[Renal leiomyosarcoma, rheumatoid arthritis and methotrexate]. / Léiomyosarcome de la veine rénale gauche dans un contexte de polyarthrite rhumatoïde sous méthotrexate.

Leiomyosarcoma of the renal vein is a rare and malignant tumor difficult to diagnose. No standard treatment has been defined and prognosis is poor. We described the case of a 68-year-old woman with rheumatoid arthritis treated by methotrexate who developed a leiomyosarcoma of the left renal vein with a fatal outcome in less than 1 year. Association of a leiomyosarcoma and rheumatoid arthritis raises the question of a casual association or of a predisposing factor since studies have shown increased risk of cancer with this rheumatism.

Surgery of the pretransversal vertebral artery: indications and results.

AIM: The aim of this study was to evaluate our results with elective vertebral arteries surgery, to emphasize the indications of such revascularization and to compare it with previous larger studies. METHODS: The medical records of all patients who underwent a pretransversal vertebral artery (VA) revascularization between 1990 and 2004 at our University Hospital were retrospectively reviewed. RESULTS: Forty patients, with a mean age of 60.5 years, met the criteria for VA surgery and accounted for 4.2% of the vascular surgeries involving the brain. Seventeen (42.5%) patients presented with vertebrobasilar insufficiency of hemodynamic origin, 16 (40%) with embolism, and 7 (17.5%) had no neurological symptoms. Direct vertebrocarotid reimplantation was the main procedure performed. No death or stroke occurred preoperatively or during the perioperative period. Mean follow-up was 31 months. Overall survival was 86.9% at 3 years and the primary patency rate was 97.5% at 3 years. CONCLUSION: Our study confirms the good results achieved by the pretransversal conventional VA surgery. This surgery remains few in number despite the fact that about 25% of ischemic strokes occur in the vertebrobasilar region. Vertebrobasilar signs should be better recognized to avoid performing this type of procedure merely based on imaging criteria.

[Spinal destruction caused by chronic contained rupture of an infra-renal abdominal aortic aneurysm]. / Erosion vertébrale par rupture chronique d'un anévrysme de l'aorte abdominale sous-rénale.

The erosion of the lumbar vertebral bodies by a chronic contained rupture of an infra-renal abdominal aortic aneurysm is a rare event. Chronic contained rupture can cause diagnostic difficulties as there are many clinical presentations, such as: back pain, sciatic pain or an expansive abdominal mass. The diagnosis is sometimes made following an incidental finding on radiological examination. Currently a CT scan is the gold standard diagnostic tool. The outcome following urgent surgical or endovascular repair is equivalent to that of an elective aneurysm repair. We report a case of a 59 year old man admitted for septic rupture of a cutaneous fistula resulting from a false aneurysm in the left groin. Pre-operative CT scan revealed a 6 cm abdominal aortic aneurysm, with chronic contained rupture. This had caused bone erosion of the vertebral body of the third lumbar vertebrae.

Local endovascular treatment of aortic aneurysms. From operating theater to lab bench.

Current treatment of aortic abdominal aneurysms by conventional surgery or endoprosthesis is flawed by high post-operative mortality and unpredictable durability of haemodynamic exclusion, respectively. We have developed endovascular approaches with cell and gene transfer, aimed at controlling further diameter expansion in an animal model of already-developed aneurysms in rats. Preliminary results suggest that both cell and gene endovascular therapy can be used to control expansion of aneurysms generated by inflammation and proteolytic destruction of the aortic wall.

[Aneurysm of the superior gluteal artery]. / Anévrysme de l'artère glutéale supérieure.

We report the case of an aneurysm of the superior gluteal artery that occurred more than ten years after a pelvic trauma. The diagnosis of this uncommon condition is sometimes difficult because of the predominant neurologic symptoms. Rupture can be life-threatening. The patient was treated by an embolization; thereafter a surgical procedure with control of the internal iliac artery and an endoaneurysmorrhaphy was performed. The main characteristics of this pathology are indicated.

[Long-term evolution of a thoraco-abdominal cryopreserved arterial allograft]. / Evolution à long terme d'une allogreffe artérielle cryoconservée en position thoraco-abdominale.

We report a case of thoraco-abdominal pseudo-coarctation which developed late after implantation of a cryopreserved arterial allograft. The allograft was placed in a thoraco-abdominal position to treat an aorto-esophageal fistula after colonic esophagoplasty. Follow-up was free of complications for eight Years. The pseudo-coarctation was discovered during the evaluation of hypertension. Surgical treatment involved transdiaphragmatic bypass between the thoracic and infra-renal abdominal aorta. Arterial pressure immediately returned to normal. Twelve Months later, the patient is alive and well with normal blood pressure. A review of the literature revealed rare cases of arterial allograft with a description of the long-term outcome.

[Compression of the inferior vena cava with thrombus: a rare complication of solitary liver cyst]. / Compression de la veine cave inférieure avec thrombose : une complication rare d'un kyste biliaire solitaire.

Because of the increase of ultrasonographic exams, nonparasitic cyst of the liver is frequently encountered. Some giant cysts have complications. The surgical treatment for complicated forms consists in resection of the protruding part. We report a case of a giant non parasitic cyst of the liver which was responsible of a compression of the inferior vena caval with thrombus. The resection of the thrombus was performed after a double control of the vena cava and a control of the aorta. The fenestration of the cyst was performed in a second time.

Infra-stellate upper thoracic sympathectomy results in a relative bradycardia during exercise, irrespective of the operated side.

OBJECTIVE: Removal of accessory fibres coming from the sub-stellar thoracic chain to the heart during infra-stellate surgical upper thoracic sympathectomy (ISS) may be responsible for a decreased heart rate to workload relationship during exercise following surgery. We hypothesised that heart rate would decrease not only following right ISS. METHODS: We performed repeated bicycle incremental exercise tests in 11 control subjects (26.9+/-9.5 years, 61.4+/-12.4 kg, 167+/-10 cm), and 11 patients (29.8+/-10 years, 59.3+/-12.0 kg, 168+/-7 cm) referred for bilateral ISS: results are mean+/-standard deviation. Surgery was performed at two distinct times allowing to study the consequences of unilateral and bilateral sympathectomy to confirm whether a significant relative bradycardia was constant and dependent on the operated side. RESULTS: For control subjects, test durations were 13.55+/-3.29, 14.09+/-4.01 and 13.00+/-3.26 min and heart rates were 187+/-7, 187+/-8 and 186+/-7 beats min(-1) at the first, second and third test, respectively. Although time to exhaustion was comparable to controls and unchanged between tests: 12.32+/-2.87, 12.3+/-2.90, 12.33+/-3.76 min, heart rate at maximum exercise decreased significantly from 176+/-16 to 164+/-15, and 148+/-15 beats min(-1), before, following unilateral and bilateral ISS, respectively. The operated side did not allow for the prediction of the effect of unilateral sympathectomy. CONCLUSIONS: Patients should be informed of the exercise bradycardia resulting from ISS, although clinical tolerance seems excellent in endurance exercise. Contrary to previous reports at rest, during exercise no right-sided dominance was observed. These findings are consistent with reports of random distribution of sub-stellate cardiac fibres from anatomical studies.

[Surgery of the proximal vertebral artery. Indications and results]. / Indications et résultats de la chirurgie de l'artère vertébrale pré-transversaire.

OBJECTIVES: The purpose of this study was to: 1) detail the clinical presentations of diseases requiring revascularization of the vertebral artery and recall the guidelines of the 1975 Ad Hoc committee; 2) identify the explorations needed to detect vertebro-basilary insufficiency; 3) define operative indications since no consensus has been reached. PATIENTS AND METHODS: We reviewed retrospectively the files of 34 patients who underwent revascularization of the vertebral artery between January 1990 and December 2000. RESULTS: Surgery of the vertebral artery accounted for 4.6% of our vascular surgery cases involving the brain. Fifty percent of the cases of vertebro-basilary insufficiency were caused by hemodynamic disorders and 26.5% by embolism; 23.5% of the patients had no neurological sign. The most frequent neurological signs were vertigo (44%), balance disorders (41%), long pathway involvement (32%). Vertebro-basilary reimplantation was performed in 76% of the cases. There were no cases of stroke and no deaths during the early postoperative period. There was one case of asymptomatic thrombosis. Mean follow-up was 33.6 months with no patients lost to follow-up. Overall survival was 85.29% at 3 years with patent arteries in 97.06% of the cases at 3 years. CONCLUSION: Our series is in agreement with others reported in the literature, emphasizing the good outcome achieved after vertebral artery surgery. Surgery helps improve signs of vertebro-basilary insufficiency with little operative risk. This surgery is rarely indicated but must be recognized. One must also resist the temptation to "treat images".

Percutaneous transluminal angioplasty for management of critical ischemia in arteries below the knee.

Percutaneous transluminal angioplasty (PTA) can be performed safely in arteries below the knee by using current coaxial catheters. This study includes 37 consecutive patients treated between March 1992 and March 1999 by PTA for limb-threatening infrageniculate occlusive artery disease. The mean duration of follow-up was 28 months. Limb salvage was achieved in 32 patients. The actuarial limb salvage rate at 2 years was 87 +/- 6%. This study shows that PTA was a viable alternative to surgical treatment for management of critical lower extremity ischemia in carefully selected patients. Limb salvage rates after PTA and conventional surgical revascularization seem comparable. Based on these findings, we recommend that PTA be attempted, whenever possible, for initial treatment of patients presenting critical, limb-threatening ischemia due to isolated or multiple stenoses of below-knee arteries.