements (62%). Cure of hypertension was better in patients with dysplasia (30% success rate) than in those with atheroma (5% success rate). Rate of clinical cure was higher for lesions of arterial branches (82%) than in main trunks (69%) or ostium (68%). Among the 38 cases of clinical failure (30%) there were 28 angiographically proven cases of restenosis including 16 which underwent redilatation leading to improvement in 6 (38%). CONCLUSION: These findings confirm the efficacy of percutaneous endoluminal angioplasty for the treatment of renovascular hypertension and suggest that this technique should be used as first line therapy.

[Treatment of abdominal aortic aneurysm: importance of the aorto-aortic tube?]. / Traitement des anévrismes de l'aorte abdominale: intérêt du tube aorto-aortique?

We compared retrospectively the immediate and mid-term outcome in 203 operations for AAA performed at the Saint-Michel Hospital in the vascular surgery department. Two groups of patients were treated either with a tube graft or with a Dacron bifurcated graft. In our experience, the tube was prefered when there were no haemodynamically significant stenosis or aneurysmal dilatations in the iliac arteries. Tube implantation was shorter and caused less haemorrhage (p < 0.01), but post-operative mortality and morbidity was not significantly different. Patients with bifurcated graft had late vascular complications requiring reoperation more often. Most were anastomotic false-aneurysms. Three patients with a tube developed iliac lesions requiring an aorto-femoral or aorto-bifemoral graft. Cure of an AAA with a tube graft is the choice treatment in patients free of severe iliac lesions or an aneurysmal bifurcation. The risk of subsequent iliac lesions requiring reoperation is low.

Isolation of yeasts from bovine milk in Belgium.

A total of 436 milk samples from non-infected and 80 from infected quarters were investigated: 24.5% of the samples collected from non-infected and 55% of those collected from infected quarters were positive. Normal milk yielded not less than 16 different species and among them many potentially pathogenic yeast species such as C. parapsilosis, C. guilliermondii, C. tropicalis, C. glabrata and T. asahii, all five able to grow at 40 degrees C. In contrast, the yeasts isolated from infected quarters were from 3 species: C. kefyr, C. catenulata and C. lambica, which were also among the yeasts species recovered from normal milk. Among the three species, only one i.e. Candida kefyr is able to grow above 40 degrees C and from there can be considered as potentially pathogenic, even if bacterial association is necessary to cause mastitis.

[Cervical plexus block for carotid surgery. 313 consecutive operations]. / Bloc plexique cervical pour chirurgie carotidienne. 313 opérations consécutives.

OBJECTIVES: The optimal method for protecting the brain from ischaemia during carotid surgery is still a matter of debate. The aim of this study was to report our early results after carotid surgery performed with cervical plexus blockade in vigilant patients. METHODS: From 1987 to 1992, 313 consecutive operations were performed on the carotid bifurcation (217 males, 96 females; mean age 67 years; age range 41-87 years). Thirteen underwent bilateral operations at a 1 month interval. There were 118 (38%) asymptomatic patients with carotid narrowing greater than 80% and 195 (62%) symptomatic patients including 96 with temporary cerebral ischaemia, 12 with regressive ischaemic events, 37 with cerebral vascular events and 50 with non-hemispheric events. The contralateral carotid artery was occluded in 30 patients (9.5%). Deep cervical blockade of the C2-C3-C4 roots then superficial blockade was obtained with 0.5% bupivacaine. Operations were endartectomy (n = 301; 96%) including 59 (18.5%) with a prosthetic patch, venous grafts (n = 8; 2.5%) and direct reimplantations (n = 3; 0.9%). All neurological complications observed during the 30 days following operation were recorded. RESULTS: At occlusion, neurological events occurred in 40 patients (12.8%) and required the use of a temporary shunt. In patients with a contralateral occlusion such events occurred in 35.5% of the patients. No cases of myocardial infarction were observed and 1 patient died due to a neurological cause, giving a morbidity of 1.6% and a mortality of 0.3%. CONCLUSION: Cervical plexus blockade was shown to be a simple and effective method for carotid surgery allowing good myocardial haemodynamics and a reliable evaluation of tolerance to occlusion.

[Results of endoprostheses in the iliac arteries; an experience apropos of 47 implantations]. / Résultats des endoprothèses dans les territoires iliaques; expérience à propos de 47 implantations.

Obstruction or stenosis of the iliac artery was treated by placement of an endoprothesis in 41 patients. A total of 47 lesions was treated. 26 patients had poor results of balloon angioplasty including residual stenosis (7 cases), restenosis post angioplasty (7 cases), and dissection (12 cases). 15 patients had iliac occlusion. The endoprothesis used was a self expandable flexible endoprothesis (Wallstent) in 26 cases and a balloon expandable flexible endoprothesis (Strecker) in 21 cases. Complications included one thrombosis of the endoprothesis occurred immediately after placement, one hematoma. No distal embolization occurred. Patency at the end of the study was 70% at 9 months and 50% at 21 months. Patency was better with the Wallstent endoprothesis (60% at 21 months) than with the Strecker endoprothesis (38% at 21 months). Results was better with lesions of the common iliac artery, and when the indication was dissection or failure of angioplasty. During the 21 months of follow-up 18 occlusions or restenosis occurred. At the end of the study 20 patients (49%) were asymptomatic and improvement was achieved in 9 (22%), the clinical success rate was 71%. One amputation was required.

[Atrophic polychondritis presenting as multiple arterial stenosis. Report of a case]. / Sténoses artérielles multiples inaugurales d'une polychondrite atrophiante. A propos d'un cas.

A case of multiple arterial stenosis is reported in a pattern with atrophic polychondritis. The disease was diagnosed retrospectively nine years after the first vascular signs on the basis of clinical course. Atrophic polychondritis is a rare connective tissue disease with characteristic chondritis. Cardiovascular involvement occurs in one-fourth of the cases during the clinical course leading to poor prognosis. Stenosis of the peripheral arteries has not been reported, to our knowledge, as the inaugural sign in atrophic polychondritis.

[Aneurysms of branches of the renal artery: surgery in situ]. / Lésions anévrismales des branches de l'artère rénale: chirurgie in situ.

Renal artery aneurysms (RAA) are rare lesions, often associated with hypertension. In order to evaluate the benefit in terms of blood pressure of elective cure of a fibrodysplastic renal artery aneurysm in hypertensive patients, 22 patients were studied retrospectively. With a mean follow-up of 66 months, correction or improvement of hypertension was obtained in all patients with an isolated aneurysm or an aneurysm associated with haemodynamic lesions of the renal artery, treated at the same time, but only 40% of cases when the aneurysm was associated with non-haemodynamic lesions. Direct criteria attributing the hypertension to the aneurysm were generally absent.

[Renal artery occlusion: percutaneous revascularization]. / Occlusion de l'artère rénale: revascularisation percutanée.

The value of percutaneous revascularization of acute or chronic occluded renal arteries is demonstrated in 9 cases. Recanalization and dilatation was technically successful in 6 patients. The authors stress the importance of anatomo-radiologic criterion for successful recanalization. This technic is an attractive alternative to surgery specially in short occlusion.

[Value of elective cure of fibrodysplastic aneurysms of the renal artery in hypertensive patients]. / Intérêt de la cure élective des anévrysmes fibrodysplasiques de l'artère rénale chez des patients hypertendus.

Renal artery aneurysms (RAA) are rare lesions, often associated with hypertension. In order to evaluate the benefit in terms of blood pressure of elective cure of a fibrodysplastic renal artery aneurysm in hypertensive patients, 22 patients were studied retrospectively. With a mean follow-up of 66 months, correction or improvement of hypertension was obtained in all patients with an isolated aneurysm or an aneurysm associated with haemodynamic lesions of the renal artery, treated at the same time, but only 40% of cases when the aneurysm was associated with non-heamodynamic lesions. Direct criteria attributing the hypertension to the aneurysm were generally absent.

[Asymptomatic carotid stenoses. Analysis of randomized studies]. / Sténoses carotidiennes asymptomatiques. Analyse des études randomisées.

Results of recent randomized clinical trials in patients with asymptomatic carotid artery stenosis have progressively tended towards a more surgical than medical attitude to treatment. Interim results of the Veterans Administration study of 444 patients randomly allocated to receive either aspirin (233 cases) or surgery (211 cases) showed the percentage of vascular accidents and postoperative mortality to be 2.4% and 1.9% respectively in the surgical group, a marked reduction when compared with the 5% neurologic events reported in the medical group. In contrast, results of the Casanova Study, an equally randomized trial of 410 patients, 344 of whom underwent carotid endarterectomy, failed to demonstrate a significant difference in neurologic events or mortality between the two groups, although these were not homogeneous. Finally, the randomized French study (AURC) in 230 patients (135 operated upon and 109 treated medically with aspirin) showed a reduction in neurologic accidents in the surgical group, significant after a follow up of about 45 months. This tendency towards a surgical approach implies a low surgical morbidity/mortality, now possible due to local and regional plexus anesthesia monitoring, which carries a morbidity of less than 2% and a practically inexistent mortality.

[Is it necessary to operate on small abdominal aortic aneurysms?]. / Faut-il opérer les petits anévrysmes de l'aorte abdominale?

The indication for surgical treatment of aneurysms of 5 cm diameter or larger is no longer the subject of much debate but the problem still arises for aneurysms equal to or less than 4 cm in diameter. This problem is a real one since epidemiologic studies have shown the frequency of aortic aneurysms to be about 45/100,000 in men and 20/100,000 in women. The incidence of rupture in these small aneurysms is null for some authors, such as Névitt, for those of less than 5 cm, but Crawford reported an incidence of 9%. Exceptionally, rupture may occur in ectatic aortitis with weakened walls. Small aneurysms are generally kept under observation and not operated upon immediately. The increase in size varies between 21 and 40 mm according to the patient. Apart from the size of the aneurysm a further factor to be allowed for is the presence or absence of an intramural clot. In addition to the possible role it can play in the course of the aneurysm itself it may be the source of an emboli, which, after rupture, are the cause of the second symptomatology of aortic aneurysms. Indications for surgery of small aneurysms should be restricted to those with large intramural aneurysms, those with irregular morphology of a segment possibly the site of weakening of the wall which can be detected by a scan or NMR imaging, without forgetting certain sacciform aneurysms suggestive of a mycotic etiology and requiring surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic false aneurysms after prosthetic reconstruction of the infrarenal aorta.

False aneurysm of the infrarenal aorta was found at the site of proximal anastomosis in 13 patients after vascular reconstruction for lower limb arterial disease. The grafts involved were aortoprosthetic in one patient, aortobiiliac in two patients, and aortobifemoral in 10 patients. They had been implanted eight years prior to reoperation on the average (range six months to 15 years). False aneurysm was diagnosed because of abdominal pain in four cases, embolism in two cases, intestinal hemorrhage in one case, and during routine sonographic or computed tomographic (CT) scan surveillance in the six other cases. Femoral false aneurysm was associated in eight of 10 cases with femoral anastomoses. Aortic false aneurysms were repaired by interposition of a prosthetic tube between the infrarenal aorta and the original prosthetic graft in 11 cases and by changing the aortobifemoral graft in two cases. In one further case, repair was accomplished by implanting an aortobifemoral prosthetic graft laterally on a prosthetic tube interposed between the infrarenal aorta and the body of the original prosthetic graft, which continued to irrigate the internal iliac arteries. There was no mortality. Thrombosis of a prosthetic branch occurred in one case and was treated by thrombectomy. One patient underwent reoperation for intestinal obstruction. Two others had distal embolism responsible for toe necrosis. Anastomotic false aneurysms should be looked for routinely during the surveillance of prosthetic grafts implanted on the infrarenal aorta, especially when femoral false aneurysm is found. Preservation of pelvic vascularization must be an integral part of management.

Elastase-induced experimental aneurysms in rats.

An experimental in vivo model of aortic aneurysm was established by perfusing an isolated segment of rat abdominal aorta with pancreatic elastase. Ten rats were used in each protocol. Saline-perfused aortas developed no aneurysmal dilations. Elastase-perfused aortas contained aneurysms in the perfused area and a total loss of elastic tissue. Control aortas contained no elastic tissue lesions. There was a quantitative relation between the amount of elastase perfused and aneurysm formation: 1-2 units induced neither macroscopic nor microscopic lesions; 3-6 units induced microscopic elastic tissue damage without macroscopic aneurysm; and more than 6 units produced aneurysmal dilation in all cases. In situ elastase secretion by macrophages was induced by perfusing rat aortas with thioglycollate-activated macrophages or with thioglycollate alone. There was aortitis without true aneurysm and a total loss of elastic tissue in the vicinity of activated macrophages within the aortic media. Perfusion of infra-aneurysmal amount of elastase (1 or 2 units) or thioglycollate plus plasmin (2 units) always induced a large aneurysm, whereas plasmin alone induced neither macroscopic nor microscopic lesions. These morphological results were supported by the significantly elevated elastolytic activity within the aortic wall of animals perfused with thioglycollate plus plasmin 9 days, after perfusion (207.6 +/- 54.8 micrograms elastin-rhodamine lysed/18 hr; control rats, 25.43 +/- 11.13). The results suggest that the presence of elastase within the aortic media leads to aneurysm formation. Activated macrophages within the aortic media may be responsible for elastase secretion and elastic tissue destruction. Plasmin may enhance elastase activity and aggravate the aneurysmal lesion.

[Magnetic resonance imaging in the diagnosis of pheochromocytoma]. / L'imagerie par résonance magnétique dans le diagnostic des phéochromocytomes.

The diagnosis of pheochromocytoma is biological. If ultrasound enables the visualization of certain adrenal tumours or hepatic metastasis, in fact two tests enable the topographic diagnosis, the screening of ectopic localizations and metastasis. They are IMBG scintigraphy and tomographic scanning. The place of magnetic resonance imaging is not yet specified. However, it has many advantages: absence of irradiations, good anatomic precision, meticulous screening of ectopic forms, of metastases and of adenopathies, study of the tissue characterization, good definition of the tumour relation with the vascular pedicles and the neighbouring structures.

[A case of artero-ureteral fistula. Review of the literature]. / Un cas de fistule artério-urétérale. Revue de la littérature.

We report a case of a 78-year old male patient with a history of hematuria. Diagnosis of a shunt between a left common iliac artery aneurysm and the ipsilateral ureter was arrived at on the basis of arteriographic findings. Surgery consisted in ligating the left ureter proximal and distal to its communication with the aneurysm (left kidney silent on intravenous urogram), in closing the arterial orifices proximal and distal to the aneurysm, and in constructing an extraanatomical interfemoral bypass. At sixteen months' hindsight, the patient is doing well. Literature is reviewed (24 entries).

Coarctation of the abdominal aorta and stenosis of the left renal artery with hypertension caused by fibrodysplasia.

The causes frequently ascribed to coarctation of the abdominal aorta include atherosclerosis, trauma, inflammatory aortitis, and extrinsic compression. We present a case of coarctation of the abdominal aorta with stenosis of the left renal artery due to fibrodysplasia in a 35-year-old woman, hospitalized for treatment of intermittent claudication and hypertension. This coarctation was resected and end-to-end anastomosis with reimplantation of the left renal artery was performed. Results of an anatomopathologic examination of the resected aortic specimen and the trunk of the left renal artery revealed typical lesions of fibromuscular dysplasia. The specific features of lesions in this case were compared with those from the literature.