Vascular complications after surgical repair of aneurysms in Behçet's disease.

The poor prognosis of vasculo Behcet's disease is often due to postoperative vascular complications (false aneurysm and graft occlusion). We report a case of an abdominal aortic aneurysm associated with an aneurysm of the left common femoral artery in a 23-year-old Portuguese man. The primary treatment was surgical (aneurysmectomy and prosthetic revascularization). The early occlusion of the left femoral revascularized artery was treated surgically with a new bypass. The occlusion of the right limb of the aortoiliac graft was asymptomatic and was not treated. Two months after admission to our hospital, the stenosis of the infrarenal aorta successfully treated by angioplasty via the occluded right limb of the graft. The patient was followed up for 18 months. He could only walk a short distance and had rest pain in the left foot. Magnetic resonance angiography showed a false aneurysm of the infrarenal aorta, and an occlusion of the remaining left limb of the aortoiliac graft. The endovascular treatment performed does not avoid the need for surgical treatment, because occlusion and false aneurysm may occur after dilatation. The endovascular approach can also be used during a sudden inflammatory surge, and makes it possible to wait for a quiescent period when surgery can be performed.

Long-term outcome in patients under 40 years after revascularization for chronic lower limb ischaemia.

BACKGROUND: In order to find out if surgical or endoluminal treatment changes the long-term results of atherosclerotic occlusive disease in patients of under 40 years of age we reviewed 17 consecutive patients. METHODS: Their mean age was 36.5. Patients with Buerger's disease or inflammatory arteriopathy were excluded. All patients were extremely heavy smokers. The indications for surgical procedures were disabling claudication (less than 100 meters) for 11 patients, rest pain for 4 patients and grangrene of a lower limb for 2 patients. The lesions were aorto-iliac in 12 cases and femoro-popliteal in 5. Ten surgical procedures were performed (5 aorto-femoral bypasses, 1 ilio-femoral bypass associated with an aorto-renal bypass, 2 femoropopliteal bypasses, 1 aorto-iliac endarteriectomy, 1 femoral endarteriectomy). On the other hand there were 7 endoluminal procedures (1 aortic, 4 iliac, 1 femoral and 1 popliteal). RESULTS: The mean follow-up was 97.3+/-50 months (range, from 34 to 216 months). Two patients died by 57 and 132 months respectively. At 5 years the survival rate was 94%; the primary patency rate was 59%; the secondary patency rate was 81% and the limb salvage rate was 94%. At 10 years these rates were respectively 94%, 44%, 54% and 75%. A total of 21 reoperations were performed. During follow-up 11 patients were better, 2 were stable and 4 were worse with 2 limbs lost. CONCLUSIONS: These bad results suggest keeping the surgical and endoluminal indications for patients younger than 40 years with threatened limbs.

[Effectiveness and safety of hydroxyethyl-rutosides in the local treatment of symptoms of venous insufficiency during air travel]. / Etude d'efficacité et de tolérance des hydroxyethyl-rutosides dans le traitement local des symptômes d'insuffisance veineuse survenant au cours des transports aériens.

During air travel, the length of time spent in a sitting position and the absence of muscular activity in the calves severely slow the rate of blood flow in the lower limbs. The aim of this randomized, cross-over, double-blind study was to evaluate local application of Hydroxyethyl-rutosides (O-Beta-Hydroxyethylrutosides) in the treatment of symptoms of venous insufficiency including stasis-induced edema during extended air travel on flights exceeding 6 hours. Hydroxyethyl-rutosides or placebo was applied every 3 or 4 hours throughout the flight. In the 51 subjects evaluated (both males and females) the results show statistically significant differences favoring treatment with Hydroxyethyl-rutosides both with regard to objective signs of edema: change in minimum ankle circumference was less during trips in which Hydroxyethyl-rutosides was applied, whether compared with the maximum measurement (p = 0.04) or the last measurement made during the flights, and with regard to subjective signs: several symptoms occurred significantly less frequently when the subject applied Hydroxyethyl-rutosides during the flight [pain (p = 0.03), sensation of heavy and tired legs (p = 0.04) and sensation of swelling (p = 0.02)]. the patient's overall assessment of the treatment was also favorable after using Hydroxyethyl-rutosides Gel (p = 0.01). the number of subjects complaining of edema (pitting edema, marks of shoes, difficulties putting shoes back on) was significantly lower during periods of treatment with Hydroxyethyl-rutosides Gel (p = 0.001). Local application of Hydroxyethyl-rutosides, 3 to 4 times during 6 to 14 hours is thus effective in treating the main symptoms of venous insufficiency including stasis-induced edema caused by extended periods in the sitting position during long air flights.

Bilateral thrombosis of the internal carotid arteries after a closed trauma. Advantages of magnetic resonance imaging and review of the literature.

Bilateral traumatic dissection of an internal carotid artery (BTDIC) after a closed injury is very rare. We report a case of bilateral thrombosis caused by internal carotid artery dissection due to a closed injury. The 22 cases documented in the literature are also reviewed. Six of the patients (26%) were asymptomatic at the initial examination, but all developed secondary symptoms, during the first 48 hours. Sixteen patients (69%) had associated traumatic lesions. Six patients died during the week after the accident, all of them had initial neurological symptoms. Magnetic resonance imaging (MRI) provided more items of information than angiography, showing a dissection on an occluded artery and a clearer picture of the length of the dissection, directly visualizing the wall hematoma and a residual signal that showed the persistence or arrest of blood flow. Treatment of BTDIC is based on early anticoagulation therapy.

Importance of cutaneous postural reflex vasoconstriction in patients with atherosclerotic occlusive disease of the lower extremities.

OBJECTIVE: The present study was designed to measure the cutaneous postural vasoconstrictive reflex (PVR) in normal controls and patients with atherosclerotic occlusive disease of the lower extremities, and to determine its diagnostic and prognostic relevance. EXPERIMENTAL DESIGN: The postural vasoconstrictive reflex was recorded in 34 patients with atherosclerotic occlusive disease of the lower limbs and 27 normal controls, using laser-Doppler flowmetry. Patients also had ankle and toe pressure measurements and transcutaneous oximetry (TcPO2). SETTING: University hospital. RESULTS: The PVR on the pulp of the big toe was 20+/-7 arbitrary perfusion units in normal controls, 9.4+/-12 in patients with claudication, and -19 +/- 5 in patients with rest pain and/or gangrene, who differed from the claudicant and control groups (p=0.001 and 0.0001 respectively). The sensitivity of negative PVR in the big toe was 89% for the diagnosis of rest pain and/or gangrene, and its specificity, 83%. The severity of foot ischaemia and PVR values exhibited a significant inverse correlation (r=-0.56, p<0.0001). All patients with a poor outcome, ie. death and/or major amputation within 100 days of follow-up, had a negative PVR, and all patients with a positive PVR had a good 100-day prognosis without even a minor amputation. CONCLUSIONS: Laser-Doppler provides useful additional information in the assessment of foot ischaemia severity by showing that postural vasoconstriction is impaired in patients with severe atherosclerotic occlusive disease of the lower limbs, resulting in increased skin microcirculatory flow during leg dependency.

Pericardial effusion and AIDS: benefits of surgical drainage.

OBJECTIVES: During the last few years, AIDS has been the main cause of large pericardial effusions in urban settings. We have therefore had to perform surgical pericardial drainage for diagnostic and/or therapeutic purposes in AIDS patients. This study was designed to establish the diagnostic and therapeutic yield of pericardial drainage for these patients. METHODS: We retrospectively reviewed the data of the 13 AIDS patients with a pericardial effusion, referred to our surgical department between December 1989 and December 1996 for surgical drainage and pericardial biopsy. RESULTS: Cytological studies and searches for bacteria, mycobacteria and parasites were all negative. The histology of the 13 pericardial biopsies disclosed three pericardial locations of a Kaposi's sarcoma (all three patients had a pre-existent extra-cardiac location of this sarcoma) and one pericardial location of an already known immature mediastinal teratoma. In the nine other cases, the lesions were aspecific. Four patients died of multivisceral failure within 30 days of surgery. For the survivors, surgical drainage afforded relief and there were no clinical signs of recurrent effusion. CONCLUSIONS: The cause of pericardial effusion in AIDS is still often unknown, even after pericardial biopsy. Here, aspecific pericarditis was the most common diagnosis. Although the prognosis of such effusion in these patients is known to be poor, surgical drainage provided relief for those who survived the post-operative period.

[Abdominal aortic aneurysms and kidney transplantation]. / Anévrisme de l'aorte abdominale et transplantation rénale.

Protection of the kidney is fundamental during the treatment of abdominal aortic aneurysms (AAA). This applies particularly in patients with a renal transplant, the artery of which has been implanted on an iliac artery. Reviewing 27 AAA in patients with a renal transplant, the authors discuss the various techniques used. The authors disagree with renal function preservation methods. To maintain perfusion during clamping, different types of bypasses have been described: axillo-femoral, the Gott aortofemoral shunt or a partial extracorporeal perfusion (Campbell). With local or total hypothermia, the clamping time can be lengthened and this is used particularly when an end-to-end anastomosis into the internal iliac artery has been carried out. Since the Lacombe 1986 publication, no renal protection has been carried out for the sake of the technical needs of an operation. To reduce relative ischemia time, either the blood flow in the aortic bifurcation is maintained during the aortic clamping and the fashioning of the proximal anastomosis, or the distal anastomoses are fashioned first (Mathey), thus ensuring sufficient flow into the kidney through the collateral anastomoses between the iliacs, or by combining the 2 techniques (Mellière). The risk of infection in these immuno-depressed patients is discussed and it is concluded that the simultaneous repair of an AAA and the performance of a renal transplantation (Cerilli) is not recommended because of the risk of sepsis.

Haemodynamics of patients with severe lower limb arterial disease: the critical aspects of critical ischaemia.

OBJECTIVES: To compare the value of ankle and toe pressures as regards the diagnosis of critical ischaemia, its prognosis, and the need for vascular surgery. DESIGN: University hospital-based retrospective study. MATERIALS AND METHODS: Fifty-seven patients (23 women and 34 men) with gangrene or rest pain had a haemodynamic evaluation combining ankle systolic pressure, toe pressure and cutaneous oximetry (tcPO2) with long-term follow-up (until death, for 44%). RESULTS: After 2 years of follow-up, actuarial rates were 49 and 79% for survival and limb salvage, respectively. Ankle and toe pressures gave rise to different subsets of patients, p < 0.001, mainly because of the existence of a group of patients with very distal foot arterial disease. Low ankle pressure was linked to the risk of major amputation. Low toe pressure was linked to a great need for vascular surgery. Diabetes increased the risk of minor amputation. CONCLUSIONS: The concept of critical ischaemia remains clinically relevant. Haemodynamic quantitative data strengthen this concept, but ankle and toe pressures are not interchangeable parameters. For these reasons, toe pressures should be changed from a recommended to a mandatory haemodynamic parameter in the definition of critical ischaemia.

Nailfold capillary microscopy in patients with anticardiolipin antibodies: a case-control study.

BACKGROUND AND DESIGN: This case-control study was undertaken to determine whether anticardiolipin antibodies (ACA) are responsible for particular abnormalities in nailfold capillary microscopy (NCM). Cases comprised 33 consecutive patients positive for ACA (24 women and 7 men). Controls comprised the same number of ACA-negative patients, with the same sex ratio, the same diagnosis and the most similar duration of disease possible. Clinical data, serum samples and NCM recordings were obtained from all patients and controls. RESULTS: In each group, 22 patients had connective-tissue-related disorders and 11 various other diseases. In ACA-positive patients, the mean IgG ACA titre was 39 +/- 58 IgG phospholipid units. Cases and controls displayed various cutaneous manifestations. In ACA-positive patients, there were Raynaud's phenomenon (54%), cutaneous vasculitis (24%), scleroderma changes (18%), photosensitivity (9%), a history of digital gangrene (6%), malar rash (6%), acrocyanosis (6%), chilblains (3%), livedo reticularis (3%) and purpura (3%). Cases and controls exhibited numerous NCM abnormalities. In ACA-positive patients, they included haemorrhages (54%), oedema (24%), bushy capillaries (21%), disordered capillaries (18%), capillary bed disorganization (12%), capillary rarefaction (9%), giant capillaries (6%) and 'desert areas' (3%). There were no correlations between the ACA titres on the one hand and the number of cutaneous manifestations or NCM abnormalities on the other. CONCLUSIONS: ACA-positive patients frequently exhibit clinical skin lesions and abnormal NCM. In this study, these lesions and NCM abnormalities resembled those of the matched ACA-negative controls.

Single-stage management of abdominal aortic aneurysm and colon carcinoma.

We report two cases in which concurrent abdominal aortic aneurysm and colon carcinoma were treated in the same surgical procedure. In the first case both lesions were detected preoperatively but were uncomplicated. Single-stage treatment was undertaken electively. In the second case the colonic lesion was found during treatment of the aneurysm and both lesions were complicated. The decision to undertake single-stage treatment was made intraoperatively. Recovery was uneventful in both cases. Based on previous case reports and our experience in these two patients, we discuss the advantages and disadvantages of single-stage management. The principal risk is prosthetic infection. The advantages include avoidance of complications of the unoperated lesion and the ability to manage both lesions with only one operation. With a two-staged approach, complications following the first procedure and/or progression of the unoperated lesion may prohibit the second procedure. Despite the successful outcome in our patients, we recommend using single-stage management only in selected cases.

[Forefoot gangrene and infra-crural bypass: sequential amputation]. / Gangrène de l'avant-pied et pontage sous-crural: amputation séquentielle.

When revascularizing for gangrene, deciding on amputation depends on the risk of infection due to trophic injury both for the foot and for the bypass and on the requirement to attempt amputation at the correct level at the first operation. In our experience, the importance of infection has led us to propose the following sequence: if the lesions are infected--immediate amputation, differed revascularization after the infection has been controlled; if the lesions are dry early vascularization followed by amputation either during the same operation with strict separation of the two operative fields or a few days later, particularly if the level of the amputation has been determined.

[Atheromatous embolisms and cholesterol embolisms: medical treatment]. / Embolies athéromateuses embolies de cholestérol: traitement médical.

In patients with an acute arterial occlusion, identification of the type of mechanism is important, because both prognosis and treatment differ for each type. The aorta is the most frequent source of arterial atheromatous emboli. Aortic arch plaques are therefore recognized as an independent risk factor for stroke, and plaques located on the thoracoabdominal aorta embolize in the visceral arteries or limb circulation. The treatment of risk factors seems the most effective preventive treatment. When atherosclerosis is patent, an anti-platelet drug such as aspirin or ticlopidine is useful. When the embolus actually occurs, heparin avoids extension of thrombus and prevents its recurrence. Surgical treatment is logical but has not been supported by any randomized trial. Cholesterol cristal embolization evolves in 3 clinical forms: 1-the paucisymptomatic form, not diagnosed during subject's lifetime and only recognized in autopsy studies; 2-a benign form such as the blue toe syndrome or cutaneous livedo, with a spontaneous mild prognosis, and 3-a diffuse multisystemic form with a very poor prognosis. More than 80% of patients with the diffuse form die. When there is renal involvement, only 25% are still alive, with renal function after 6 months of follow up. Vascular surgery is limited to patients with aneurysms, which in themselves constitute a surgical indication. For all other patients, surgery is rarely indicated because 1-the source of cholesterol cristal embolization is not certain, 2-patients are usually too weak for a major surgical intervention, and 3-the necessary aortic clamping during surgery would induce a major risk of recurrence. Prevention is the most effective treatment because in 30% of patients, embolization is due to one of the following: anticoagulant drug, recent fibrinolysis, percutaneous angioplasty, vascular surgery, diagnosis angiography and/or coronarography. The medical treatment is mostly symptomatic: rest, warm conditions, appropriate dressing, antiplatelet drugs, hydration, and organ supply when necessary, principally to ensure renal function. In diffuse and multi-visceral embolization, either colchicine or corticosteroids adjuvant therapy might be useful Prostanoid drugs are also a possible adjuvant treatment.

[Treatment of an exposed femorol-popliteal bypass: ex-situ replacement]. / Traitement d'un pontage fémoro-poplité exposé: remplacement ex-situ.

From December 1990 to July 1995 we performed 171 sub-inguinal revascularizations including 35 popliteal revascularizations and 146 revascularizations of an artery in the leg or foot. Five cases of infection were observed within a delay of 7 and 25 days after the operation. There were 3 men and 2 women (mean age 78 years). Four femoro-tibial bypasses were made for critical ischaemia (2 necroses of the toes, one eschar of the heal, one stage III). There was one femoro-popliteal bypass which was associated with a femoro-femoral for necrosis of the toes. Two bypasses were made with polytetrafluoroethylene, one with Dacron and two with the greater saphenous vein. Signs of sepsis were bleeding in 2 patients who had a venous bypass and septicaemia in 2 patients. Local skin necrosis and/or apparently infected discharge or patent pus were seen in all patients. Staphylococcus aureus was found in 4 patients and Enterobacter cloacae in one. Revascularization was done with an extra-anatomic bypass in 4 patients and with a cryopreserved in situ allograft in 1. Mortality was 20% and amputation rate was 40%. All exposed bypasses were infected but the severity of the infection varied depending on the causal germ, general signs and ischaemia of the limb. Conservative treatment has its limits: 1) intact anastomoses, 2) absence of bleeding, 3) patent bypass, 4) absence of generalized sepsis. Results of in situ revascularization depend on the virulence of the causal germ. Radical treatment (explanation + extra-anatomic revascularization) still has indications in infected infra-inguinal bypass surgery.

Incorporation of fibronectin-impregnated vascular prostheses in the pig. Microscope study.

An interface near the endothelial extracellular matrix is necessary to augment and maintain endothelial cell attachment. The use of plasma lectins constitutes one of the present lines of research designed to improve this interface. We studied the incorporation of 2 series of arterial prostheses with a diameter of 4 mm and a mean length of 9 cm. They were implanted in the carotid arteries of adult Europig minipigs. Prostheses were of two types: polytetrafluoro-ethylene (PTFE) and knitted Dacron. Two series of 12 pigs each were used. One was explanted at 3 months and the other at six. Each pig was grafted with one prosthesis impregnated with the plasma components of diluted Fibrogel and one non-impregnated prosthesis which served as control. The explanted prostheses and adjacent parts of the carotid were prepared for light or scanning electron microscopy. Proximal, median and distal segments were cut and embedded in resin. Collagen distribution was revealed by Milligan's trichrome stain, and fibrin distribution by Picro-Mallory staining. Macroscopic examination showed discrete periprosthetic adhesion for impregnated prostheses and complete adhesion for non-impregnated prostheses. Scanning electron microscopy revealed a median endothelial cell coating on impregnated grafts whereas the only endothelial cells on non-impregnated grafts, were perianastomotic. On impregnated grafts, Milligan's trichrome staining revealed an even collagen distribution. The walls of non-impregnated grafts exhibited capillary cell infiltrations with breaches in the outer structures. In impregnated prostheses, the absence of such breaches enabled us to postulate that their incorporation was better than that of the non-impregnated grafts. The minipig model was hard to handle because of the aggressiveness engendered by restricted feeding designed to limit weight increases. In general, however, we may justifiably conclude that in this model, the use of plasma lectins improved prosthetic incorporation.

[Medical treatment of aortic aneurysms using beta-blockers]. / Le traitement médical des anévrismes de l'aorte par les bêta-bloquants.

There is no known treatment capable of avoiding extension and rupture of aneurysms of the abdominal aorta. There has however been much work recently suggesting a favourable effect of beta-blockers. Early work with experimental animal models of aortic aneurysms showed that Propranolol has a protective effect on extension and rupture of these aneurysms. Studies of the biochemistry of the aortic wall have shown that Propranolol has an independent effect on blood pressure, stimulation lysyl-oxidase and production of intermolecular elastin bridges which strengthen the arterial wall. In man, Propranolol slows the progressive dilatation of the aorta in Marfan's disease. These data on atherosclerosis aneurysms are only part of the picture, but 3 studies have shown that slower widening of the aorta diameter is related to treatment with beta-blockers. In conclusion, the surgical indications for aneurysms in 1995 are unchanged from those in 1994. In cases where surgery is not indicated (patient refusal, operative risk too high, small aneurysms) could comprise a study group for a randomized evaluation against placebo of the effect of beta-blockers. A controlled study is required before therapeutic strategies can be modified.

Distal bypass for limb salvage: comparative study in patients below and above 80 years of age.

Revascularization for chronic lower extremity ischemia in patients of 80 years and older is controversial. To better define operative risk and outcome after peripheral vascular procedures in the elderly, our experience from January 1990 to December 1992 was reviewed. We compared two groups of patients: group I with 26 patients (28 revascularizations) 80 years of age and older (84 +/- 3 years) and group II with 29 patients (32 revascularizations) younger than 80 years (70 +/- 8 year). The two groups were similar with regard to risk factors, surgical indication (rest pain and/or gangrene) and type of graft (in situ vein: 35, reversed vein: 12, PTFE: 13). Fourteen femoro-popliteal bypasses, 17 femoro-tibial bypasses (8 to the anterior tibial artery and 9 to the posterior tibial artery) and 29 femoro-peroneal bypasses were performed. The operative mortality rate was 11.5% in group I and 6.9% in group II. The cumulative life-table survival rate at 24 months was 39.5% in group I and 55% in group II. Primary patency rate at 24 months was 64% in group I and 67% in group II. Secondary patency rate at 24 months was 74.5% in group I and 73% in group II. Limb salvage at 24 months was 80% in group I and 83% in group II. Comparison of the older and younger groups showed no statistically significant difference in mortality rate, graft patency and limb salvage. Operative mortality and graft patency were not different with regard to age of patients.

Aneurysm of the gastroduodenal artery associated with stenosis of the superior mesenteric artery.

A 68-year-old patient was hospitalized after the incidental discovery of an aneurysm of the gastroduodenal artery associated with stenosis of the superior mesenteric artery. This patient had severe heart failure, which led to acute pulmonary edema and inoperable triple-vessel coronary disease. In the first of two procedures the superior mesenteric artery was dilated; 48 hours later the gastroduodenal artery aneurysm was embolized with minicoils and acryl glue. Immediate and follow-up arteriograms at 10 months showed that results were satisfactory. Transluminal treatment of both lesions is an alternative to surgical treatment, especially in high-risk patients.

[Surgical strategy in the association: aneurysm of the abdominal aorta and colonic lesion]. / Stratégie chirurgicale devant l'association: anévrisme de l'aorte abdominale et lésion colique.

An association of an aneurysm of the abdominal aorta and a lesion of the colon raises an important question as to the correct sequence to follow. A simultaneous operation raises the major risk of infection and most authors prefer a sequential approach, treating either the aneurysm or the lesion of the colon first depending on the initial clinical situation or complications. In our first patient, both pathologies were known before surgery and simultaneous procedures were deliberately programmed. In the second case, both lesions were complicated and required simultaneous cure. In the third case, both were recognized before surgery and a sequential approach was followed--colon then abdominal aorta. In the fourth case, the colon disease was complicated and responded to medical treatment; three months later surgery was performed on the aneurysm followed by a colectomy two months later. A review of the literature and an analysis of our four cases offer a means of developing a management strategy for patients with an aneurysm of the abdominal aorta associated with a lesion of the colon.

[Leg volumetry: a precise method for quantification in phlebology]. / La volumétrie: une méthode précise de quantification en phlébologie.

UNLABELLED: Chronic venous insufficiency is usually quantified by venous pressure measurement, which is an invasive method. Air plethysmography has also been used, but it is expensive, time consuming and only suitable for sophisticated research laboratories. Leg volumetry might be suitable for routine use, as it is simple, inexpensive, fast, non invasive and can be performed by non medical personnel. Here, we only evaluated its practicability, accuracy and reproducibility. PATIENTS: The study group included 28 legs of 14 healthy volunteers, and 22 legs of 11 patients suffering from varicose veins. METHOD: The device used was a plexiglass boot, 50 cm high, 20 cm wide. It was filled with water at 24 +/- 2 degrees C. The leg was immersed and the volume of water displaced recorded. RESULTS: Normal legs displaced a volume of 2,449 +/- 153 ml (mean +/- SD), range: 2,080-2,720, and variability 6.2%. Patients' legs displaced a volume of 2,576 +/- 290, range: 2,110-3,120, (p = 0.05 vs normals) and variability 11.2%. Accuracy was 0.7%, as from 2 consecutive measurements of the same patients' legs by 2 different observers. Intra-individual variability was 1.3%, as recorded in 12 repeated measurements of the same leg on different mornings. In normal legs, the difference between morning and evening volumes was statistically significant (18 +/- 15 ml, p = 0.0001), a finding consistent with the deterioration of the venous function in normal extremities during daily activities. CONCLUSION: This simple, cheap, objective, non-invasive reproducible and accurate method of leg volume measurement might be useful in routine practice for chronic venous insufficiency quantification.

[Surgical treatment of deep venous reflux. Techniques, indications and results]. / Traitement chirurgical des reflux de la voie veineuse profonde. Techniques, indications et résultats.

INTRODUCTION: complications of deep venous insufficiency can lead to surgery if one fails with medical treatment. The etiology can be primitive or secondary, the symptoms are identical. They go from heaviness of the legs to chronic leg ulcers. Indication and technic of surgery depend on the etiology and the preoperative evaluation. PREOPERATIVE EVALUATION: it has to be anatomical and functional. Invasive investigations as venous blood pressure, ascending and descending venography, and non invasive investigations as duplex or triplex Doppler and plethysmography are used. TECHNICS: one can use three techniques. Valvuloplasty with or without venotomy, and with or without Dacron cuff. Transplantation of an axillary valvulated venous segment to femoral or popliteal vein. Transposition to a valvulated and competent great saphenous vein or deep femoral vein. INDICATIONS: one can propose transplantation or transposition for secondary deep venous insufficiency, and valvuloplasty for primary deep venous insufficiency. Stage 2 or 3 can be a clinical indication for surgery. RESULTS: valvuloplasty has good results with 60 to 80% free of clinical recurrence at 2 years. The results of the other technics seem to be less good. CONCLUSION: the fair results of surgery allow the use of it for some patients with a good evaluation. The improvement of the surgical results lie on the development of paraclinical evaluation and research on venous valvular hemodynamic.