Endarterectomy with "systematized" resection anastomosis of carotid bulb, about 240 cases.

OBJECTIVE: Carotid endarterectomy has traditionally been the strategy for the surgical management of carotid stenosis. Alongside the usual techniques, this study presents another technique: endarterectomy with systematized resection-anastomosis. MATERIAL AND METHODS: A retrospective study from January 2006 to December 2018, included all patients managed for carotid stenosis at Meaux hospital with the "endarterectomy with systematized resection-anastomosis" technique. The perioperative death and stroke rate were evaluated according to the judgment criterion "homolateral ischemic stroke and any stroke or perioperative death". Statistical analysis of the data was performed using SPSS software. RESULTS: For 415 carotids operated, we identified 240 managed with this technique. The average age was 71.7±9.6 years, 70% men and 30% women. The main cardiovascular risk factor was hypertension (76.7%), 24.2% of patients had an ischemic heart disease history, 43.7% homolateral ischemic stroke and 29% transient ischemic attack. Bilateral lesions were diagnosed in 6.2% of patients and 7.5% had contralateral occlusion. Carotid stenosis was symptomatic in 52.9% of patients. The average stenosis rate observed was 82.9±8.1% on computed tomography angiogram and 83.7±7.7% on magnetic resonance angiogram. The shunt was used in 45.4% of procedures. The average length of stay was 5.9±2.3 days. All patients had satisfactory results in terms of patency and anatomical appearance on the 1st check. In the post-operative period during the first month, complications occurred in 12.5% of patients (1.6% acute coronary syndrome, 0.8% neurological event, 0.8% death, 0.4% infection, 12.1% hematoma, 1.6% recovery for bleeding). The overall perioperative death and stroke rate was 2.6%. Myocardial infarction and sepsis were the causes of death for the 2 patients in the peri operative period. The mean duration of follow-up was 21.2 months, without any restenosis or occurrence of neurological complications. One patient died beyond the 1st month of follow-up without established cause, and the overall mortality rate was 1.3%. CONCLUSION: Thromboendarterectomy with "systematized" anastomosis resection represents an angioplasty method for carotid stenosis surgical management under visual control.

Early and mid-term results of total laparoscopic bypass for aortoiliac occlusive lesions.

AIM: The aim of this study was to investigate the early and mid term results of total laparoscopic bypass for aortoiliac occlusive lesions. METHODS: From December 2001 to January 2007, we performed 32 laparoscopic bypasses for aortoiliac lesions. The mean age was 52.9 years. Clinical stages included: severe intermittent claudication (N.=24) ischemic rest pain (N.=5) and tissue loss or gangrene (N.=3). According to the TASC classification, the lesions were type B in three cases, C in nine cases and D in 20 cases. Graft patency was controlled by means of duplex scan before discharge and during the follow-up. The patency rates were calculated using Kaplan-Meier analysis. RESULTS: In 27 out of 32 patients the total laparoscopic bypass was successful (84%). Conversion was necessary in five patients. The mean operative time was 338 minutes (range, 200-620 minutes), the mean aortic clamping time was 73 minutes (range, 35-144 minutes). Mortality was 0%. The postoperative course was uneventful in 19 patients (70%). The mean follow-up was 32.1 months. In this period we had two deaths, one from breast cancer after 12 months. The second patient has committed suicide after 48 months. Two graft occlusions occurred at 3 and 21 months. No other late complications were observed. The primary and secondary graft patency rate was estimated by Kaplan-Meier analysis at 92% and 96% on the first year and 87% and 93% at three years, respectively. CONCLUSION: Early and mid-term results of total laparoscopic bypass are good in selected patients and comparable to these of conventional surgery.

[A modified Gritti-Stokes amputation for vascular indications in the elderly: futility or utility?]. / Amputation de genou dérivée de la technique de Gritti-Stokes pour artériopathie chronique chez le sujet âgé : est-ce faisable et raisonnable ?

AIM: Major lower limb amputation in elderly patients is a dreaded event with high mortality and morbidity. Peripheral arterial disease is the nearly exclusive etiology. The aim of this retrospective study was to assess the feasibility of through-knee amputation, and the morbidity and mortality risk in the elderly (>65 years). PATIENTS AND METHODS: From January 2000 to October 2010, 65 Gritti-Stokes through-knee amputations were performed in 58 patients (30 women, 28 men; mean age 79 years). Acute limb ischemia was the most common cause (40%). The others indications were: severe peripheral arterial disease with extensive necrotic lesions (19%), diabetic foot ulcers (15%), non-healing below-knee amputation (10%) and vascular graft infection after prosthetic lower extremity bypass surgery (6%). RESULTS: Overall 30-day mortality was 24% (n=14/58). Vascular morbidity was 9% (n=6/65). The mean hospital stay was 31 days (range 3 to 96). The overall healing rate was 78% (n=51/65). Conversion to above-knee amputation for failed Gritti-Stokes amputation was performed in one patient. CONCLUSION: Gritti-Stokes amputation is feasible in the elderly with an acceptable one-month mortality and a satisfactory overall healing rate. Most amputations are necessitated by complications of acute limb ischemia. For this subpopulation, Gritti-Stokes amputation should be the standard amputation level. The data collected in this study provide important information that can be useful before amputation for this population, their families and primary care physicians. Ambulation is an important postoperative goal and a multidisciplinary approach in specialized centers is required to achieve good wound healing rates.

Curative treatment of pelvic arteriovenous malformation--an alternative strategy: transvenous intra-operative embolisation.

OBJECTIVES: Pelvic arteriovenous malformations (AVMs) are difficult to treat. Arterial embolisation is the most common strategy but often has poor results. We report an alternative surgical approach of controlled intra-operative transvenous embolisation with long-term results in seven cases. MATERIALS AND METHODS: Between 1980 and 2008, we treated seven patients (four men, three women, mean age 50 years). Indications were rectal bleeding (one case), urinary tract problems (four cases), oedema of lower limb (one case) and high-output cardiac failure (one case). Four of them had previous operations and three had previous attempts for embolisation. Embolisation of the malformation was performed through the internal iliac vein. This was done after clamping of all the feeding and draining vessels. The agent used was cyanocrylate (one case), Ethibloc (one case) and bone wax (five cases). RESULTS: Mortality was 0%. Complications occurred in two patients (28,5%), one pulmonary embolism and one regressive femoral paresis. Three patients were re-operated for various reasons. The mean follow-up period was 6 years (1-12 years). Symptoms resolved in all patients, while control by computed tomography (CT) angioscan revealed one residual shunt. CONCLUSION: Complete surgical excision of pelvic AVMs is not always possible. Embolisation does not offer a permanent cure. Intra-operative transvenous embolisation of persisting complex AVMs appears to be an alternative approach with good immediate and long-term results. Ethylene glycol appears to be the most suitable agent.

[Radiation arteritis- and radiodermitis-induced leg ulcer: surgical revascularization]. / Un ulcère de jambe par artérite radique et radio-dermite. Revascularisation chirurgicale.

A forty-four-year old man was hospitalized for diagnosis and treatment of a left leg ulcer which did not heal despite good compliance with a three-month medical regimen. Twenty years before he had undergone surgical curettage and radiotherapy (81 gy) for an osteosarcoma of the upper third of the left tibia. He was considered completely cured with regular findings. On examination he had a 5 X 7 cm deep ulcer with raised margins and no signs of infection, localized on the radiodermatitis on the medial aspect of his left leg. Arterial examination confirmed the left arteriopathy with absence of distal pulses; the Ankle Brachial Pressure Index was 0.69 and the foot TcPO2 27 mmHg. Arteriography confirmed the localized left lesions with three distal popliteal and proximal arterial occlusions, all other arteries being strictly normal. Arterial and dermatological radiation leg ulcer was retained as the etiological diagnosis. As the ulcer was very painful, extensive and limited walking distance, surgical revascularisation was undertaken because endoluminal revascularization was impossible. A femoroperoneal saphenous bypass was performed with surgical incisions beyond the radiodermatitis area. Two months after a split skin graft, the ulcer was considered healed and the patency of the by-pass confirmed on duplex examination. This is the first case report of a successful distal by-pass performed for radiation arteritis and ulcer healing. Long-term follow up should be reported.

[Late occlusion of the subclavian artery proximal to mammary bypass]. / Occlusion tardive de l'artère sous-clavière en amont d'un pontage mammaire. 2 observations.

We report the cases of two patients with an occlusion of the left subclavian artery several years after left internal mammary bypass of the anterior interventricular artery. The effect on the myocardium was only apparent after scintigraphy in one case, and was clinical in the second with angina pain on exertion of the upper limb. Re-implantation of the subclavian artery in the common carotid relieved the signs of myocardial ischaemia. While the internal mammary artery is the conduit of choice for coronary revascularisation because it is not affected by atheromatous lesions, this does apply to the proximal subclavian artery. Stenosis or occlusion here can entail ischaemia in the revascularised myocardial territory. Regular clinical and ultrasound surveillance can detect these lesions.

[Critical ischemia of the leg. A technique for distal anastomosis in a a small caliber artery]. / Ischémie critique des membres inférieurs. Un artifice pour anastomose distale sur artère de petit calibre.

CRITICAL ISCHEMIA OF THE LOWER LIMBS: This type of lesion, which spontaneously progresses to gangrene and amputation, is encountered more and more frequently. Emergency endoluminal revascularization or bypass surgery is required. When conventional endoluminal techniques cannot be used, a distal graft using the autologous saphenous vein is a promising alternative to achieve patent vascularization and salvage the limb. IF VENOUS MATERIAL IS NOT AVAILABLE: Usable venous material is not always available due to varicosities, thrombus formation, small size or previous surgery (stripping, coronary surgery, prior revascularization procedure); rates reported range from 20 to 40%. For such patients, other veins (external saphenous, arm veins, superficial femoral veins) may be useful but are not always appropriate for distal repair. Different prostheses might also be used but again do not always provide improved permeability. Most teams however use a polytetrafluoroethylene stent for revascularization of the distal leg. Different technical improvements favor success of prosthetic bypasses, but when used below the knee, flow remains less satisfactory than with venous bypasses. VEIN CUFFS: This procedure is a common adjuvant technique positioning a venous cuff between the recipient artery and the prosthesis. The cuff avoids the direct contact between the prosthesis and the fragile artery that is often difficult to suture. RESULTS: Several series have demonstrated that the rate of success of vein cuff procedures remains lower than venous bypass procedures, but also that flow is better than with simple femorotibial prostheses. PATHOGENIC HYPOTHESES: The reduction of the neo-intimal hyperplasia observed in experimental models is insufficient to explain entirely the observed in vivo benefit. The fact that the suture is easier to make is one possible reason. Indeed the rate of failure of simple prosthetic bypass surgery is high in the immediate postoperative period. These cases of thrombosis result from technical insufficiencies and are undoubtedly overcome by the use of the venous cuff.

[Blunt force rupture of the thoracic aorta and diaphragm: an unusual association]. / Rupture de l'isthme aortique et de la coupole diaphragmatique droite: une association inhabituelle.

The aim of this study was to report two cases of rupture of the right hemidiaphragm with intra-thoracic liver hernia, associated with a traumatic aortic disruption. These two lesions followed traffic accidents, and were both treated separately. Both patients had a long-term favourable progression. Association of these two lesions is particularly rare: fewer than 50 cases have been previously described in an extensive review of the literature. CT-scan seems to be particularly efficient in diagnosis, even if less efficient than other more specific explorations. The order of surgical management is guided by the physical examination, and especially by abdominal emergency.

Aneurysms of the internal iliac artery: management strategy.

With the widespread use of CT scans, detection and treatment of internal iliac artery aneurysms (IIA) have become more frequent. In the last few years, endovascular repair has been added to the therapeutic arsenal. We reviewed the records of 38 patients treated for 44 IIA between 1987 and 1997 to assess immediate and long-term outcome using various therapeutic methods. Aneurysms were divided into three groups according to the circumstances of treatment. Group I included 25 IIA treated at the same time as abdominal aortic aneurysm (AAA). The morbidity/mortality rate in this group was comparable to that in patients who underwent isolated AAA repair. Group II included 14 IIA treated during follow-up of AAA repair. Most complications in this group were intraoperative. Group III included five isolated IIA not associated with AAA repair. Complications were similar to those in group I. On the basis of this retrospective analysis, we propose a management strategy in which open surgery, endovascular repair, or both are used, depending on the circumstances of treatment.

[Atherosclerotic lesions of the subclavian artery. Indications for subclavian carotid transposition]. / Lésions athéroscléreuses de l'artère sous-clavière. Place de la transposition sous-clavière carotide.

PURPOSE: To analyze the clinical and anatomical outcome after subclavian carotid transposition and to compare the results with other surgical procedures. METHODS: The hospital records of 51 patients undergoing subclavian carotid transposition were reviewed retrospectively for preoperative symptoms, Doppler and arteriography findings, preoperative details and postoperative complications. Long-term patency and symptoms were determined by physical and Doppler examination during the follow-up. RESULTS: The indications for subclavian transposition were: vertebrobasilar ischemia (24%), ischemia of the upper limb (45%), asymptomatic occlusion or non-specific symptoms (31%). Subclavian artery transposition was associated with vertebral revascularization (7 cases), and homolateral carotid surgery (11 cases). There were no deaths. Early occlusions occurred in two cases, one required reoperation. Minor complications were observed in 21% of the patients with no permanent morbidity. Overall patency after a mean 54 months follow-up was 96%. CONCLUSION: Subclavian carotid transposition is a good method for the treatment of proximal subclavian occlusive disease. Long-term patency can be achieved. Carotido-subclavian bypass should be limited to cases with extensive occlusive lesions as patency rate is lower.

Inadvertent arterial injury during saphenous vein stripping: three cases and therapeutic strategies.

We report 3 cases of iatrogenic arterial injuries in relation to saphenous vein stripping. In 2 cases the patients sustained acute severe ischemia and required prompt revascularization. The third patient was seen at a later stage with chronic ischemia and claudication. All 3 patients had their limbs salvaged without severe sequelae. The therapeutic strategies for different situations are discussed.

Infrapopliteal polytetrafluoroethylene and composite bypass: factors influencing patency.

Between January 1, 1979, and December 31, 1988, 149 infrapopliteal polytetrafluoroethylene (PTFE) bypasses were performed in 145 patients with chronic, critical, limb-threatening ischemia. These operations represented 27.9% of 534 infrapopliteal bypasses performed during the same period. There were 92 males and 53 females. Mean age was 71.8 +/- 12.3 years. Signs and symptoms of critical ischemia were gangrene, ulceration, and isolated rest pain in 101 (69%), 23 (15.3%), and 25 (16.7%) cases, respectively. A composite (PTFE-saphenous vein) graft was used in 53 (35%) cases. In 96 prosthetic bypasses the distal anastomosis was performed using vein patch angioplasty in 65 (44%) cases and directly in 31 (21%). The in-hospital mortality rate was 3.3%. Patency, limb salvage, and patient survival rates were plotted according to the actuarial method and the curves obtained were compared using the log-rank test. Actuarial survival rates were 68% +/- 5% and 57% +/- 7% at 3 and 5 years, respectively. Primary patency and lower limb salvage rates were 41% +/- 5% and 68% +/- 6% at 3 years and 35% +/- 9% and 65% +/- 10% at 5 years, respectively. There was no statistically significant difference noted in primary patency rates at 3 years according to the type of bypass (composite or all-prosthetic: 36% vs. 44%), the type of distal anastomosis (direct or vein patch angioplasty: 43% vs. 45%), the site of distal anastomosis (upper or lower half of the leg: 38% vs. 46%), lateral or medial placement of the bypass (39% vs. 43%), or according to whether or not it was a repeat operation (40% vs. 44%). In conclusion, patency rates using infrapopliteal PTFE bypasses are low. Certain technical approaches, although they do not seem to improve patency, definitely increase the feasibility of bypass and in our opinion decrease the risk of early failure in unfavorable anatomic settings. The limb salvage rates following infrapopliteal PTFE and composite bypass are encouraging and justify the use of routine distal revascularization, even in the absence of autogenous vein graft.

[Revascularization of distal arteriopathies: a new approach]. / Revascularisation des artériopathies distales: une nouvelle approche.

The diffuse nature of arterial occlusions in Buerger's disease compromises the effect of revascularization. Nevertheless, the muscle branches are quite often unaffected by the occlusive disease making revascularization of collateral arterial branches a promising alternative to conventional procedures. Revascularization by a short autologous venous graft from the grand anastomotic or gastrocnemius artery can be an alternative technique. Advances in microsurgery have made such revascularizations possible.

Low-molecular-weight heparin vs. unfractionated heparin in femorodistal reconstructive surgery: a multicenter open randomized study. Enoxart Study Group.

Several clinical trials have been conducted to study the role of low-molecular-weight heparin (LMWH) in the prevention and treatment of venous thrombosis. In contrast, there have been few studies investigating LMWH in the prophylaxis in arterial thrombosis. After informed consent and institutional approval were obtained, 201 consecutive patients scheduled for femorodistal reconstructive surgery under general anesthesia were enrolled in an open randomized multicenter (n = 14) study (from November 1990 to November 1992). Immediately before arterial cross-clamping, patients were given an intravenous bolus of either enoxaparin (ENX), 75 anti-Xa IU/kg (n = 100), or unfractionated heparin (UFH), 50 IU kg (n = 101). Meanwhile the saphenous vein or a prosthetic graft was flushed with ENX (25,000 anti-Xa IU) or UFH (25,000 IU) in 250 ml of saline solution. Subsequent treatment consisted of subcutaneous administration of ENX, 75 anti-Xa IU/kg, or UFH, 150 IU kg, beginning 8 hours after the intravenous injection and then every 12 hours thereafter for 10 days. The primary end point was graft patency on day 10 +/- 2 after surgery as assessed clinically and/or by arteriography on day 10 +/- 2 and/or during reintervention or autopsy. Analysis of patients on an intention-to-treat basis (patients who received at least on injection of ENX or UFH and who had at least one end-point evaluation) showed that graft thrombosis occurred in 30 of 199 cases: eight (8%) in the ENX group and 22 (22%) in the UFH group (p = 0.009). Among the 131 patients who were evaluated by arteriography before day 12, twelve (9.1%) had graft thrombosis: four (6%) in the ENX group and eight (12.5%) in the UFH group (NS). There were no significant differences between the two groups in terms of safety--that is, there were 12 major hemorrhages in each group, and during the follow-up period five patients in the ENX group died compared to nine in the UFH group (NS). These results indicate that ENX is as safe as but more effective than UFH when used for the prevention of early graft thrombosis in patients undergoing femorodistal reconstructive surgery.

[Atypical coarctation of the thoracic aorta caused by fibromuscular dysplasia]. / Coarctation atypique de l'aorte thoracique par dysplasie fibromusculaire.

Fibromuscular dysplasia is a non-inflammatory disease unrelated to atherosclerosis of the small and medium sized arterial walls, which often affects the renal and carotid arteries and occurs mainly in women. The authors report a case of atypical coarctation of the thoracic aorta due to fibromuscular dysplasia confirmed histologically in a 27 year old man. Arteriography was performed because of hypertension and asymmetry of blood pressure measurements and showed irregular stenosis of the aortic isthmus and of the origin of the left subclavian artery. Surgery comprised resection of the pathological segment of the aorta which was replaced by a prosthetic tube with reimplantation of the left subclavian artery. Histological examination showed fibromuscular dysplasia in perimedial areas and diffusely throughout the media. To the author's knowledge this is the first case to be reported in the medical literature.

[Rare forms of chronic venous insufficiency of the lower limbs]. / Formes rares d'insuffisance veineuse chronique des membres inférieurs.

Ultrasound examination, digital phlebography, and CT scan have facilitated the diagnosis of unusual forms of chronic venous insufficiency. Congenital anomalies of the deep venous system and vascular malformations are the most common forms. The lesions are more frequent in the deep venous system of the lower limbs than in the vena cava or the iliac veins. Agenesia and traumatic lesions of the inferior vena cava are rare. Occlusion of the iliac veins is often diagnosed during late childhood; they are secondary to the traumatic catheterization of the femoral vein. Valvular incompetence and vascular malformations are localized to the lower limbs. Surgery has some indications. Reconstructive techniques are used for the iliac vein or the inferior vena cava. In the lower limb, valvuloplasty of the femoral vein is proposed only after conservative therapy has failed.

Infected infrarenal aortic aneurysms: when is in situ reconstruction safe?

Twenty-five infected infrarenal aortic aneurysms operated on between 1968 and 1989 were reviewed. They were classified into post-embolic (mycotic) aneurysms (group I), infective aortitis (group II), and infected atherosclerotic aneurysms (group III). Aortoduodenal fistulas were found in eight patients and aortocaval in two. Five patients were operated on in a state of shock, and 12 had preoperative positive blood cultures. Surgical procedures included in situ reconstruction of the aorta (n = 21) and extra-anatomic bypass associated with aneurysmal resection (n = 4). In 19 patients, prostheses were covered with omental flaps, and antibiotics were continued for more than 6 weeks in all patients. In patients who underwent in situ reconstruction, three deaths were related to the initial surgery. All surviving patients were regularly followed up, and none showed any sign of late septic recurrence. In patients who underwent extra-anatomic bypass, two died in the postoperative period, one underwent reoperation 2 years after the initial surgery, and the last patient is doing well. Positive postoperative blood cultures (n = 4) revealed persistent sepsis: two cholecystitis, one spondylitis, and one aortic infection. An exhaustive review of the literature was performed; clinical, bacteriologic, and operative features and results were analyzed; prognostic factors were evaluated; and a practical therapeutic approach was suggested. The importance of preoperative diagnosis, complete resection, debridement of infected tissues, omental flap coverage, and long-term antibiotic therapy with regular computerized tomographic scanning follow-up is stressed.

Long-term follow-up of positive cultures in 500 abdominal aortic aneurysms.

Routine aneurysm culture is frequently performed as it is thought that a positive culture could be a risk factor for secondary graft infection. Five hundred aneurysms, in a series of 796 patients, had microbiologic examination of the thrombus and/or aneurysm wall. Cultures were positive in 185 cases (37%), mostly due to normal skin flora microorganisms (80%), whereas 16 patients (3.2%) had infectious aortitis. Gram-stained smears were positive in nine of these 16 patients compared with two of the other 169. Of the 185 patients with positive culture, after a mean length of follow-up of 35 months, only one had a graft infection that occurred 6 years later and was not due to the same microorganism. Graft sepsis was diagnosed in six of the 296 patients who did not have a positive culture, and was related to clinically obvious locoregional or systemic foci. In this series, positive cultures from aneurysm without rupture or signs of infection were not a risk factor for secondary graft sepsis. Therefore, in cases of asymptomatic unruptured aneurysm, routine culturing is not necessary as a positive result has no pathogenic significance or therapeutic implication.

Lower-limb revascularization from the supracoeliac aorta through a transcrural approach.

From October 1978 to December 1989, 51 patients underwent lower-limb revascularization from the supracoeliac aorta through a transcrural approach. Symptoms were related to lower-limb ischaemia in all patients: 20 had critical ischaemia (three with severe acute ischaemia) and 31 claudication. One patient had renal failure with hypertension and stenosis of the renal arteries associated with an infrarenal aneurysm induced by Takayasu's disease. Indications for exposure of the supracoeliac aorta were Takayasu's disease in two patients and atheroma in 34 (implantation of the graft on the supracoeliac aorta because of the status of the aortic wall (calcification, inflammation) in 25 and because antegrade revascularization of the visceral arteries was required in nine). In 15 patients repeat aortic surgery was performed; four of these had undergone three previous aortic approaches. The postoperative mortality rate at 30 days was 2%. There were four (8%) acute postoperative graft occlusions and four late occlusions, which occurred between 13 months and 6 years. Life-table analysis showed a 5-year primary patency rate(s.d.) of 83(10)% and a 5-year secondary patency rate(s.d.) of 88(8)%. There are few indications for the transcrural approach to the supracoeliac aorta. Nevertheless, this technique can prove useful in selected cases, for example in those with a calcified aorta, for repeat aortic surgery and for aortic thrombosis near the renal arteries. It is also useful when combined revascularization of the lower limb and right renal or hepatic artery is being considered.