[Thoracoscopic bypass from the descending thoracic aorta to the femoral artery. Experimental study and clinical application]. / Pontage thoracoscopique entre l'aorte thoracique descendante et l'artère fémorale. Etude expérimentale et application clinique.

OBJECTIVE: Descending thoracic aorta to femoral artery bypass (DTAFB) has demonstrated usefulness in the treatment of aorto-iliac occlusive disease but related morbidity and mortality are not negligible. We wanted to determine the feasibility of thoracoscopic DTAFB and to report our clinical experience. MATERIAL AND METHODS: An experimental study was performed on 8 pigs in helicoidal position under general anesthesia with right selective ventilation ). Three trocars were inserted and the descending aorta was dissected ). After tunnelisation of a 6 mm graft, a lateral aortic anastomosis was thoracoscopically performed ) then femoral anastomoses were made. At the end of the procedure, an angiogram and then an autopsy were performed ). Subsequently, three patients were operated, two for thrombosis of a previous aortobifémoral bypass and one for infrarenal aortic hypoplasia. Dissection and graft tunnelisation were performed thoracoscopically ). Then, the aortic anastomosis ) was constructed through a left lateral minithoracotomy (10 cm). RESULTS: One pig died during surgery of acute lung oedema due to the difficulties of selective ventilation. Excluding this case, the average times of surgery and of dissection were respectively 246 (205-325) and 68 minutes (50-90). The average aortic clamping and anastomosing times were 135 (105-220) and 120 minutes (80-210) ). Three aortic tears were noted; one was repaired. Angiogram was normal 5 times; one pig had a minor stenosis and a leak, and another one had a leak. All the anastomoses were patent without stenosis at autopsy; no organ lesion was found. In humans, the procedure was performed with simple postoperative course in 2 patients and a conversion (20 cm long thoracotomy) was necessary for the third due to poorly supported selective ventilation. CONCLUSION: Totally thoracoscopic DTAFB can be performed in pigs. In clinical practice, we recommend the use of a mini thoracotomy. This way, the aortic anastomosis can be performed with aortic clamping time under 30 minutes, reducing the risk of spinal cord ischemia. These results allow to propose mini invasive thoracoscopically assisted DTAFB for the patients for whom laparoscopic access of the abdominal aorta appears to be difficult (calcified aorta, hostile belly.).

[Per and early postoperative use of low molecular weight heparin in carotid surgery]. / Utilisation per et postopératoire précoce des héparines de bas poids moléculaire en chirurgie carotidienne.

The goal of this study was to evaluate per and postoperative use of nadroparin during carotid surgery with mortality and neurologic morbidity as primary end points. From January 1995 to December 1999, 237 procedures were performed on 215 patients for isolated carotid surgery; 57% were symptomatic. Surgery was performed under general anesthesia. Before clamping, patients received an intravenous bolus of 70 UI/kg of nadroparin. Shunting was used in 40% of patients. Postoperatively, from the 6(th) hour, nadroparin was given subcutaneously, 2,850 UI or 3,800 UI every 12 hours depending on the patient weight (less or more than 70 kg). The only biologic surveillance was platelet count twice a week. Antiplatelet drugs were given at day 2. Completion Duplex scan was performed before day 30. Seven postoperative ischemic strokes (3 non disabling) occurred including one fatal stroke. Another patient died at day 25 from inaugural duodenal bleeding due to pancreas cancer. The 30 days stroke or death rate was 3.37% (5.92% in symptomatic; 0% in asymptomatic). No hemorrhagic stroke occurred. Four patients were reoperated for cervical hematoma (1.68%). No thrombocytopenia occurred. Duplex scan, performed on 235 operated carotid arteries, showed 2 asymptomatic carotid thromboses. No other cardiovascular complication was found on clinical data. These results are comparable to published literature data in prospective as well as retrospective studies. Per and postoperative use of nadroparin in carotid surgery gave results similar to previously published reports in terms of mortality, neurologic morbidity and hematoma. Its easy use, needing only 2 injections a day and platelet count, with a reduction of the risk of heparin-induced thrombocytopenia make the use of nadroparin very attractive during the perioperative period.

[Laparoscopic transperitoneal replacement of the abdominal aorta with left renal artery reimplantation: experimental study on pigs]. / Remplacement laparoscopique transpéritonéal de l'aorte abdominale avec réimplantation de l'artère rénale gauche.

OBJECTIVE: To study the feasibility and the tolerance of a combined laparoscopic transperitoneal aortic and renal restoration performed on animals. METHODS: Six pigs (mean weight: 79.5 kg, range 73-86) underwent laparoscopic replacement of the abdominal aorta using a 6-mm Dacron(R) graft, with direct reimplantation of the left renal artery. The study protocol was approved by the Advisory committee of Animal Ethics. The animal was placed supine on the operative table with a pillow under the lumbar region in order to raise the aortic area. A first midline, 10-mm diameter trocar was placed under direct vision, 5 cm above the pubis and allowed the insufflation of a 12-mm Hg pneumoperitoneum. One 30 degrees optic was used during the intervention. The pig was then tilted to a 30 degrees Trendelenbourg's position and two other 10-mm trocars were introduced 5 cm medially to the right and left antero-superior iliac spines ). Four other 10-mm incisions were necessary for introduction of an intestinal retractor, a suction-irrigation device and two laparoscopic aortic clamps. RESULTS: The procedure was performed in all animals in a mean operative time of 320 min (292-366), including ): - a time for aortic and renal artery dissection of 104 min (90-120), - a supra-renal aortic clamping time of 221 min (180-276), - a time for confection of proximal and distal aorto-prosthetic anastomosis of respectively 59 min (40-75) and 64 min (50-80), - a time for the left renal artery reimplantation of 72 min (40-140). Average blood loss was 525 ml (250-1050), and the mean pre and postoperative hemoglobin and pH values were 9.9 g/dl (8.9-10.7) versus 9.4 g/dl (8.5-11.3) and 7.36 (7.31-7.38) versus 7.30 (7.21-7.43) respectively. An angiogram ) performed before the sacrifice of animals showed a wide patent anastomosis in 18 (56%) cases, a<50% stenosis in 4 cases (22%), a > 50% stenosis in 1 case (5%) and a thrombosis of the first three renal artery restorations (17%) probably due to insufficient intraoperative heparinization. CONCLUSION: This experimental study shows the feasibility of laparoscopic transperitoneal abdominal aortic restoration with re-implantation of the left renal artery (fig. et ). The techniques of arterial sutures must be improved in order to decrease aortic and renal clamping times.

Endovascular treatment of iliocaval occlusion caused by retroperitoneal fibrosis: late results in two cases.

We report two cases of iliocaval occlusion caused by retroperitoneal fibrosis; one presented acute symptoms and one chronic. Both were treated by use of transluminal angioplasty and stenting with excellent clinical, hemodynamic, and imaging results at 36 and 51 months. These cases confirm the benefit of endovascular techniques in the treatment of nonmalignant obstructive disease of large veins, and specifically in the case of retroperitoneal fibrosis.

Treatment of nonmalignant obstructive iliocaval lesions by stent placement: mid-term results.

This report describes mid-term results of endovascular treatment of obstructive iliocaval lesions. Between November 1995 and December 1999, a total of 15 patients were treated by angioplasty and stent placement in the iliac vein. These patients were divided into two groups. Group I consisted of six patients with acute iliofemoral thrombosis of less than 10 days duration, with associated caval involvement in three cases. Angioplasty was performed after surgical thrombectomy, and creation of an arteriovenous fistula as a one-stage procedure in four cases and as a two-stage procedure in two cases. The underlying chronic lesion was stenosis of the left iliocaval junction (Cockett syndrome) in five cases and retroperitoneal fibrosis in one. Group II comprised nine patients with chronic symptomatic stenosis or occlusion. The etiology was Cockett syndrome in seven cases, post-thrombotic syndrome in three cases, including two associated with Cockett syndrome, and retroperitoneal fibrosis in one case. The mean number of stents per patient was 1.5. The mean duration of follow-up was 23.5 months. Evaluation of clinical outcome according to CEAP criteria for chronic syndromes showed significant improvement. Given good mid-term findings, venous angioplasty with stent placement appears to be a safe and effective technique for treatment of acute or chronic obstructive iliocaval lesions.

Laparoscopic aortoiliac surgery for aneurysm and occlusive disease: when should a minilaparotomy be performed?

PURPOSE: The purpose of this study was to determine the benefits and the indications of performing a minilaparotomy during laparoscopic abdominal aortoiliac reconstructions. METHODS: This prospective study was approved by the Commission Consultative de Protection des Personnes dans la Recherche Biomédicale of the University of Marseilles, and all patients gave their informed consent. Between January 1998 and March 2000, 27 patients (23 men; 4 women) with a mean age of 58.2 years (range, 42-76 years) underwent aortoaortic (n = 3), aortounifemoral (n = 4), or aortobifemoral (n = 20) bypass graft for aortoiliac occlusive disease (n = 20), emboligenic aortitis (n = 1), or abdominal aortic aneurysm (AAA) (n = 6). At the beginning of the trial, the decision was made to perform an intraoperative conversion to open surgery in case of bleeding (group 0), when a totally laparoscopic procedure was possible (group I), or when a 6- to 8-cm supraumbilical minilaparotomy was needed in case of technical difficulty (group II). In each case of AAA, the remaining lumbar arteries were controlled (group III); and for the last six patients of this series (group IV), a minilaparotomy was systematically performed. RESULTS: One patient was admitted with multiple organ failure and died on day 12 (3.7%) with a patent graft. One intraoperative conversion to open surgery (3.7%, group 0) was performed for bleeding; recovery was uneventful. Seven postoperative surgical procedures (26%) were necessary, including two cases of aortic bleeding because of hypertensive access. Seven procedures were totally laparoscopic (group I), and a minilaparotomy was performed in the other 19 cases, including seven cases of technical difficulty (group II). The mean operative and clamping times and the mean postoperative hospital stay were globally (P =.021) and individually (P < or =.016) significantly shorter in group IV when compared with those of the other three groups. Twenty patients (74%) had a postoperative hospital stay of 6 days or less (3-6 days), with minimal complaints of pain, tolerance of oral feeding on day 2, and mobilization on day 2 or 3. All bypass grafts remained patent after a mean follow-up of 11 months (1-26 months). CONCLUSION: With regard to the instrumentation presently available, this study shows the benefit of a minilaparotomy when performing a laparoscopic aortoaortic or aortofemoral bypass graft for the treatment of aortoiliac occlusive disease and AAA.

Intestinal retractor for transperitoneal laparoscopic aortoiliac reconstruction: experimental study on human cadavers and initial clinical experience.

BACKGROUND: We set out to design a bowel retractor for use during laparoscopic transperitoneal reconstruction of the infrarenal aorta and of both iliac axes. METHODS: This study was performed on five cadavers. After the insertion of four trocars, a pneumoperitoneum was created, and the bowels were gathered to the right flank. On each cadaver, the following four measurements were made: the distance between the Treitz angle and the aortic bifurcation (L1), the distance between the aortic bifurcation and the right internal inguinal ring (L2), the angles between L1 and L2 in the axial plane (A1), and the angles between them in the sagittal (A2) plane. These measurements enabled us to create a bowel retractor. The device was composed of a malleable metallic rod with a 2.5-mm diameter that was fixed to the operating table and whose intraabdominal section was designed to follow the outline of the mesenteric root in addition, a 25 x 12 cm polypropylene net was slipped around the rod. The infrarenal aorta and both iliac axes were then dissected. Secondarily, the bowel retractor was used in eight patients (seven men and one woman; mean age, 56 years; range 44-76) during laparoscopic aortoiliac reconstruction for occlusive (n = 6) or aneurysmal (n = 2) disease. RESULTS: The statistical analysis of the measurements performed on cadavers showed a significant correlation between body height and L1 (r = 0.8769; p < 0.05) and L2 (r = 0. 9706; p < 0.01) distances. It was then possible to design the shape of two metallic rods (one small and one large) so that they would be adaptable to the height of the patients (<1.65 m and >1.65 m). During our clinical experience, all laparoscopic procedures were completed in a mean operative and clamping time of 266 min (range, 215-360) and 54 min (range, 18-90), respectively. Mean postoperative hospital stay was 6 days (range, 3-13). CONCLUSION: Our experimental study allowed us to develop a bowel retractor that can make it easier to perform laparoscopic transperitoneal aortoiliac reconstruction in humans.

Abdominal aortic laparoscopic surgery: retroperitoneal or transperitoneal approach?

OBJECTIVE: to define the respective advantages and pitfalls of the trans- or retroperitoneal approaches in laparoscopic abdominal aortic reconstruction (LAOR). DESIGN: prospective study. MATERIAL: ten patients (8 males; average age 58) underwent an aortouni- (n=2) or bifemoral bypass (n=8) to treat aortoiliac occlusive disease (n=8) or an aortic aneurysm (n=2). METHODS: a retroperitoneal approach (the "apron" technique) was used in the first 5 cases (Group I) and a transperitoneal approach in the last 5 cases (Group II). RESULTS: no early or late death occurred, and all bypasses remain patent after a mean follow-up of 5.7 months. Mean surgical and clamping times are similar in both groups (370 and 126 min in Group I; 324 and 137 min in Group II). One intraoperative conversion to open surgery and two postoperative surgical complications occurred in Group I. Four minilaparotomies of 8-10 cm were necessary in Group II. Two patients were discharged on postoperative day 6 in Group I and five in Group II. CONCLUSION: this preliminary study shows the feasibility of LAOR through both approaches. In Group II, a better exposure of the right aortic wall and of the right iliac axis was noted and division of the inferior mesenteric artery was not always necessary.

Surgical venous thrombectomy.

Rehabilitation of the technique of venous thrombectomy is justified, but, in order for this technique to be effective, it must only be performed in selected cases. In the authors' view it is of the utmost value in young patients when the venous thrombosis occurs accidentally, after traumatism or surgery and when a diagnostic is made without delay.

[Infections of vascular prostheses of the abdominal aorta. Diagnostic and therapeutic problems]. / Les infections de prothèses vasculaires de l'aorte sous-rénale. Problèmes diagnostiques et thérapeutiques.

UNLABELLED: Aortic graft infection is one of the most serious complication of vascular surgery. While the incidence of such infections has declined over the years, it continues to be associated with high mortality and high rates of limb loss. Graft implanted in the inguinal area have a higher rate of infection than those that lie entirely within the abdomen. Infection of the intraabdominal extremities of vascular grafts is most frequently associated with prostheto-enteric fistula. DIAGNOSIS AND TREATMENT: Despite the many available sophisticated imaging techniques diagnosis remains difficult, particularly with intra-abdominal grafts because of nonspecific clinical and imaging findings. A variety of approaches to aortic graft infection have been proposed and optimal treatment usually requires an association of systemic antibiotic administration with surgery. Removal of the entire infected graft is often necessary for cure and there are only few situations in which conservative treatment is acceptable. A careful identification of the infecting microorganisms and in vitro susceptibility testing are essential for successful therapy. PREVENTION: Prevention consists in a strict adherence to principles of asepsis and the use of prophylactic antibiotics in vascular surgery. The use of antibiotics-bound knitted grafts has been recently proposed.

Bilateral dissection of the internal carotid artery at the base of the skull due to blunt trauma: incidence and severity.

Between January 1, 1992 and December 31, 1996, a total of 1095 head trauma vicims were admitted in our intensive care unit. If CT scans demonstrated ischemic brain lesions, arteriography to visualize supraaortic vessels was performed. Carotid artery dissection was observed in ten patients (0.91%) and was bilateral in eight patients (0.73%). In the bilateral carotid artery dissection (BCAD) group, there were five women and three men, with a mean age of 35.2 years (range: 17 to 54 years). Injuries resulted from traffic accidents in seven patients and a fall in one patient. Upon admission, six patients presented with alteration of consciousness and three with hemiplegia or hemiparesia, associated with aphasia in two cases. In two other cases, hemiplegia occurred 24 hr and 13 days after the accident. All patients had brain infarction, which was unilateral in five cases and bilateral in three cases. The severity of lesions was graded on the basis of arteriographic findings as follows: Type I, wall involvement without significant stenosis or dilation; Type II, arterial dissection with stenosis >70% (Type IIA) or dilatation >50% (Type IIB) and the normal diameter of the proximal or distal internal carotid artery; and Type III, thrombosis of the internal carotid artery. Lesions were asymmetrical in six patients, including two with Type II and III lesions and four with Type I and II lesions, and symmetrical in two patients, including one with bilateral Type III lesions and one with bilateral Type II lesions. Surgery was performed in two patients with Type II lesions, including one case associated with contralateral carotid thrombosis. The intrapetrous carotid artery was exposed by an ear-nose-throat (ENT) surgeon and repaired by interposition grafting. Follow-up in these two surgical cases was 28 and 31 months. In the remaining six cases, medical treatment was performed. Outcome in nonsurgical cases was variable: death in two cases at 31 and 43 days after the accident, severe permanent hemiplegia in two cases, and minimal or no sequels in two cases. Following blunt trauma, arteriography of supraaortic vessels should be performed to detect BCAD in any patient with immediate or delayed neurologic symptoms that cannot be explained by CT-scan findings. To better understand the natural course of these lesions and define the indications for surgery, we propose a three-grade classification according to arteriographic findings. If surgery is undertaken, vein grafting should be performed following resection of the carotid artery lesions.

New trends in the surgical and endovascular reconstructions of large veins for nonmalignant chronic venous occlusive disease.

Considerable advances have been made in reconstructive venous surgery in the past two decades because of an increased recognition of venous disease and because of extensive experimental work. Meaningful evaluation of longterm patency of bypass grafts and midterm patency of stent placement are now available and seem appropriate to provide guidelines. Based on our experience and on the literature, this article highlights the techniques and the respective indications of surgical and endovascular treatment of large vein reconstructions.

[Laparoscopic replacement of the abdominal aorta. Experimental study in the pig]. / Remplacement laparoscopique de l'aorte abdominale. Etude expérimentale chez le porc.

BACKGROUND: Progress in abdominal laparoscopy led us to study end-to-end anastomoses performed laparoscopically. METHOD: An experimental protocol in 10 castrated male pigs weighing 74-95 kg was approved by the ethics committee. After conventional anesthesia, each animal was positioned in lateral decubitus and a retropneumoperitoneum was created. CO2 inflation was maintained at 14 mmHg for insertion of 3 trocars, 5 to 10 mm width. The entire infrarenal aorta was dissected and resected with insertion of a 6 mm dacron prosthesis. Postoperative arteriography was performed in all cases. The animal was sacrificed for direct examination. RESULTS: One animal died during anesthesia induction and the entire protocol was conducted in 9 animals. Mean operative time was 397 min (305-535 min) including a mean 123 min (65-150) for aortic dissection, 82 min (30-155) for proximal anastomosis and 70 min (45-105) for distal anastomosis. Total blood loss varied from 100 to 450 cc (mean 252 cc). Mean difference between pre- and postoperative hematocrits was 4% (0-6%). Among the 18 aortic anastomoses performed, arteriography showed one with moderate leakage and one anastomotic thrombus. Stenosis > 50% was found in 4 cases and < 50% in 4 cases. Analysis of the different operative parameters showed a learning curve with decreasing operative time and improved quality of the anastomoses. CONCLUSION: This study demonstrates the feasibility of aortic reconstruction via retroperitoneal laparoscopy in the animal. This procedure could be introduced in man.

Use of 16S rRNA gene sequencing to identify Lactobacillus casei in septicaemia secondary to a paraprosthetic enteric fistula.

Human infections caused by Lactobacillus spp. are rarely reported in the literature. Underlying conditions are frequently reported, and identification of lactobacilli to the species level remains rare. A case of Lactobacillus casei septicaemia secondary to a vascular graft infection is reported. The 16S rRNA sequencing technique was used to definitively identify Lactobacillus casei.

Rupture of an abdominal aortic aneurysm after endovascular graft placement and aneurysm size reduction.

Reduction in aneurysm size during the months after an endovascular graft placement generally is considered one of the criteria of success. We report the case of a patient with an abdominal aortic aneurysm rupture occurring 9 months after a bifurcated endovascular graft placement despite a greater than 45% reduction in size noted on contrast-enhanced computed tomography scan performed at 7 months. Biomaterial modifications of the stent and of the Dacron explanted stent-graft are analyzed.

Iliac transluminal angioplasty and distal surgical revascularisation can be performed in a one-step technique.

PURPOSE: A few authors have suggested treating double-level atherosclerotic lesions in high risk patients by an association of iliac transluminal angioplasty (ITA) and distal surgical restoration in a two-step technique with an interval of one to three weeks between the two procedures. Previous reports of ITA showed the influence of the quality of the outflow on early results, we therefore decided to perform the two procedures mentioned above during the same operation. METHODS: During a five-year period, 51 patients (42 men, 9 women) underwent an isolated ITA in 32 cases (group I) or associated with a simultaneous surgical reconstruction (group II) in 19 cases. Mean age (56.4+/-12 years versus 63.9+/-11.8 years, p<0.01), frequency of limb-threatened ischaemia (2.6% versus 42.1% p<0.001), and of an ipsilateral thrombosed or severely stenotic femoral artery (20% versus 100%, p<0.001) were significantly higher in group II. In group I (n=32), 45 unique or double iliac lesions (unilateral=25, bilateral=7) including 42 stenosis (>75%) and three thrombosis were treated. In group II (n=19), ITA was performed on unique and unilateral iliac stenosis (>75%) in association with a femoro-femoral bypass (n=4), an ipsilateral femoro-popliteal bypass (n=5) or femoro-tibial bypass (n=3) or an ipsilateral deep or common femoral reconstruction (n=7). RESULTS: Early complications consisted of one haematoma (group I), one death and one iliac restenosis (group 2). After a mean follow-up of 20 months, cumulative patency of groups I and II was respectively 81% and 88% (p=ns), with an increase in the ankle/brachial systolic pressure ratio from 0.73+/-0.14 to 0.92+/-0.14 (p<0.001) in group I, and from 0.57+/-0.15 to 0.84+/-0.12 (p<0.001) in group II. CONCLUSIONS: Early and mid-term results of the one-step technique are similar to those obtained with patients who underwent ITA with good initial outflow. This technique can therefore be recommended in high-risk patients with double-level atherosclerotic lesions including severe iliac stenosis.

Surgical interruption of a left inferior vena cava following the transfemoral implantation of a permanent pacing lead.

This report describes the case of a patient in whom, after an unsuccessful attempt through the subclavian vein, a permanent pacing lead was inserted through the femoral vein and a left inferior vena cava with azygos continuation. The procedure was followed 4 months later by a pulmonary embolism complicating a right femoroiliac thrombosis. The patient was successfully treated by a percutaneous lead extraction procedure combined with an inferior vena caval surgical interruption.

Iliac vein reconstructions to treat acute and chronic venous occlusive disease.

PURPOSE: The treatment of permanent and benign iliac vein occlusion responsible for acute vein thrombosis or chronic symptoms remains controversial. Different methods of reconstruction using a reinforced expanded polytetrafluoroethylene bypass graft associated with an arteriovenous fistula and their intermediate-term results are analyzed. METHODS: Eight consecutive patients (six men, two women; mean age, 45.6 years; range, 29 to 70 years) were treated over a period of 38 months for iliac vein obstruction. Three short bypass procedures between the left iliac vein and the right common iliac vein with temporary arteriovenous fistulas were carried out after an iliofemoral (and caval in two cases) venous thrombectomy, which revealed May-Thurner syndrome (n = 1) and a compression of the left common iliac vein by the left hypogastric artery (n = 2). Five long bypass procedures (one femorofemoral, two left common femoral-vena caval, one right superficial femoral-common iliac, and one bifemorocaval) with a definitive arteriovenous fistula were performed for long chronic venous occlusion in four cases (responsible for venous claudication [n = 3], recurrent ulcers [n = 1] and after iatrogenic ligature of the left external iliac vein during total cystectomy with double ureterostomy in one case. RESULTS: There was no evidence of pulmonary embolism, and no deaths were recorded in the perioperative period. Two patients had an early bypass thrombectomy, but one returned with a further graft occlusion. Seven grafts remained patent after a mean follow-up of 19.5 months (range, 10 to 45 months). One successful thrombectomy was necessary during the twenty-third postoperative month. CONCLUSIONS: Reconstruction of iliac veins in case of permanent compression, mostly discovered after venous thrombectomy, or for selected patients with symptomatic benign iliac vein occlusion, is safe and provides good intermediate-term results.

Late results of iliofemoral venous thrombectomy.

PURPOSE: Although anticoagulation therapy for iliofemoral venous thrombosis prevents pulmonary embolism, it is not designed to avoid the postthrombotic syndrome. Mechanical removal of the thrombus in the form of venous thrombectomy should yield better long-term results. The purpose of our study was to analyze the clinical outcome and venous valvular function of limbs 5 to 13 years after iliofemoral venous thrombectomy. METHODS: Seventy-seven lower extremities underwent venous thrombectomy for acute iliofemoral venous thrombosis and were monitored for a mean follow-up of 8 1/2 years (range, 5 to 13 years). Patency of the iliofemoral venous system, competence of the femoral popliteal valves, and clinical signs and symptoms of chronic venous insufficiency were evaluated in each case. RESULTS: Subsequent to early perioperative failure, patency remained stable over time at 84%. Valvular competence was preserved in 80% at 5 years; however, it decreased to 56% at 10 years. It is important that more than 90% of the limbs had no symptoms or mild symptoms of chronic venous insufficiency. CONCLUSIONS: Venous thrombectomy should be considered for primary treatment in selected cases of early iliofemoral venous thrombosis.

[Recurrence following surgery of the gastrocnemius veins]. / Récidives après chirurgie des veines jumelles.

Routine preoperative investigation of chronic venous insufficiency of the lower limbs with echo-Doppler has brought to light the presence of reflux into the gastrocnemius veins in almost 30% of the patients. Surgical treatment to stop this reflux consists in dividing the gastrocnemius vein flush to the popliteal vein. Early postoperative investigation of patients operated on in this way, who are symptomless and with no residual varices, has revealed the presence of persistent, symptomless, postoperative reflux into the gastrocnemius veins. One hundred and six patients were checked six months postoperatively by Duplex Doppler scanning. On the basis of the anatomical and functional findings, postoperative incompetence of the gastrocnemius veins could be classified into several types according to the cause: 1. Persistence of a complete and incompetent gastrocnemius vein, probably missed at operation: 16 patients (15%). 2. Neoangiogenesis: 11 patients (10%). 3. Persistence of an incompetent lower gastrocnemius perforating vein: 17 patients (16%). Thus, echography has revealed that in 44 lower limbs out of 106 (42%) in which the gastrocnemius veins were operated on, six months postoperatively evidence of reflux into the gastrocnemius venous network was present. All these patients were asymptomatic. In a sub-group of 48 lower limbs which had an interval Doppler check at 2 months: 6 already showed a reflux (12.5%), in 11 the gastrocnemius reflux appeared between the second and the sixth months (23%), 31 showed no reflux at 6 months (64.5%). From these findings, certain rules on the surgery of the gastrocnemius veins have been drawn up.