Protection from atherosclerosis in vein grafts by a rigid external support.

Atherosclerosis is a common feature of autogenous vein bypass grafts resulting in their long-term failure. Arterial pressure-induced distension is thought to play a major role in the wall thickening of vein grafts, which may in turn favor atherosclerotic complications. In this study, we evaluated the influence of vein distension on the development of atherosclerotic lesions in jugular vein grafts interposed into the common carotid arteries of rabbits. The proximal half of each vein graft was wrapped with a 4-mm-diameter polytetrafluoroethylene graft that reduced the vein graft diameter by 46 +/- 5%. Fourteen animals were fed a 1% cholesterol-rich diet for 8 weeks, and five animals were fed a normal diet. In normocholesterolemic and hypercholesterolemic animals, the wall thickness and the total cross-sectional area were significantly reduced in wrapped compared with unwrapped segments. Foam cells were never observed in normocholesterolemic animals. In hypercholesterolemic rabbits, the sudanophilic lesions covered 62 +/- 4% of the luminal surface in unwrapped segments and 31 +/- 7% in wrapped segments (p < 0.0001). In transverse sections, the surface areas of foam cells were also markedly reduced in wrapped compared with unwrapped segments. Reduction of the wall distension using a rigid external support protected the vein grafts from atherosclerosis, possibly as a result of the decrease in wall thickening that occurred in response to arterialization.

[Acute aortic dissection during pregnancy. Surgical treatment with maternal and fetal rescue]. / Dissection aortique aiguë pendant la grossesse. Traitement chirurgical avec sauvetage maternel et foetal.

Acute aortic dissection (AD) seldom affects young women, but when it occurs it is, in almost one out of two cases, during pregnancy. We report a case of severe AD during pregnancy in which emergency surgery immediately saved the life of the mother and the foetus. The mother died of cardiac complications 13 days after the operation; the condition of the newborn is satisfactory.

[Atherosclerosis of an arterialized venous graft. Reduction by rigid external support]. / Athérogenèse du greffon veineux artérialisé. Réduction par un manchon externe.

Vein grafts undergo early intimal thickening and accelerated atherosclerosis. To assess the role of increased wall stress and distension in the pathogenic responses, 11 New Zealand white rabbits underwent interposition of an autologous jugular vein graft in the left common carotid artery. To relieve wall stress and reduce distension, the half proximal part of the vein was wrapped with a polytetrafluoroethylene graft (i.d. 4 mm). Animals were fed 1% cholesterol for 8 weeks. Vein graft and carotid artery were perfusion fixed with Karnovsky solution at 100 mmHg. They were stained with Sudan IV, and 5-microns cross sections were stained with hematoxylin-eosin and orcein. The internal diameter was reduced by 46 +/- 10% in wrapped vein graft segments as compared with unwrapped ones. The percentage of luminal surface covered by sudanophilic lesions (%AS) was assessed by automatic planimetry. Results (mean +/- SD) were as follows. [table: see text]. Abundant foam cells were found in the intima of unwrapped veins, whereas they were absent or rare in wrapped segments. We concluded that atherosclerotic lesions could be prevented in vein grafts by reducing wall stress and distension.

[Reduction of atherogenesis in an arterialized venous graft by using an external sleeve]. / Réduction de l'athérogenèse d'un greffon veineux artérialisé par un manchon externe.

The parietal thickening of a vein under hemodynamical conditions in the arterial system can be reduced when supporting the vein with a rigid external sleeve. To assess the role of thickness reduction in atherogenesis of an arterialized vein graft, a 4 mm thick external sleeve was implemented around the proximal half of a carotid-carotid vein graft in 16 New Zealand rabbits. Eleven rabbits were submitted to a hypercholesterolemic diet (HC group), while five others were submitted to a normal cholesterol diet (NC group). After eight weeks, a statistically significant difference in thickness was observed between free and sleeved segments, in the NC group with 105 +/- 9 microns versus 65 +/- 6 microns (p < 10.0001) respectively as well as in the HC group with 180 +/- 37 microns versus 99 +/- 35 microns (p < 10.0001) respectively. Studying the extent of soudanophilic lesions showed a statistically significant difference according to the use or not of an external sleeve where average extent is 68 +/- 17% in free segments versus 31 +/- 26% (p < 10.0001) is sleeved segments. The reduction in vein overfullness using an external constrictive sleeve prevents structural parietal changes in the vein and allows reducing atherogenesis of the arterialized vein graft.

[Aneurysms of the abdominal aorta. Value and mode of detection]. / Les anévrismes de l'aorte abdominale. Intérêt et modalités de leur dépistage.

Despite improvements in the treatment of risk factors for atherosclerosis, the incidence and mortality rate for aneurysms of the abdominal aorta have increased during the past 40 years. The prevalence of these aneurysms is 2.5 percent in unselected populations but reaches 13.5 percent in selected populations. The pathogenesis of aneurysms involves multiple factors and the lesion is progressive, leading to lethal rupture in 25 percent of the cases. In elective surgery of abdominal aortic aneurysms the mortality rate is about 2 percent, as against 60 percent in emergency surgery for rupture. The presence of such aneurysms must be detected primarily in populations at risk, using physical examination and abdominal ultrasonography. If this is done, the ratio of detection costs to benefits of preventive surgery is in favour of a decidedly active approach of this dangerous disease.

[Surgery of gastrointestinal vessels, selective indications for revascularization in a syndrome suggestive of chronic small intestinal ischemia]. / Chirurgie des vaisseaux digestifs, indications électives de revascularisation face à un syndrome évoquant une ischémie chronique de l'intestin grêle.

The authors present a critical review of the indications for revascularization of intestinal arteries in the presence of chronic ischaemia of the small intestine. They stress the extreme lability of the "chronic" clinical stage and emphasize the fundamental importance of establishing the diagnosis before the development of acute complications. Based on a personal experience of 92 intestinal revascularizations with a follow-up of one to 26 years, they stress the good quality of the results obtained after isolated revascularization of the superior mesenteric artery by direct or indirect reimplantation into the infrarenal aorta. However, they do not challenge the current tendency towards multiple revascularizations, but consider that the essential prerequisite for a correct result is the early surgical treatment of a disease which is still poorly understood and frequently disappointing.

[Transluminal angioplasty of the brachiocephalic artery with cerebral protection]. / Angioplastie trans-luminale du tronc artériel brachio-céphalique, sous protection cérébrale.

The authors report one case of percutaneous angioplasty of atherosclerotic symptomatic stenosis of brachiocephalic artery. Angioplasty had been performed using an occlusive balloon in internal carotid artery to realize a cerebral protection. This safer technics allowed to heal the stenosis and the brachiocephalic steal syndrome, without cerebral embolies.

Superior mesenteric artery embolism: eighty-two cases.

Eighty-two consecutive patients with superior mesenteric artery embolism were treated between 1966 and 1988. Abdominal pain was atypical or absent in 19 (23%) patients. Except for two instances of intraoperative embolism, emergency mesenteric arteriography was diagnostic in all cases. Seventeen patients were treated medically either because the site of embolism was peripheral, or because there were no life-threatening signs. Sixty-five patients underwent surgery, 31 for mesenteric infarction, and 34 for acute mesenteric ischemia without intestinal necrosis. Surgical treatment included 34 isolated embolectomies, 20 embolectomies associated with intestinal resection, two short segmental resections for limited necrosis of the small intestine, and nine exploratory laparotomies. Of the 34 patients operated on for acute mesenteric ischemia, 12 (35%) died. Of the 31 remaining patients operated on for intestinal infarction, 21 (68%) (p less than 0.05) died. The mean duration of ischemia before operation was 13 hours 20 +/- 6 min and 21 hours 24 +/- 24 min, respectively (p less than 0.05). Two patients (12%) receiving medical treatment died. This study confirms that survival is directly related to early diagnosis based on emergency mesenteric arteriography. Treatment is determined by clinical and roentgenographic criteria. Medical treatment is indicated in certain circumstances.

Aortic reimplantation of the superior mesenteric artery for atherosclerotic lesions of the visceral arteries: sixty cases.

We report the results of a series of patients who had isolated or associated reimplantation of the superior mesenteric artery directly into the infrarenal aorta. Between 1967 and 1988, a total of 91 revascularizations for atheromatous lesions of the visceral arteries were performed in 89 patients. The superior mesenteric artery was reconstructed in 87 instances, 60 of which were direct or indirect reimplantations into the juxtarenal aorta. The procedure was isolated in 51 cases, and associated with the revascularization of another visceral artery in nine cases. These 60 patients were divided into three groups: Group A--seven patients undergoing emergency operation for acute intestinal ischemia; Group B--30 patients operated upon for chronic intestinal angina; and Group C--22 asymptomatic patients who underwent prophylactic revascularization. Two patients died in the immediate postoperative period (3.5%). Although most of the 29 late deaths were due to vascular disorders, only one was secondary to intestinal infarction. Twenty-one patients followed had good functional results; six patients had relapse of abdominal pain. Three of these underwent repeat revascularization of the superior mesenteric artery 12 days, 18 months, and 22 months, postoperatively. Follow-up ranged from six months to 18 years. Two patients were lost to follow-up. Overall actuarial survival at five years was 69.60 +/- 15%. In our experience, isolated reimplantation of the superior mesenteric artery on the anterior aspect of the infrarenal aorta is a simple and reliable technique which affords good long-term results.

[Paraplegia caused by extradural spinal hematoma after radical pulmonary lobectomy in cancer]. / Paraplégie par hématome extra-dural rachidien après lobectomie pulmonaire élargie pour cancer.

The authors report a case of spinal cord complication after surgery for lung cancer. Amongst the 12 cases published in the literature, only one reports spinal cord ischaemia secondary to a compressive mechanism by spinal extradural haematoma. In the present case, due to an identical mechanism, paraplegia developed as a result of intraoperative meningeal rupture during extension of a pulmonary lobectomy for cancer to the adjacent vertebrae. The diagnosis was established by CT scan combined with emergency myelography. Certain preventative measures are proposed based on analysis of the mechanisms of this complication.

[Ectopic openings of the common bile duct. A contribution to the physiological study of the sphincter of Oddi (author's transl)]. / Les abouchements ectopiques du cholédoque. Contribution à l'étude de la physiologie du sphincter d'Oddi.

Two cases of ectopic openings of the common bile duct are reported. In one case there was a congenital short duct opening into DI, the presence of a spontaneous duodenobiliary reflux due to absence of the papilla being demonstrated by clinical and radiological examinations. The other patient had a long duct opening into D3 and no duodenobiliary reflux, but with an intact sphincter of Oddi explored in detail by means of combined choledochoduodenal manometry. These two cases demonstrate that the duodenal wall has only a moderate effect in preventing duodenobiliary reflux. The essential element is the sphincter of Oddi: if present, there is no reflux, if absent, reflux occurs.