[Compressive therapy after varicose vein surgery: results of a French national inquiry]. / Résultats d'une enquête sur les techniques compressives et contensives utilisées dans le traitement chirurgical des varices.

OBJECTIVES: A survey on postoperative compression after varicose vein surgery was undertaken in 2001 among surgeons of the French-speaking Vascular Surgery Society as well as non-members with a heavy caseload in varicose vein surgery. The aims of the study were to 1) identify the various medical devices and protocols used postoperatively, 2) estimate the frequency and duration of use, and 3) identify the surgeon's rationale for prescribing postoperative compression. The first part of the inquiry was devoted to surgical procedures and has been previously published (J Mal Vasc 2003; 28: 277-86). MATERIAL AND METHODS: A questionnaire with 11 items for postoperative treatments and a patient form was mailed to 675 surgeons. RESULTS: The response rate was 41.5% (280 surgeons). Results were assessed by a scientific committee. Surgeons were classified into different groups according to their membership in the French-speaking Vascular Surgery Society or not, the type of practice (private, public hospital, mixed), and caseload. Compression was widely used (97.1%). It was the only postoperative treatment for 25.2% of the surgeons, was associated with anticoagulant treatment for 38.8% or non-steroidal antiinflammatory drugs for 11.2%. Prescription was evidence-based for only 11.6%. Compression therapy was mainly started postoperatively (93.2%). Elastic bandages (long stretch) were used by 87%. Duration of bandage therapy was variable (less than 8 days for 38.8%, 8-15 days for 24.5%). After bandage therapy, medical compression stockings (above knee 74.7%) or French class II (77.9%) were used. Compression stockings were prescribed for 8-15 days or 15-30 days by 12.7% and 84.6% of the surgeons respectively. Prolonged postoperative treatment was not common (28%) and was prescribed for patients with trophic changes.

[Surgical techniques used for the treatment of varicose veins: survey of practice in France]. / Résultats d'une enquête sur les techniques chirurgicales utilisées dans le traitement des varices.

UNLABELLED: This survey was undertaken in 2001 among surgeons of the French speaking Vascular Surgery Society (SCV-Société de Chirurgie Vasculaire de Langue Française) and SCV non-members with a heavy caseload in varicose vein surgery. AIM OF THE STUDY: To identify --the various surgical procedures used for treating chronic venous disease and in particular varicose veins; --the current use of preoperative investigation with duplex ultrasound; --the type of anesthesia used; --the postoperative treatment prescribed, and specifically compression therapy. MATERIAL AND METHODS: This survey was conducted by mail through a "half open" questionnaire including 17 questions and a patient form (see appendices I and II). 675 surgeons were questioned (501 were SCV members and 174 non members). RESULTS: Two-hundred and eighty surgeons answered (41.5%). The level of replies for French surgeons was 45.3%. A scientific committee assessed these replies. The surgeons were classified into different groups according to their membership of the SCV, own practice, and caseload. The 2 most performed procedures were respectively high ligation + saphenous trunk stripping + tributaries stab avulsion (71.9%) and high ligation + saphenous trunk stripping (17.3%). Isolated phlebectomy was 5.6%, high ligation + tributaries stab avulsion + saphenous trunk preservation 2.8%, isolated high ligation 2.2%, and ambulatory hemodynamic and conservative treatment of venous insufficiency (CHIVA) 0.3% ). The various procedures used (total number, average and percentage) inside the different groups are displayed in, and. Concerning trunk stripping modality the 2 most frequently used techniques were invagination and Babcock techniques. Both were evaluated respectively for the great saphenous vein (invagination 78.1%, Babcock technique 44.2%) and the small saphenous vein (invagination 77.1%, Babcock technique 31.8%). Complete resection of the saphenous trunk was more frequently performed than partial stripping. Pre-operative duplex scanning was systematically undertaken by 85.4% of surgeons without a statistical difference between the different groups. General anesthesia remains the most used form of anesthesia (83.9%) followed by spinal or epidural anesthesia (70.4%), and local or loco-regional (29.2%). As multiple answers were allowed, the most frequent procedures associated with general anesthesia were spinal or epidural (36.9%). Responders prescribed postoperative compression and anticoagulation in 97.1% and 55.8% respectively. Intra-group comparison was then undertaken in order to determine if their practice was different. Annual caseload was significantly (P=0.001) higher in Group I (353) than in Group II (226) and Group III (152). There was no difference in terms of the various surgical procedures used between the different groups. Group 1 favored the trunk stripping modality invagination for avulsion of the great saphenous vein and small saphenous vein. Concerning anesthesia, local and loco-regional anesthesia was used more by Group I than by the other groups as was anticoagulation. Responders perform perforator ligation and deep venous reconstructive surgery respectively in 70.3% and 22.4% without any intra group difference, however we have no information on frequency and indications for this type of surgery as these items were not included in the questionnaire. DISCUSSION: Total number of procedures recorded in this survey is in keeping with the yearly French data concerning surgical treatment of varicose veins (ie, approximately 200,000 procedures). Since the emphasis was on surgical procedures sparing the saphenous trunks in varicose vein treatment only 10.9% of the techniques used in this survey were compatible with this purpose. Invagination technique for stripping both the great and small saphenous trunk was preferentially used by the Group I. Although it is surprising that all groups favored total trunk stripping particularly for the small saphenous vein. It is not surprising that a large majority, despite very little controversy on this point, performed preoperative duplex scanning. Although postoperative compression can be only quoted as a grade C recommendation according to evidence-based medicine, it was prescribed in almost all cases. CONCLUSION: Surgery for varicose veins is one of the most frequently performed surgical procedures in France, mainly by surgeons exercising in private practice. There is no significant difference between the various groups (SCV Member or not, type of practice and annual case load) concerning the various procedures used, although through careful analysis certain different tendencies may be identified. In addition postoperative compression is systematically prescribed.

Critical hand ischemia after angioaccess surgery: diagnosis and treatment.

Severe hand ischemia is an uncommon complication of angioaccess surgery. Prompt recognition is necessary to prevent finger necrosis and permanent nerve damage. Treatment should relieve symptoms without compromising dialysis access. From January 1989 to September 1999, we treated critical hand ischemia in 23 patients (16 men, 7 women), including 8 diabetic patients with a total of 19 arteriovenous fistulas (AVF) and 4 arteriovenous grafts (AVG). In 21 patients, the symptom was critical ischemia, with finger necrosis occurring in 7 patients. In the remaining two patients, the manifestation was acute ischemia due to venous thrombosis. Four patients required finger amputation. Fifteen patients (65%) had previous AVF on the lateral extremity. The mean number of previous AVF in this group was 2.5 (range, 2 to 6). Various treatments were used for arterial insufficiency (n = 20), including ligation of the fistula (n = 8), distal revascularization-interval ligation (DRIL) (n = 4), bypass (n = 4), sympathectomy (n = 1), ligation of the radial artery (n = 1), medical therapy (n = 1), and banding technique (n = 1). Medical therapy and banding relieved symptoms after thrombosis of the AVF. Through the use of DRIL, healing of finger necrosis (n = 3) and improvement of symptoms (n = 1) were achieved. The findings of this study indicate that severe hand ischemia occurs mainly in diabetic patients with multiple previous AVF and finger arteriopathy. DRIL is the conservative treatment of choice, since it can be used to achieve both symptomatic relief and maintenance of dialysis access.

Management of symptomatic and asymptomatic popliteal venous aneurysms: a retrospective analysis of 25 patients and review of the literature.

OBJECTIVE: Popliteal venous aneurysms (PVAs) are an uncommon but potentially life-threatening disease because they can be a source for pulmonary emboli (PE). With the widespread use of venous duplex scanning, PVAs are increasingly found in patients with deep or superficial vein insufficiency, and questions have arisen as to the management of these aneurysms. The purpose of this study was to review our experience in the management of PVAs diagnosed in patients with PE and in patients with chronic venous diseases. METHODS: Twenty-five patients with PVAs were treated in two centers between 1985 and 1999. There were 20 women and five men, with an average age ranging from 33 to 79 years (mean age, 59 years). Twenty-four percent (6/25) presented with PE, and 76% (19/25) of PVAs were discovered during investigation for chronic venous disease (varicosities, n = 13; post-thrombotic symptoms, n = 6). The diagnosis of PVA was achieved in all cases with venous duplex scanning and phlebography. Aneurysms were located in the proximal popliteal vein (n = 17) and at the saphenopopliteal junction (n = 8). Seventy-two percent (18/25) of PVAs were saccular, and 40% (10/25) had an intraluminal thrombus. Two patients with PE underwent cardiac arrest, with one requiring a pulmonary embolectomy. The Fisher exact test showed a statistically significant correlation between PE and the presence of thrombus (50% vs 7% without thrombus, P =.02). Aneurysms were treated with tangential aneurysmectomy and lateral venorrhaphy (n = 19), resection with end-to-end anastomosis (n = 2), resection with interposition of the greater saphenous vein (n = 2) or the superficial femoral vein (n = 1), and resection with vein transposition (n = 1). Two patients who experienced a PE had an inferior vena cava filter placement before surgical repair of the PVA. RESULTS: Mean follow-up was 63 months (range, 11-168 months). No operative deaths occurred, and no patient had evidence of a recurrent PE. Postoperative minor complications (20%) included transient common peroneal nerve palsy (n = 2), postoperative hematoma (n = 2), and wound infection (n = 1). Postoperative thrombosis of the surgical repair occurred in three patients, and patency was restored with anticoagulation therapy. CONCLUSION: Despite its rarity, PVAs should be ruled out with venous duplex scanning in patients with PE and in patients presenting with chronic venous diseases. Because of the unpredictable risk of thromboembolic complications, surgical treatment that is accompanied by a low morbidity rate is indicated in all PVAs. Tangential aneurysmectomy with lateral venorrhaphy is the procedure of choice.

[Inframalleolar bypass in limb salvage. Late results]. / Les pontages périmalléolaires dans les sauvetages de membre. Résultats tardifs.

STUDY OBJECTIVE: The objective of this retrospective study was to report the long-term results of distal revascularization at the ankle in patients with critical ischemia. PATIENTS AND METHODS: From January 1989 to November 1999, 50 inframalleolar bypasses were performed in 49 patients (35 males and 14 females with a mean age of 75 years [range: 51 to 95 years]). Twenty-five patients (50%) were diabetics. All patients presented with critical ischemia of the lower limb. Distal anastomosis was performed at the retromalleolar posterior tibial artery in 28 cases (56%), pedal artery in 20 cases (40%) and distal fibular artery in two cases (4%). Bypasses were performed using a greater saphenous vein (n = 38), a cryopreserved arterial allograft (n = 9), or a PTFE graft (n = 2). A composite graft with greater saphenous vein and arterial allograft was performed in two cases. RESULTS: There were two early postoperative deaths. One patient presented a blow-out of the distal anastomosis that required bypass ligation and subsequent leg amputation. Early thrombosis of the graft occurred in four cases, leading to major amputation in three cases. No patients were lost to follow-up and mean follow-up was 26.7 months (range: 1 to 86 months). Graft thrombosis occurred in 15 patients and led to amputation in 6 cases. Bypass graft patency rate was 72% and 61% at 1 year and 3 years, respectively, yielding a 80% limb salvage rate at 3 years. The 3-year actuarial survival rate was 53%. CONCLUSION: Inframalleolar bypasses are a valuable tool in patients with critical ischemia. The lower limb salvage rate is satisfactory in this elderly population. Based on this experience, angiography with good run-off and, when necessary, a surgical approach to verify patency of the arteries at the ankle should always be performed before undertaking a major amputation.

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.

[Fate of the competence of the valvular apparatus of the femoral veins after cryopreservation. Preliminary study]. / Devenir de la compétence de l'appareil valvulaire des veines fémorales après cryopréservation. Etude préliminaire.

PURPOSE: The aim of this study was to determine the impact of cryopreservation on the competency of human femoral vein valve. MATERIALS AND METHODS: Nine superficial femoral veins bearing 24 valves were harvested in brain death patients (5 men, mean age 32 years, range 16 to 63 years). Veins were divided in 24 segments bearing only one valve. Each segments was tested for reflux by using a pressure column filled with heparinized saline. After harvest, vein segments were kept in Belzer solution with antibiotics (gentamycin, colistin, lincomycin and amphotericin B). Histological study was undertaken in a fresh valve segment (n = 9). The remaining segments (n = 15) were stored in 15% dimethyl sulfoxide (DMSO) and cryopreserved in liquid nitrogen vapor for 120 days. Afterwards the 15 cryopreserved vein segments were thawed in 37 degrees C water bath and were studied for mechanical and histological changes. RESULTS: All the 24 valve segments initially tested were competent. Off the 15 cryopreserved segments only 4 (26%) were found to be non refluxive after cryopreservation. Histological study performed before cryopreservation showed a normal appearance of the vein wall (n = 9). On the contrary after cryopreservation, microscopic examination showed that in the incompetent veins, the endothelium surface was either absent or poor with a marked decrease in elastic fibres. CONCLUSION: This preliminary study indicates that DMSO cryopreservation must be improved in order to preserve vein valve competency: 26% of the cryopreserved valves remained competent. Histological findings also suggest that elastic fibres play a major role in the failure of the vein competency.

[Venous aneurysm of unusual localization revealed by a pulmonary embolism. Report of two cases]. / Anévrysme veineux de siège inhabituel révélé par une embolie pulmonaire. A propos de deux cas.

We report two uncommon cases of venous aneurysm involving the soleus vein and the saphenofemoral junction. Both cases presented with pulmonary embolism. Diagnosis of the venous aneurysm was achieved by Doppler ultrasonography during the evaluation for deep vein thrombosis. Venography showed a large fusiform aneurysm. Both aneurysms were treated by resection and ligation. At follow-up, there was no evidence of recurrent pulmonary embolism. These cases clearly illustrate the risk of pulmonary embolism associated with uncommon localizations of venous aneurysms and the potential for thrombus formation due to the venous stasis. Surgical treatment, as in the case of popliteal aneurysms, is mandatory to avoid such embolic complications.

[Evaluation of a clinical and scintigraphic management strategy for cardiac risk before abdominal aorta surgery. Apropos of 982 surgical patients]. / Evaluation d'une stratégie clinique et scintigraphique de prise en charge du risque cardiologique avant chirurgie de l'aorte abdominale. A propos de 982 patients opérés.

The incidence of major cardiac events (death, infarction) is over 5% after programmed aortic vascular surgery. The aim of this study was to evaluate a management strategy of this risk based on the clinical status and targeted indication of myocardial scintigraphy, coronary angiography and myocardial revascularisation. A first phase (1991-1993, 451 patients) confirmed the prognostic value of clinical (age, previous cardiac history, diabetes, hypertension, electrocardiogrammes) and scintigraphic features: the cardiac mortality was 1.25% in patients with a low clinical risk (70.3% of cases) and 4.5% in patients with a high clinical risk (2 factors, 29.3% of cases) (p < 0.01). In the latter group, the mortality was zero after normal myocardial scintigraphy and 7.2% after abnormal myocardial scintigraphy (p < 0.01) and 12.5% in cases with reversible defects (p < 0.01). During the second phase of the study (1994-1997, 531 patients) coronary angiography was performed in patients with a high clinical risk and abnormal scintigraphy (10.9% of cases). This led to a myocardial revascularisation in 3.6% of patients. The cardiac mortality was then the same in the low and high a priori clinical risk: 2.3 and 2.8% (NS). The use of simple clinical criteria enables surgery in the majority of candidates for aortic vascular surgery, scintigraphy being reserved for about one patient in ten with myocardial revascularisation in less than 4% of cases. The operative cardiac mortality then decreases to under 2.5%.

Infected aneurysms of the infrarenal abdominal aorta: diagnostic criteria and therapeutic strategy.

From 1976 to 1994 we performed surgical treatment of 18 infected aneurysms of the infrarenal abdominal aorta. The aneurysm had ruptured in nine patients: into the retroperitoneum in six patients, and into an adjacent structure in three patients (duodenum, inferior vena cava, left renal vein). Two patients had an associated spondylitis. Four patients were in shock at the time of surgical treatment. Six patients (including four patients with Salmonella infection and two patients with spondylitis) had positive preoperative blood cultures. Salmonella was the most common microorganism (27%). Anaerobes accounted for 16%. In situ replacement was performed in 13 patients including three procedures performed under emergency conditions with frank purulent infection. Extraanatomic bypass was performed in five patients. Early postoperative death occurred in two patients (11%) due to septic complications (rupture of aortic anastomosis in one patient and rupture of aortic stump in one patient). All surviving patients underwent prolonged antibiotic therapy for at least 6 weeks. Overall mortality secondary to infected aneurysm was 16%. Infection of the aortic graft occurred in four patients (38%) including two patients with Salmonella infection and one patient with spondylitis. One patient developed a false anastomotic aneurysm 6 months postoperatively and was treated by in situ arterial allograft replacement. Postoperative blood cultures were positive in two patients presenting spondylitis and infection of the aortic prosthesis occurred in one of these patients. In addition to rupture, poor prognostic factors included spondylitis and Salmonella infection that were found to greatly enhance the risk of postoperative graft infection following in situ reconstruction.

Below-knee bypass using fresh arterial allografts for limb salvage: early results.

The purpose of this study was to evaluate early results of below-knee bypass using fresh arterial allografts as arterial substitutes for limb salvage. From April 1991 to September 1993, we performed 28 below-knee bypass procedures using fresh arterial allografts in patients without a suitable autologous vein. Allografts were obtained by multiorgan harvesting from brain-dead subjects and preserved at 4 degrees C. Histologic examination of grafts was carried out. Secondary patency at 2 years calculated using the Kaplan-Meier method was 64% (confidence interval [CI] 45%-79%). No signs of graft deterioration or rejection were noted. These preliminary results are encouraging but long-term assessment is needed before expanding the range of application.

[Traumatic and iatrogenic lesions of abdominal vessels]. / Les lésions traumatiques et iatrogènes des vaisseaux abdominaux.

Gravity of abdominal vessels traumatisms is secondary to multiple factors. It depends on the type of injured vessels, aetiology and associated lesions. Between September 1984 and March 1995, 22 abdominal vessel traumatisms in 16 patients (mean age: 39 years) were treated. At surgical exploration, 4 aortic and 2 renal vein lesions, 7 iliac artery and 3 renal artery contusions, 2 superior mesenteric artery dissections; 3 infra-renal vena cava ruptures and 1 superior mesenteric vein dilaceration were found. All lesions were caused by penetrant wounds secondary to firearm or blade injury or secondary to injuries due to ski or traffic accidents. In 5 cases, lesions were iatrogenic. There was no mortality in the post-operative period, 14 patients out of the 16 patients operated on have been followed during a period from 1 to 120 months.

[Renal revascularization from the digestive arteries in the treatment of renovascular hypertension in high risk patients]. / Revascularisation rénale à partir des artères digestives dans le traitement de l'hypertension réno-vasculaire chez les patients à haut risque.

Five extra-anatomic hepatospleno- and gastroduodenorenal revascularizations were performed in 5 high-risk cardiac patients. The procedure followed failure of endoluminal angioplasy for osteal stenosis of the renal artery in 4 cases. All patients had a diffuse lesion of the aorta contraindicating direct aortorenal bypass. The indication for surgery was renovascular hypertension poorly-controlled with medical therapy in all 5 patients; 4 patients also had renal failure. There was no mortality in the perioperative period. Blood pressure returned to normal in 50% of the cases, and improved in the other 50%. There was a clear improvement in renal function in all patients.

[Carotid revascularizations by venous grafting: long-term results]. / Revascularisations carotidiennes par greffes veineuses: résultats à long-terme.

Carotid artery reconstruction (CAR) may be achieved through a variety of techniques. The method of choice is based upon the patient's symptoms, the diffusion of the atheromatous lesion in the internal carotid artery and the experience of the surgical team that usually deals with these patients. Between January 1987 and May 1995, we performed 185 CAR using saphenous vein graft. The indication for surgery was atherosclerotic occlusive desease in all patients, sixty-two per cent of whom were asymptomatic. In the early postoperative period one patient died of aspiration, two patients suffered a stroke (one major and one minor) and five patients had a transcient ischemic attack due to carotid clamping intolerance. Two late restenosis and two graft occlusions occurred. The cumulative operative morbidity and mortality rate was 1.6%. This series demonstrates than venous grafting for carotid reconstruction yields satisfactory short- and long-term results and is a valuable alternative to endarteriectomy. Follow-up by Duplex-scan revealed no evidence of morphological degradation of the vein grafts.

Additive value of thallium single-photon emission computed tomography myocardial imaging for prediction of perioperative events in clinically selected high cardiac risk patients having abdominal aortic surgery.

The present study was designed to prospectively evaluate whether reinjection thallium-201 single-photon emission computed tomography (SPECT) has a significant additive predictive value for occurrence of perioperative cardiac events in clinically selected patients at high cardiac risk undergoing abdominal aortic surgery. Of a group of 517 consecutive patients referred, 134 had > or = 2 of the following clinical or electrocardiographic cardiac risk variables: age > 70 years; history of myocardial infarction, angina, or congestive heart failure; diabetes mellitus; hypertension with severe left ventricular hypertrophy; and Q waves or ischemic ST-segment abnormalities on electrocardiogram at rest. Operation was performed after thallium SPECT study. Twelve patients (9%) had major perioperative events (cardiac death or nonfatal myocardial infarction) and 18 patients had other cardiac events (unstable angina, congestive heart failure, or severe ventricular tachyarrhythmia). Variables correlated with the occurrence of major events were history of myocardial infarction (p < 0.05) and the presence (p < 0.001) and number of segments with thallium reversible defects (p < 0.001). In multivariate analysis, history of myocardial infarction (p < 0.05) and the number of segments with reversible thallium defects (p < 0.001) were independent predictors. When all the cardiac events were taken into consideration, all the previous variables, as well as Q waves and ischemic ST abnormalities on the electrocardiogram, showed significant predictive value in both univariate and multivariate analyses. Furthermore, thallium SPECT imaging has an additive predictive value for major cardiac events over clinical and electrocardiographic risk factors. When performed on clinically selected patients at high cardiac risk undergoing abdominal aortic surgery, thallium SPECT demonstrates significant prognostic value for cardiac events over that provided by clinical variables alone.

[Vascular surgery and organ transplantation]. / La chirurgie vasculaire et la transplantation d'organes.

Among the recent advances in organ transplantation, the introduction of cryropreservation fluids in 1989 has allowed routine protection against ischemia over prolonged periods. There remain however several obstacles which can compromise graft survival and consequently lead to second transplantations and increased organ demand. Vascular complications are one of these complications. In many cases, close collaboration between transplantation surgery and the vascular surgery teams could reduce the number of problems. The aim of this work was to study situations in which collaboration could be useful. There are three areas of particular interest: kidney transplantations, liver transplantations and obviously, multiple organ transplantations.

[Chronic venous insufficiency 7 to 10 years after partial vena cava interruption with a clip]. / Insuffisance veineuse chronique 7 à 10 ans après interruption partielle de la veine cave inférieure par clip exocave.

In order to test the responsibility of inferior vena cava clips in post thrombotic venous disease, we performed a comparative retrospective study 7 to 10 years after vena cava interruption by clip. Patients were compared with patients matched for sex, age, and prior deep vein thrombosis (same period and same localisation) but without inferior vena cava partial interruption. The results show that 1) functional complaints were significantly higher in the vena cava clip group; 2) valvular incompetency, in the initially thrombosed leg, (tested by scanning duplex) was not different in the two groups: 3) inversely, on the other leg, valvular incompetency was greater in the vena cava clip group. Furthermore this valvular incompetency was principally located at a femoral level, suggesting that the vena cava clip may induce backward thrombosis; 4) complications were independent of vena cava thrombosis.

[Leg ulcer and Klinefelter syndrome]. / Ulcère de jambe et syndrome de Klinefelter.

We report a case of 47 years old patient who was admitted to hospital because of bilateral leg ulcers for 6 years. Chromosome analysis revealed XXY karyotype, confirming the clinical diagnosis of Klinefelter's syndrome. Testosterone level was low and Plasminogen Activator Inhibitor (PAI-1) was elevated. The patient was given androgen therapy which resulted in a normalization of the PAI-1 activity. The frequency of leg ulcers in patients with Klinefelter syndrome is between 6 and 12% according to studies. Different causes would explain the tendency towards leg ulcers in Klinefelter's syndrome: conjunctive tissues abnormalities were revealed in some studies. A higher frequency of venous insufficiency is reported in patients with Klinefelter's syndrome, either due to the particular morphology (obesity, taller size) or due to an androgen deficiency. A few arterial dysplasias cases of arteries's legs were described in patients with leg ulcers and Klinefelter syndrome. Haemostasis disorders presented in this case and normalized after androgen therapy will contribute to the physiopathologic discussion.