Infrapopliteal arterial recanalization: A true advance for limb salvage in diabetics.

The world is facing an epidemic of diabetes; consequently in the next years, critical limb ischemia (CLI) due to diabetic arterial disease, characterized by multiple and long occlusions of below-the-knee (BTK) vessels, will become a major issue for vascular operators. Revascularization is a key therapy in these patients as restoring adequate blood supply to the wound is essential for healing, thus avoiding major amputations. Endoluminal therapy for BTK arteries is now a key part of the vascular specialist armamentarium. Tibial artery endovascular approaches have been shown to achieve high limb salvage rates with low morbidity and mortality and endovascular interventions one should now consider to be the first line treatment in the majority of CLI patients, especially in those with associated medical comorbidities. To do so, the vascular specialist requires detailed knowledge of the BTK endovascular techniques and devices. The first step decision in tibial endovascular therapy is access. In this context, the anterograde ipsilateral approach is generally preferred. The next critical decision is the choice of the vessel(s) to be approached in order to achieve successful limb salvage. Obtaining pulsatile flow to the correct portion of the foot is the paramount for ulcer healing. As such, a good understanding of the current angiosome model should enhance clinical results. The devices used should be carefully selected and optimal choice of guide wire is also extremely important and should be based on the characteristics of the lesion (location, length, and stenosis/occlusion) together with the characteristics of the guide wire itself (tip load, stiffness, hydrophilic/hydrophobic coating, flexibility, torque transmission, trackability, and pushability). Passing through chronic total occlusions can be quite challenging. The vascular interventional radiologist needs therefore to master the techniques that have been recently described: anterograde approaches, including the drilling technique, the penetrating technique, the subintimal technique and the parallel technique; subintimal arterial flossing with anterograde-retrograde procedures (Safari); the pedal-plantar loop technique and revascularization through collateral fibular artery vessels.

Acute deep vein thrombosis and endovascular techniques: It is time for a new aggiornamento!

The stated aims of treating acute deep vein thrombosis (DVT) are to prevent a pulmonary embolism, stop the clot from spreading, reduce the risk of a recurrence; they are less concerned with the late morbidity associated with post-thrombotic syndrome (PTS). In accordance with the French (Afssaps, 2009) and North American (ACCP, 2008) recommendations, anticoagulants (LMWH, heparin, AVK) form the cornerstone for treating DVT. These treatments appear to be far less effective in preventing post-thrombotic syndrome (PTS), associated with venous hypertension, residual occlusion, and with reflux caused by valve incompetence. Given that, the new aim is to optimise the prevention of PTS, the ACCP guidelines, unlike those of Afssaps, "suggest" for selected patients suffering from acute iliofemoral DVT, the use of both classic anticoagulants, and in situ percutaneous administration of thrombolytic drugs (recommendation grade 2B) and simultaneous correction of any underlying anatomical anomalies using angioplasty and stenting (recommendation 2C). Contemporary endovascular methods, referred to collectively as "facilitated" thrombolysis, combine low doses of rtPa or Urokinase administered locally, and the removal of the clot using various mechanical, rotating, rheolytic systems, or using ultrasound. The results of non-randomised, heterogeneous studies objectivised a lysis rate of 80%, a 50% lower risk of haemorrhage complications compared with systemic thrombolysis (<4%), and a clear reduction in treatment time (one-shot methods possible for procedures lasting less than 2 hours). This data ties in with the modern "open vein" concept which underpins the hope of an improvement in the late prognosis of acute DVT, through the removal of a clot, thereby improving permeability and valve integrity; this hypothesis is supported by the results at 24 months of a randomised CaVent objectifying absolute risk reduction of 15% in the thrombolysis in situ. The current randomised study (ATTRACT trial) comparing the combination of "facilitated thrombolysis" in addition to the usual treatment with the traditional treatment alone for acute iliofemoral DVT, the statistical power of which has been established (600 patients) to authenticate a reduction by a third in the number of PTS (CaVent trial, showing a 15% reduction rate of 24 months PTS in the thrombolysed group results expected in 2016), might, if the results are positive, lead to a profound change in the paradigms for the treatment of acute iliofemoral DVT.

[Pelvi-perineal venous insufficiency and varicose veins of the lower limbs: duplex Doppler diagnosis and endoluminal treatment in thirty females]. / Insuffisance veineuse pelvipérinéale et varices des membres inférieurs. Diagnostic par écho-doppler et traitement endoluminal chez trente patientes.

Pelvic congestion is the most commonly recognized consequence of pelvi-perineal venous insufficiency (PPVI). The implication of PPVI in the generation of varicoceles and varicose veins of the lower limbs arising from perineal varices has not been studied specifically. We report our duplex-Doppler findings in a series of 150 women seen over a period of 36 months. All patients presented perineal varices and, more specifically, utero-ovarian venous reflux. Thirty women were retained for phlebography then treatment by embolization. All of the left utero-ovarian veins were incontinent, the right utero-ovarian vein could not be explored in one patient, and only three of the eight opacified veins were incontinent. Twenty-two patients presented an associated incontinence of the hypogastric branch (7 left, 15 bilateral). Embolization was performed on 29 left utero-ovarian veins and one right vein with, as complementary treatment, embolization of 15 hypogastric branches, six during a second session. There were no serious complications. At six months (range 2-20 months), no improvement was noted in 10% of the patients, symptoms had improved or the varices had diminished in 59%, and all symptoms had disappeared in 31%. A duplex-Doppler exploration should be performed to search for perineal involvement in all patients presenting varicose veins of the lower limbs. The good preliminary results obtained after embolization of the pelvic veins, and particularly the left utero-ovarian vein, suggests this therapeutic approach should be pursued. The long-term effect should be assessed because of the plexiform nature of recurrent venous disorders.

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

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

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

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

[Measurement of oxygen tension in normal and varicose vein walls]. / Mesure de la pression en oxygène dans la paroides veines normales et variqueuses.

Oxygen tension (PO2) was investigated in vivo in the long saphenous vein from 21 varicose patients (31 veins) during venous surgery and 7 patients with normal venous network undergoing popliteo-femoral by-pass. Measurement was achieved using computerized polarographic system Kimoc 6650 (Eppendorf, Hamburg) providing a microdriven stepwise progression of a needle probe. Oxygen tension profile was similar in both groups of patients. A slow PO2 decrease was observed from adventitia up to the union of the middle and inner thirds of the media where values were at the lowest then followed by a marked increased in the intima and the saphenous lumen. Oxygenation of the two external thirds of the venous wall was provided by vasa vasorum. The average minimum values in the media was significantly reduced in varicose veins compared to no-varicose veins (7,9 mmHg versus 13,4 mmHg; p < 0,05). These results indicated the key role of vasa vasorum flux in the long saphenous vein nutrition and suggest a primary or secondary deficiency in oxygen supply in varicose veins.

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

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

Aortic false aneurysms after prosthetic reconstruction of the infrarenal aorta.

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

[Jejunal perforation by cholesterol embolus: a case treated surgically]. / Perforation jéjunale par embolie de cholestérol: à propos d'un cas traité chirurgicalement.

A case of ischaemic jejunal perforation which could be attributed to mesenteric cholesterol emboli is reported. The jejunal pathology had been preceded by other, more classical sites of systemic cholesterol embolization that occurred immediately after arterial catheterization in this male patient with aneurysm of the abdominal aorta. Emergency segmental resection of the jejunum was performed with satisfactory immediate results. Histological examination of the operative specimen confirmed that the perforation was caused by cholesterol emboli. Cholesterol embolization of the intestine may have various clinical consequences which are reviewed by the authors.