In situ revascularization with rifampicin-soaked silver polyester graft for aortic infection: Results of a retrospective monocentric series of 18 cases.

OBJECTIVE: To evaluate the short and long-term results of in situ prosthetic graft treatment using rifampicin-soaked silver polyester graft in patients with aortic infection. MATERIAL AND METHOD: All the patients surgically managed in our center for an aortic infection were retrospectively analyzed. The primary endpoint was the intra-hospital mortality, secondary outcomes were limb salvage, persistent or recurrent infection, prosthetic graft patency, and long-term survival. RESULTS: From January 2004 to December 2015, 18 consecutive patients (12 men and 6 women) were operated on for aortic infection. Six mycotic aneurysms and 12 prosthetic infections, including 8 para-entero-prosthetic fistulas, were treated. In 5 cases, surgery was performed in emergency. During the early postoperative period, we performed one major amputation and two aortic infections were persistent. Intra-hospital mortality was 27.7%. The median follow-up among the 13 surviving patients was 26 months. During follow-up, none of the 13 patients presented reinfection or bypass thrombosis. CONCLUSION: This series shows that in situ revascularization with rifampicin-soaked silver polyester graft for aortic infection have results in agreement with the literature in terms of intra-hospital mortality with a low reinfection rate.

[Postexercise duplex ultrasound to diagnose external iliac endofibrosis]. / Endofibrose de l'artère iliaque externe diagnostiquée par écho-doppler post-effort.

Arterial endofibrosis is a disease of recent discovery which concerns high-performance athletes, predominantly competitive cyclists. The preferential location is the external iliac artery. The symptoms are diverse (pain, edema, paresthesia), always linked to an effort. The diagnosis may be delayed due to atypical symptoms in athletes. Complementary tests are measure of the systolic pressure index after exercise, duplex ultrasound, CT angiography, MR angiography and arteriography. We report a case of endofibrosis where late diagnosis was established with postexercise duplex ultrasound, while CT angiography and arteriography failed to reveal characteristic abnormalities.

Circulating lipoprotein-associated phospholipase A2 in high-grade carotid stenosis: a new biomarker for predicting unstable plaque.

OBJECTIVE: To test plasma levels of lipoprotein-associated phospholipase A2 (Lp-PLA2) in patients with high-grade carotid stenosis according to plaque histology. METHODS: This cross-sectional single-centre study included patients with ≥70% North American Symptomatic Carotid Endarterectomy Trial (NASCET) carotid stenosis, who were treated surgically. Serum Lp-PLA2 and high-sensitivity C-reactive protein (hs-CRP) were determined on the day of surgery. Histopathological analysis classified carotid plaque as stable or unstable, according to AHA classification. RESULTS: Of the 42 patients (mean age 70.4 ± 10.5 years; 67% men), neurological symptoms were present in 16 (38%). Unstable plaques were found in 23 (55%). Median plasma level of Lp-PLA2 was significantly higher in patients with unstable plaque compared to those with stable plaque (222.4 (174.9-437.5) interquartile range (IQR) 63.5 vs. 211.1 (174.9-270.6) IQR 37.2 ng ml(-1); p = 0.02). Moreover, median Lp-PLA2 level were higher in asymptomatic patients with unstable plaque (226.8 ng ml(-1) (174.9-437.5) IQR 76.8) vs. stable plaque (206.9 ng ml(-1) (174.9-270.6) IQR 33.7; p = 0.16). Logistic regression showed that only the neurological symptoms (OR = 30.9 (3.7-244.6); p < 0.001) and the plasma Lp-PLA2 level (OR = 1.7 (1.1-12.3); p = 0.03) were independently associated with unstable carotid plaque as defined by histology. CONCLUSIONS: This study showed that circulating Lp-PLA2 was increased in patients with high-grade carotid stenosis and unstable plaque. Lp-PLA2 may be a relevant biomarker to guide for invasive therapy in asymptomatic patients with carotid artery disease.

Multicentric retrospective study of endovascular treatment for restenosis after open carotid surgery.

OBJECTIVES: To analyse perioperative and midterm outcomes of carotid artery stenting (CAS) for symptomatic >50% and asymptomatic >70% restenosis after open carotid surgery (OCS). DESIGN: A multicentric retrospective study. METHODS: Outcome measures 30-day death, neurologic and anatomic (thrombosis, restenosis) events. Univariant and multivariant logistic regression analyses were performed to identify predictive factors for neurologic and anatomic events. RESULTS: A total of 249 patients with a mean age of 69 years (range, 45-88) were treated for asymptomatic (86%) or symptomatic (14%) restenosis. The 30-day combined operative mortality and stroke morbidity was 2.8% in asymptomatic patients and 2.9% in symptomatic patients. Events during follow-up (mean duration, 29 months) included stroke in four cases, TIA in two, stent thrombosis in four and restenosis in 21. Kaplan-Meier estimates of overall survival, neurologic-event-free survival, anatomic-event-free survival and reintervention-free survival were 95.4%, 94.7%, 96.7% and 99.5%, respectively, at 1 year and 80.3%, 93.8%, 85.1% and 96%, respectively, at 4 years. Multivariant analysis showed that statin use was correlated with a lower risk of anatomic events (odds ratio (OR) = 0.15 (95% confidence interval (CI) 0.03-0.68), p = 0.01) and that bypass was associated with a higher risk of anatomic events than endarterectomy (OR = 5.0 (95% CI 1.6-16.6), p = 0.009). CONCLUSION: CAS is a feasible therapeutic alternative to OCS for carotid restenosis with acceptable risks in the perioperative period. Restenosis rate may be higher in patients treated after bypass.

[Long-term patency of a popliteal venous aneurysm treated surgically]. / Perméabilité à long terme d'un anévrisme veineux poplité traité chirurgicalement.

Popliteal venous aneurysms are infrequent but should be screened for with venous ultrasound in patients with acute or chronic venous diseases because of the unpredictable high risk of thromboembolism and potential curability. Therapeutic alternatives are discussed: follow-up, anticoagulation, surgery with different techniques. To illustrate this, we report the case of a 51-year-old woman presenting pulmonary embolism and left popliteal venous aneurysm treated surgically. Anticoagulation was stopped 12 months after surgery and primary patency was maintained 40 months after surgery. In patients with thromboembolism disease, clinicians should search for popliteal venous aneurysms in order to prevent recurrent thrombosis and adapt follow-up and treatment.

Fenestrated endovascular grafting: the French multicentre experience.

PURPOSE: This study aims to evaluate the medium-term outcomes following aortic aneurysm repair using fenestrated endografts performed in 16 French academic centres. MATERIALS AND METHODS: A retrospective analysis of prospectively collected data was carried out. This study included all patients treated with fenestrated endografts in France between May 2004 and January 2009. Patients were judged to be at high risk for open surgical repair. Fenestrated endografts were designed using computed tomography (CT) reconstructions performed on three-dimensional (3D) workstations. All patients were evaluated with CT, duplex ultrasound and plain film radiograph at discharge, 6, 12, 18 and 24 months, and annually thereafter. RESULTS: A total of 134 patients (129 males) were treated over the study period. Median age and aneurysm size were 73 years (range 48-91 years) and 56 mm (range 45-91 mm), respectively. A total of 403 visceral vessels were perfused through a fabric fenestration, including 265 renal arteries. One early conversion to open surgery was required. Completion angiography and discharge CT scan showed that 398/403 (99%) and 389/394 (99%) respective target vessels were patent. The 30-day mortality rate was 2% (3/134). Pre-discharge imaging identified 16 (12%) endoleaks: three type I, 12 type II and one type III. After the procedure, transient or permanent dialysis was required in four (3%) and two (1%) patients, respectively. The median duration of follow-up was 15 months (range 2-53 months). No aneurysms ruptured or required open conversion during the follow-up period. Twelve of 131 patients (9%) died during follow-up (actuarial survival at 12 and 24 months: 93% and 86%, respectively). Median time from procedure to death was 15 months. None of these deaths were aneurysm related. Aneurysm sac size decreased by more than 5 mm in 52%, 65.6% and 75% of patients at 1, 2 and 3 years, respectively. Three (4%) patients had sac enlargement within the first year, associated with a persistent endoleak. During follow-up, four renal artery occlusions were detected. A total of 12 procedure-related re-interventions were performed in 12 patients during follow-up, including six to correct endoleaks, and five to correct threatened visceral vessels. CONCLUSIONS: The use of endovascular prostheses with graft material incorporating the visceral arteries is safe and effective in preventing rupture in the medium term. A predictable high mortality rate was depicted during follow-up in this high-risk cohort. Meticulous follow-up to assess sac behaviour and visceral ostia is critical to ensure optimal results.

Early carotid endarterectomy after intravenous thrombolysis for acute ischaemic stroke.

UNLABELLED: After intravenous thrombolysis (IVT) for acute ischaemic stroke (AIS), a severe cervical internal carotid artery (ICA) stenosis may remain and increase the risk of recurrent stroke. Carotid endarterectomy (CEA) has been shown to be effective in reducing the risk of stroke. However, it is not well known whether CEA can be performed safely after thrombolysis, and, if so, when. We report a prospective study of CEA for residual high-grade cervical ICA stenosis performed within 15 days after IVT for AIS. METHODS: All the patients had a brain magnetic resonance imaging (MRI) within 3h of the stroke onset. One day after IVT in neurovascular unit, computed tomography (CT) angiography was performed to assess the brain and the patency of cervical arteries. CEA was performed on neurologically stable patients after full cerebral artery re-canalisation. Blood pressure was controlled with particular caution before and after CEA. RESULTS: Between January 2005 and January 2008, we operated consecutively on 12 patients. Their median National Institutes of Health Stroke Scale (NIHSS) score was 12 (range: 5-21). Combined intracranial (ICA)-middle cerebral artery (MCA) occlusion was present in 58.3% of the patients. The median time between onset of symptoms until CEA was 8 days (range: 1-16 days). Stroke and death rate at 30 days was 8.3% (one nonfatal haemorrhagic stroke). At 90 days, nine patients had a Rankin score of 0-1, one had a score of 2 and two had a score of 3. CONCLUSION: In patients with residual cervical ICA stenosis after IVT, we achieved full patency of the occluded artery and good functional prognosis at 3 months in all cases. We advocate for an extremely close monitoring of the blood pressure in the pre-, peri- and post-operative course and a close collaboration between neurologist and surgeon to determine the best timing for CEA.

[Endovascular aneurysm repair follow-up by unenhanced and contrast-enhanced duplex ultrasound]. / Surveillance des endoprothèses aortiques abdominales : intérêt de l'échographie-doppler standard et avec contraste.

OBJECTIVE: Long-term surveillance is needed after endovascular aneurysm repair to monitor the aneurysm and search for persistent endoleaks. Our aim was to compare follow-up with duplex ultrasound, with and without a new contrast agent to track endoleaks, versus computed tomography angiography taken as the gold standard. MATERIAL AND METHOD: Patients treated with endograft were included prospectively from December 2005 to July 2006. Aortic duplex ultrasound and computed tomography were used to measure maximal aneurysm diameter and detect endoleaks. Patients with a high risk of endoleaks had a contrast-enhanced ultrasound with Sonovue (Bracco, Milan, Italy). We compared echographic and tomographic diameter and studied the sensitivity of ultrasound endoleak diagnosis. RESULTS: Sixty-seven patients were included. There was a good correlation between maximum anteroposterior diameters (CCI=0.98) measured by ultrasound and tomography, as well as mean maximum cross section diameters (CCI=0.96). Compared to tomography, the sensitivity of ultrasound endoleaks diagnosis was 44% (kappa=0.58). Contrast injection improved this sensitivity significantly (p<0.001) (sensitivity=88%; kappa=0.72). CONCLUSION: These findings confirmed the performance of our ultrasound method for endograft surveillance. Contrast-enhanced ultrasound significantly improves the sensitivity of detection of endoleaks. We suggest alternating ultrasound and tomographic exams. A unique report chart for use nationwide would be useful for standardizing follow-up.

The haemodynamics of the distal arterial Y-shaped autograft bypass-flap in a porcine experimental model.

BACKGROUND: The haemodynamic effects of revascularisation with combined bypass and free-muscle flap remain controversial. In a porcine experimental model, we investigated the transplantation-induced changes in the haemodynamics of a Y-shaped combined arterial autograft bypass-muscle flap (AABF). METHODS: Anatomy of AABF was identified in eight dissections in four porcine cadavers. In five animals, AABF served as a superficial femoral artery (SFA) defect replacement. Modelled, triggered pulsatile pressure (P) and flow (Q) waves delivered mean haemodynamics and PQ hysteresis loops before and after transplantation at days 0 and 10. RESULTS: Anatomically, AABF combined subscapular and circumflex-scapular arteries, and thoracodorsal artery as latissimus dorsi flap pedicle. Surgical feasibility and AABF patency were confirmed in each case. At day 0, the proximal flow was increased in the grafted Y-shaped AABF, which also adopted the specific SFA pulsatile haemodynamics. Regulatory mechanisms of AABF vasomotricity were preserved and AABF-flow-dependence amplified the flow in the distal segment, which otherwise preserved its own flow dependence. At 10 days, the AABF flow was unchanged in the distal segment, and remained elevated in the proximal and pedicle segments. CONCLUSIONS: Combined AABF, as a single one-piece arterial autograft, was shown highly adaptive to the receiving arteries. The transplantation-induced changes in AABF pulsatile flow profile and vascular reactivity improve the overall graft flow, and strongly advocate for beneficial effects on the blood propelling capacity of the grafted circulation.

Endovascular treatment of anastomotic false aneurysms of the abdominal aorta.

Conventional surgical treatment of anastomotic false abdominal aortic aneurysms (AFAA) is technically difficult. Morbidity-mortality rates are higher than those for surgery of infrarenal abdominal aortic aneurysm (AAA). Endovascular management without laparotomy or aortic clamping represents an attractive alternative. The purpose of this study was to determine the immediate and middle-term outcome of endovascular management of AFAA. Between 1998 and 2001, 10 patients were treated for AFAA by placement of an endograft. The initial procedure was aortobifemoral bypass for occlusive artery disease in eight cases and resection and grafting for AAA in two cases. Mean age was 70 years. Seven patients were classified ASA 3 or 4. Three patients presented cardiac insufficiency with left ventricular ejection fraction <40%. Eight patients were treated using an aortounilateral iliac artery endograft in association with crossover femorofemoral bypass (3 AneuRx, 2 Endologix, 1 Talent, 1 Zenith, 1 surgeon-made stent). Two patients were treated with an aortoaortic endograft (1 Talent, 1 surgeon-made stent). In two patients extraperitoneal exposure of the common iliac artery was required for introduction of the stent in one case and for surgical closure of the iliac artery in the other case. A total of nine patients underwent another surgical procedure in association with stenting. Four endografts were custom-made. Endograft deployment was successful in all cases. No patient died during the postoperative period. Postoperative computed tomography (CT) scan confirmed exclusion of the aneurysmal sac in all cases. The mean duration of hospitalization was 13 days (range, 5-28 days). During follow-up (mean duration, 17.7 months; range, 5-42 months), one patient died from heart-related causes. No direct or indirect endoleak was detected by CT scan follow-up and a significant reduction in AFAA diameter was noted in the eight patients with follow-up periods lasting 6 months or more. One patient developed occlusion of an aortounilateral iliac artery endograft and was treated by axillobifemoral bypass. In one patient stenosis of the distal end of an aortounilateral iliac endograft was discovered by duplex scan and successfully treated by dilatation. Endovascular treatment of AFAA is technically feasible but requires more complex procedures involving associated surgical procedures and use of custom-made endografts. The morbidity-mortality rate in this small series of high-risk patients was low. Immediate and middleterm exclusion of AFAA was good.

Mortality and morbidity following endovascular repair of abdominal aortic aneurysms: analysis of two single centre experiences.

OBJECTIVE: to show how differences in anatomical and physiological risk factors can affect the outcome of endovascular repair of AAA by describing the experience of two centres with different selection policies. METHODS: one hundred and thirty-five patients (group I) were treated at Queen's Medical Centre (Nottingham, U.K.) using 101 in-house made and 34 manufactured stent-grafts. Median diameter, length and angulation of the proximal aneurysm neck were 26 mm, 27 mm, 40 degrees, respectively. Seventy-six patients had ischaemic heart disease, 47 had left ventricular failure, median forced expiratory volume in one second (FEV1) was 83%, median creatinine was 100 micromol/l and median age was 72 years. Fifty patients (group II) were treated at Timone Hospital (Marseilles, France) using seven in-house made and 43 manufactured stent-grafts. Median diameter, length and angulation of the proximal aneurysm neck were 25 mm, 34 mm, 33 degrees, respectively. Thirteen patients had ischaemic heart disease, two had left ventricular failure, median forced expiratory volume in one second was 101%, median creatinine was 108 micromol/l and mean age was 72 years. RESULTS: anatomical characteristics of the proximal neck were significantly worse in group I (p=0.02 for the three variables). Cardiac comorbidities were more frequent and mean FEV1 was lower in group I (p<0.0001 and p=0.001, respectively. Median aneurysm diameter was significantly greater in group I (65 mm) than in group II (53 mm) (p<0.001). Postoperative mortality was 9% and 0% in groups I and II respectively (p=0.03). The incidence of technical complications (groin wound complications and side branches endoleaks being excluded) was 20% and 0% in groups I and II, respectively (p=0.0006). CONCLUSION: postoperative mortality and technical complication rates were significantly greater in group I than in group II, readily explained by poorer general condition and worse anatomical characteristics of the proximal neck in group I.

Endovascular treatment of occlusive lesions in the distal aorta: mid-term results in a series of 31 consecutive patients.

The purpose of this study was to evaluate the early and mid-term results of endovascular treatment of occlusive lesions in the distal aorta in a consecutive series of patients. Between February 1996 and March 1999, a total of 31 patients underwent transluminal procedures for treatment of occlusive atherosclerotic lesions located at the lower end of the aorta. Thirty patients presented with intermittent claudication and one had critical ischemia. Manifestations were bilateral in 26 cases and unilateral in 5. The lesion was confined to the lower aorta in 3 patients and extended to the common iliac arteries in 19, with predominant proximal lesions of the common iliac artery occurring in 9 patients. Fourteen patients had concurrent infracrural occlusive lesions. All patients underwent exclusive endovascular treatment without any associated open surgical procedure. The three patients with isolated aortic lesions were treated by angioplasty, followed by stent placement in two cases. The 19 patients with aortobiiliac lesions were treated by bilateral common iliac artery angioplasty according to the "kissing-balloon" technique; 7 of these patients also underwent aortic angioplasty. In these 19 patients, aortic stenting was performed in 3 cases and bilateral iliac stenting in 10 cases, including 3 in association with aortic stenting. The nine patients with a proximal lesion of the common iliac arteries were treated by angioplasty, followed by bilateral stenting in three cases and unilateral stenting in three cases. The findings of this study show that the mid-term anatomical and functional results of endovascular treatment for atherosclerotic lesions of the distal aorta are satisfactory. We recommend it as the initial treatment modality.

Results of lower limb revascularization from the descending thoracic aorta.

The aim of this retrospective study was to substantiate our results of lower limb revascularizations from the descending thoracic aorta. From November 1984 to November 1994, we used bypass grafting from the descending thoracic aorta to revascularize 69 lower limbs in 36 patients, 34 men and 2 women, whose mean age was 61.8 years. Patients were divided into two groups. Group I (primary indications) included 10 patients who had not had any prior lower limb arterial reconstruction. Group II (secondary indications) consisted of 26 patients who had had a prior arterial reconstruction that was either occluded or complicated. There were three early graft occlusions, all of them successfully treated. Complete flaccid, paraplegia occurred in one patient. Five patients presented with one or several late graft occlusions. Two patients had to undergo below-knee amputation, bilateral in one patient. Routine late control of the repair was performed by CT scanning, at a mean interval of 50.8 months. The good results recorded for bypasses revascularizing lower limbs from the descending thoracic aorta make this technique a satisfactory alternative when the abdominal aorta cannot be used.

Long-term results of arterial allograft below-knee bypass grafts for limb salvage: a retrospective multicenter study.

PURPOSE: Arterial allografts (AAs) have been recently reconsidered in the treatment of critical limb ischemia when vein material is absent, because of the disappointing results with artificial grafts. The aim of this study was to report the results observed in three centers where AAs were used for infrainguinal reconstruction in limb-threatening ischemia. METHODS: Between 1991 and 1997, 165 AA bypass procedures were performed in 148 patients (male, 90) with a mean age of 70 years (range, 20-93 years). Indications for operation were rest pain in 54 cases and tissue loss in 111 cases. Mean resting ankle pressure was 53 mm Hg in 96 patients who did not have diabetes and mean transcutaneous pressure of oxygen was 10 mm Hg in 52 patients who did have diabetes. In 123 cases (75%), there was at least one previous revascularization on the same limb. AAs were obtained from cadaveric donors. The distal anastomosis was to the below-knee popliteal artery in 34 cases, to a tibial artery in 114 cases, and to a pedal artery in 17 cases. RESULTS: At 30 days, the mortality rate was 3.4%; the primary patency rate was 83.3%; the secondary patency rate was 90%; and the limb salvage rate was 98%. During follow-up (mean, 31 months), 65 grafts failed primarily. Causes of primary failure were thought to be progression of the distal disease in 15 cases, myointimal hyperplasia in 16 cases, graft degradation in 10 cases (four dilations, three stenoses, two ruptures, and one dissection), miscellaneous in eight cases, and not known in 16 cases. Primary patency rates at 1, 3, and 5 years were, respectively, 48.7% +/- 4%, 34.9% +/- 6%, and 16.1% +/- 7%. Secondary patency rates at 1, 3, and 5 years were, respectively, 59. 8% +/- 4%, 42.1% +/- 5%, and 25.9% +/- 8%. Limb salvage rates at 1, 3, and 5 years were, respectively, 83.8% +/- 3%, 76.4% +/- 5%, and 74.2 % +/- 8%. CONCLUSION: AA leads to an acceptable limb salvage rate but poor patency rates. A randomized trial that will compare AAs and polytetrafluoroethylene should be undertaken.

Surgical treatment of extracranial internal carotid artery aneurysms.

PURPOSE: Extracranial internal carotid artery aneurysms (EICAs) can be treated by carotid ligation or surgical reconstruction. In the consideration of the risk of stroke after internal carotid artery (ICA) occlusion, the aim of this study was to report the results of reconstructive surgery for these aneurysms, including lesions located at the base of the skull. METHODS: From 1980 to 1997, 25 ICA reconstructions were performed for EICA: 22 male patients and 3 female patients (mean age, 54.4 years). The cause was atherosclerosis (n = nine patients), dysplasia (n = 12 patients), trauma (n = three patients), and undetermined (n = one patient). The symptoms were focal in 15 cases (12 hemispheric, three ocular), nonfocal in three cases (trouble with balance and visual blurring), and glossopharyngeal nerve compression in one case. Six cases were asymptomatic, including three cases that were diagnosed during surveillance after ICA dissection. In nine cases, the upper limit of the EICA reached the base of the skull. A combined approach with an ear, nose, and throat surgeon allowed exposure and control of the ICA. RESULTS: After operation, there were no deaths, one temporary stroke, two transient ischemic attacks, and 11 cranial nerve palsies (one with sequelae). The ICA was patent on the postoperative angiogram in all but one case. During follow-up (mean, 66 months), there were two deaths (myocardial infarction), one occurrence of focal epileptic seizure at 2 months, and one transient ischemic attack at 2 years. In December 1998, duplex scanning showed patency of the reconstructed ICA in all but one surviving patient. CONCLUSION: Surgical reconstruction is a satisfactory therapeutic choice for EICA, even when located at the base of the skull.

Surgery for asymptomatic carotid stenosis: a study of three patient subgroups.

The purpose of this retrospective study was to determine whether patients who undergo prophylactic surgery for asymptomatic carotid stenosis represent a single homogeneous population. Of the 805 carotid reconstructions performed between January 1984 and December 1992, a total of 357 were for asymptomatic atherosclerotic stenosis in 312 patients (227 men, 85 women) with a mean age of 69.6 years. Patients were divided into three groups. Group I included 141 patients (161 procedures) who presented no neurologic manifestations. Group II included 49 patients (55 procedures) who underwent carotid reconstruction before or at the same time as another cardiovascular procedure. Group III included 122 patients (141 procedures) who presented nonhemispheric manifestations. Patients in group III had a significantly higher number of obstructive lesions in brain arteries (p < 0.01). Seven patients died within the first 30 postoperative days, including three who underwent combined single-stage procedures. Nine patients presented nonfatal stroke, including three who progressively recovered. The cumulative death-stroke rate (CDSR) was 5.12% overall, 3.54% in group I, 12.24% in group II, and 4.09% in group III. The difference between groups I and II was statistically significant (p < 0.05). Taking into account only deaths related to carotid surgery and stroke with permanent disability, the CDSR was 2. 83% in group I and 3.25% in group III. Follow-up ranged from 24 to 132 months (mean: 66.2) with a total of 11 patients being lost from follow-up. Actuarial 5-year survival was 81.99 +/- 7.13% in group I, 70.65 +/- 13.72% in group II, and 68.51 +/- 8.93% in group III. Differences between group I and both groups II (p < 0.01) and III (p < 0.05) were statistically significant. Overall 5-year patency was 95.59 +/- 2.28%. Stroke occurred during follow-up in 13 patients. The probability of stroke-free survival was 95.29 +/- 3.76% in group I, 91.03 +/- 8.52% in group II, and 89.09 +/- 6.39% in group III. The difference between groups I and III was statistically significant (p < 0.05). Patients with asymptomatic carotid lesions can be divided into different prognostic groups. Life expectancy is shorter for patients with multiple artery disease. Long-term stroke risk is higher in patients with nonhemispheric neurological manifestations.

Surgical management of Candida suppurative thrombophlebitis of superior vena cava after central venous catheterization.

Septic deep venous thrombosis is a major complication associated with central venous catheterization in intensive care units. The most common causative organisms are Staphylococcus aureus, gram-negative bacilli and Candida species. The incidence of Candida infections is increasing, especially in intensive care patients receiving total parenteral nutrition and long-term broad-spectrum antibiotics. Although intravascular catheter-induced septic thrombophlebitis is quite common, superior vena cava obstruction is a rare complication. However, few data exist concerning the best strategy for managing septic thrombophlebitis, especially when medical therapy fails. We report successful surgical management of Candida albicans suppurative thrombosis of the superior vena cava in a young patient.

Saphenous vein bypass: an alternative to internal carotid reconstruction.

OBJECTIVE: Venous grafting is rarely employed for carotid reconstruction; the aim of this retrospective study was to assess its value as an alternative to endarterectomy. MATERIAL: Between January 1980 and June 1990, we performed 212 carotid artery venous bypasses (CVB) on 208 patients. Twenty-nine patients were asymptomatic, 60 had non-hemispheric symptoms and 119 focal symptoms. The indication for surgery was stenosis in 185 cases, kinking in 18 and aneurysms in nine. The main criteria to use CVB were length of the lesion in 86 cases, extent of atherosclerosis in 75, dysplasia in 12, intraoperative failure of endarterectomy in 21, aneurysms in seven and long-term restenosis or occlusion in 12. RESULTS: There were 11 deaths, three strokes and nine transient ischaemic attacks. Angiographic control showed one occlusion giving an immediate patency rate of 99.5%. Mean follow-up was 104.3 +/- 46.1 months with 15 patients lost to follow-up. Eighty patients died; life expectancy was 52.4 +/- 7.5 at 10 years. Including occlusions and restenosis as failures, the secondary patency rate was 96.4 +/- 3.7 at 10 years. The annual stroke rate was 1.3% and the neurologic event-free-population 87 +/- 2.4% at 10 years. CONCLUSION: CVB is a valuable alternative to endarterectomy for reconstruction of the carotid artery. The indications are extensive atherosclerosis involving the common carotid artery, intraoperative anatomic failure of endarterectomy, and long-term restenosis.