Closure of carotid bifurcation endarterectomy using a polyurethane patch. A multicentre prospective study with 252 patients.

BACKGROUND: In order to evaluate the results of carotid endarterectomy with closure using a polyurethane patch, a multicentre prospective study of 252 patients (263 interventions) undergoing this operation was performed between November 1996 and August 2001. METHODS: One hundred and seventy-one men and 81 women with a mean age of 70 years were studied. Fifty-five percent of the patients had neurological symptoms. The degree of carotid stenosis evaluated using the European carotid surgery trialist's collaborative group (ECST) criteria was greater than or equal to 70% in 95% of cases. RESULTS: The combined mortality-morbidity operation rate (CMMR) was 2% (1 death from cerebrovascular haemorrhage on Day 3, 1 non-regressive cerebrovascular accident (CVA), 3 regressive CVAs). The patients had follow-up clinical examinations and Doppler ultrasound scans for 2 years. Fifteen patients died during follow-up, 8 of these patients died from heart-related causes and 2 patients died from CVA. Four patients presented with CVAs ipsilateral or contralateral to the endarterectomy. Two false aseptic aneurysms and 1 false septic aneurysm required further surgery. Three asymptomatic carotid occlusions occurred during follow-up. The rate of restenosis greater than 50% was 1.2% at 6 months, 2.3% at 1 year and 5.3% at 2 years. CONCLUSIONS: These results confirm the value of po-lyurethane patch closure of carotid endarterectomy.

Coronary subclavian steal syndrome after left internal mammary bypass in a patient with Takayasu's disease.

We report the case of a 56-year-old symptomatic woman who underwent 2 coronary bypasses (left internal mammary artery on the left anterior artery and saphenous venous bypass on the circumflex) for a tight stenosis of the left main coronary. An inflammatory syndrome had been explored for 1 year without specific diagnosis. Eight months later, coronary angiography was performed for recurrence of angina: both bypasses were patent without stenosis and the left main stenosis was unchanged, but significant stenosis of the subclavian artery was found just before the LIMA. The diagnosis of Takayasu's disease was suspected in accordance with the ARC criteria and corticosteroids were started. One year later, because of recurrent angina, the patient was surgically treated with subclavian, vertebral and internal mammary endofibrectomy and an inverted saphenous vein graft from the subclavian to the axillary artery for extensive supra-aortic lesions. The patient remains symptom free at 1 year follow-up.

[Endarteriectomy of the femoral tripod: long-term results and analysis of failure factors]. / Endartériectomie du trépied fémoral: résultats à long terme et analyse des facteurs d'échec.

STUDY AIM: The aim of this retrospective study was to report immediate and long term results of endarteriectomies of the common femoral artery (CFA) and/or femoral tripod and to analyse predictive factors of failure. PATIENTS AND METHODS: Between 1982 and 1995, 110 endarteriectomies were performed in 101 patients, 52% of them in limb salvage situation. The arteriogram showed a thrombosis or stenosis of the common femoral artery in 100% of cases. There was a stenosis of the deep femoral artery (DFA) in 79% of cases. The superficial femoral artery (SFA) was thrombosed in 40% of cases. One artery only of the lower leg was permeable in 43.3% of cases. Run off was judged bad in 38% of patients. RESULTS: The endarteriectomy could be realised in 93 patients (84.5%). It concerned the only common femoral artery in 20% of cases (patch angioplasty in 55% of cases), common and deep femoral arteries in 50.5% of cases (82% of patch), CFA, DFA and SFA at its origin in 29.1% of cases (93% of patch). Perioperative mortality rate was 1%. Local morbidity rate was 21.6% with 18% of minor complications and 3.6% of complications requiring a second operation. There were 2% of vascular complications (1 thrombosis and 1 false-aneurysm). Mean follow-up was 43 months in 90 patients. There were restenosis or thrombosis (5.5%), false-aneurysms (2.2%) and amputations (6.6%). Femoro-popliteal (10%) and iliac complementary bypasses (6.6%) were necessary. Permeability was 94.9% at 3 years and 88.8% at 5 years. Clinical results were considered good in 80.7% of the cases at 3 years and in 71.7% at 5 years. With univariate analysis, the predictive factors for failure were: limb salvage (P < 0.01), altered popliteal run off (P < 0.03) and extended distortion of the deep femoral artery (P < 0.05). CONCLUSION: Isolated endarteriectomy of the femoral tripod is a low risk and effective technique. A femoropopliteal revascularisation should be associated in case of a major alteration of the deep femoral artery.

Pseudo-aneurysm of the popliteal artery by femoral exostosis in a young child.

Exostosis is a solitary benign bone tumor frequently observed in children. It may be totally quiescent or provoke complications. We report a case of pseudo-aneurysm of the popliteal artery caused by an exostosis on the lower metaphysis of the femur in a 12-year-old boy. This unusual complication mostly reported in young males (mean age 19 years) occurs in the context of an initial trauma in half the cases. Surgical treatment is a semi-emergency requiring both bone and arterial repair. Preventive surgery should be discussed for all cases of exostosis with a risk of arterial damage due to the gravity of the potential vascular complications.

Sealing of polyester prostheses with autologous fibrin glue and bone marrow.

The purpose of this study was to develop a sealing technique for polyester prosthetic grafts able to promote healing and reduce intimal hyperplasia. The porcine experimental model was aortoiliac bypass with a 6-mm diameter knitted polyester prosthetic graft implanted for 14 and 90 days. Animals were divided into three groups according to sealing technique as follows: pre-clotting with blood (group I, n = 12), sealing with autologous fibrin glue (group II, n = 14), and sealing with autologous fibrin glue and bone marrow cells (group III, n = 16). Feasibility and quality of sealing were evaluated by scanning electron microscopy prior to implantation and by assessment of blood loss. After removal, prostheses were cut into three segments comprising the proximal anastomosis, midsection, and distal anastomosis. Pieces were fixed, embedded in paraffin, and serially sectioned for histologic study. Histological study focused on the degree of stenosis and hyperplasia of the neointima of each prosthesis. The results of this short-term study indicate that sealing of polyester vascular prosthetic grafts with autologous fibrin glue and bone marrow cells is effective in reducing intimal hyperplasia. However further study will be needed to assess long-term healing.

[Isolated popliteal arteries: results of surgical treatment and causes of failure]. / Artères poplitées suspendues: résultats du traitement chirurgical et causes des échecs.

UNLABELLED: Isolated popliteal artery is defined as an obstruction of a superficial femoral artery with a patent popliteal segment followed by an obstructed distal popliteal artery or a patent leg artery less than 5 cm long. PURPOSE: The aim of this retrospective study was to report the results of surgical treatment and the causes of failures. PATIENTS AND METHODS: From 1988 to 1996, 31 patients with isolated popliteal artery were operated on with femoropopliteal bypass. The age of the patients ranged from 45 to 92 years, (mean: 79 years); all had critical ischemia that threatened limb viability. All underwent preoperative arteriography and diagnosis was confirmed by intraoperative arteriography. RESULTS: In the postoperative course, there were 22 patent bypasses (68%) with minor amputation in five patients, and nine thromboses that required a major amputation in seven patients, a trans-metatarsal amputation in one, and a medical treatment in one. With a mean 37-month follow-up, seven thromboses required a major amputation in five patients, a new bypass in one and a medical treatment in one. The death rate was 34% at two years. The actuarial patency rates of the bypasses were 51% at one year, 38% at two years and 25% at five years. The limb salvage rate was identical. The patency rates were 65% at one, two and five years for venous bypasses and 38%, 13% and 0% respectively for PTFE bypasses. Statistical analysis showed two causes of failure: the absence of a run-off branch and the use of PTFE prostheses. No other statistically significant cause of failure was demonstrated among those analysed. Favourable anatomic conditions for a bypass to a leg artery were not predictive of failure of a femoro-popliteal bypass on the isolated arterial segment. CONCLUSION: Bypass to isolated popliteal artery is indicated in patients whose limb viability is jeopardized. Results may be considered as satisfactory especially if there is a run-off branch and if a venous graft is available for the bypass.

The role of polyester patch angioplasty in carotid endarterectomy: a multicenter study.

The objectives of this study were to examine the morphology, restenosis, dilatation, and possible complications of polyester collagen impregnated carotid patches. Between March 1994 and January 1995, 207 patients (56 females and 151 males) undergoing 221 carotid endarterectomies (CE) with a collagen-impregnated knitted polyester patch were enrolled in a European prospective multicenter study. Patches were used for arteries deemed to be smaller than usual by visual inspection. General anesthesia was used in 201 procedures (91%), and a shunt was used in 76 procedures (34.4%). One hundred fourteen CE (51.6%) were checked by a perioperative arteriography or angioscopy. The diameter of the internal carotid artery (ICA) and carotid bulb (CB) were measured by duplex scan both preoperatively and every 6 months during follow-up. The main end point was carotid occlusion or restenosis, defined as a stenosis of 50% or more according to NASCET criteria. Carotid polyester-impregnated patches appear to be reliable. The patch was easy to cut and suture, and hemostasis was obtained immediately. No rupture occurred. However, the higher restenosis rate in women may restrict the use of polyester patch to men.

Quantification of carotid stenoses using 3D morphometer, CT angiography and conventional angiography.

BACKGROUND: The aim of this study is to compare the performances of 3D morphometer (M3D) regarding the quantification of extracranial carotid stenoses with selective 2D conventional angiography (reference technique) and spiral CT scan. METHODS: It is a prospective study, including 15 patients (mean age 75) presenting a symptomatic carotid lesion detected via duplex Doppler to be operated. Patients had to hold their breath for 20 seconds. Twenty-nine carotid bifurcations were studied by means of M3D and 2D conventional angiography (15 patients). Only 10 patients (19 bifurcations) underwent a CT scan. The measures were performed on a visual display unit by measuring the pixels as per the NASCET technique. Diameters (MIP technique) and surfaces (reformated axial slices) were measured. RESULTS: With MIP technique, a good correlation was found 20 times in 29 (69%) (overestimation: n=8/29) between M3D and angiography, but only in 9 of 19 cases (47%) between CT scan and angiography. Unlike with M3D, the slices re-oriented with CT scan gave better correlations: 15 times in 19 (79%). With the CT scan, the measures were impossible 8 times on MIP technique, and twice on reformated slices for calcified tight stenoses. Therefore, the quantification by means of spiral CT scan is easier by planimetry on slices. CONCLUSIONS: The reliability of these 3D explorations regarding quantification remains uncertain. The use of a morphometer, provided that technical adaptations are made, could replace selective sequences in multiple incidences that become accessible in the post-treatment period, with an acquisition field larger than the one of the CT scan.

[Biomechanical study of the vasomotor system of the arterial smooth muscle after long-term cryopreservation of a human arterial graft at two different temperatures -80 and -150C]. / Etude biomécanique et de la vasomotricité du muscle lisse artériel après cryocongélation de longue durée de greffon artériel humain à deux températures différentes -80 degrees et -150 degrees C.

We conducted two parallel studies on cryopreserved arterial homografts: a biomechanical study based on traction tests and a functional study coupled with a histology examination. Twenty-four arterial segments from 6 donors (2 iliac and 2 superficial femoral segments per donor) were cryopreserved at -150 degrees C and -80 degrees C. Cryopreservation lasted at least 6 months. Lengthening at rupture, the Young elasticity module, and rupture stress were calculated from the traction test. Results were significantly different depending on the preservation temperature. The functional properties of the cryopreserved arterial grafts were evaluated by studying the vasomotricity capacity of the vascular smooth muscle (VSM) and the endothelium. The expected results (direct contracture of VSM induced by PHE and endothelial dependent relaxation of VSM induced by ACH) were measured on fresh arteries. Cryopreserved arteries showed no response to physiological doses of PHE and ACH, whatever the preservation temperature. In one-third of the cases, a lower amplitude vasoconstriction was obtained using nonphysiological doses of PHE; there was no relaxation with ACH.

Results of isolated carotid surgery in patients with vertebrobasilar insufficiency.

The purpose of this study was to establish whether carotid-revascularized patients who had preoperative vertebrobasilar insufficiency (VBI) displayed distinctive characteristics and whether a particular prognosis would ensure. From January 1985 to December 1993, 1022 carotid revascularizations were performed, of which 114 (11%) were for high-grade stenosis associated with VBI. The group with VBI and the group without VBI were compared according to a set of 121 prospectively collected variables. Of all the demographic and risk-factor variables, only female prevalence (42% vs. 27%) and hypertension (77% vs. 27%) distinguished the group with VBI, who also exhibited a significantly higher proportion of significant contralateral carotid lesions (27.2% vs. 8.9%) and vertebrosubclavian lesions (38.6% vs. 24.8%). Following isolated carotid surgery, there was no statistically significant difference between the two groups as to their cumulative rate of permanent neurological mortality and morbidity (2.6% in the group with VBI vs. 3.4% in the group without it). With an average follow-up of 60 months, VBI was cured in 82.4% and improved condition shown in 6.5% of patients. However, the proportion of good results fell to 65% in patients with a nonfunctional circle of Willis. Out of 13 cases of failure to control VBI, cure was finally effected by means of contralateral revascularization in 3 cases and by means of vertebrosubclavian revascularization in 5 cases out of 6. At 5 years, the actuarial rates of neurological event-free intervals and survival were not different from one group to another. In most cases, isolated carotid surgery is sufficient to bring vertebrobasilar insufficiency under control, except when significant vertebrosubclavian lesions and a nonpatent circle of Willis call for simultaneous carotid and vertebral artery surgery.

Computed tomography guided thoracic sympatholysis for palmar hyperhidrosis.

METHODS: Sixteen patients (mean age 26.3 years; range 18-38) with palmar hyperhidrosis underwent 29 sympatholyses after unsuccessful medical, and in 8 ionophoresis, treatments. Sympatholysis was performed under local anesthesia with computed tomographic guidance. After opacification of the injection site at T3 with Iopamiron 200, phenolization was performed with 10 ml 6% phenol. RESULTS: Good immediate results evaluated on the basis of venous dilatation, and dryness and warmth of the skin were obtained in 23 cases (80%). There were 6 immediately unsuccessful procedures in 4 patients. At 20 months, good results, assessed on the basis of objective criteria and subjective patient self-evaluation were obtained in 22 cases (75% including immediate failures). Computed tomography guided thoracic sympatholysis performed under local anesthesia is an effective treatment for palmar hyperhidrosis. Morbidity is low and hospital stay is short. CONCLUSIONS: Our findings suggest that thoracic sympatholysis should be indicated as the first intention procedure when surgery is required in patients with palmar hyperhidrosis.

Results of carotid surgery in elderly patients.

METHODS: We have evaluated the results of carotid surgery in 252 patients of 75 years and over age (A group) including 281 interventions between June 1st 1985 and December 31st 1993. RESULTS: These results have been compared to those obtained in 660 patients of less 75 years (B group), operated on over the same period of time (741 interventions). In the A group, the mean age was 78.2 (from 75 to 89) and 37.3% were women. Nicotinism, obesity and dyslipaemia was significantly more frequent in A group. An angor was shown in 48% in A group (versus 38.8% in B group). In A group, 34.5% (n = 97) of patients were neurologically asymptomatic against 41.7% (n = 309) in B group. Four patients aged over 75 died (1.42% per intervention), one from myocardial infarction, the other from postoperative stroke. Three other patients showed a non regressive postoperative neurological deficiency. The Cumulated Rate of Mortality Morbidity (CRMM) in A group is then 2.49% per intervention. It does not significantly differ from B group results: mortality = 1.48% (n = 11, 10 of neurological origin), CRMM = 3.23% per intervention. We counted 4 myocardial infarctions (1.58%) in A group and 5 (0.75%) in B group. The mean time after the interventions was 58 months. The five years actuarial survival is 73% of A group patients and 85% for B group patients. In A group patients, 44% of deaths are of coronary origin and 35% in B group patients. The actuarial rate of people free from neurological deficiency, after 5 years, is 90.9% in A group and 92.4% in B group. CONCLUSIONS: In this study, age does not seem to be a risk factor in carotid surgery. The elderly patients must be selected according to the same criteria as the under 75, save the estimation of intellectual faculties and autonomy.

Iliac aneurysm in a child complicating umbilical artery catheterization.

We report a case of an iliac artery aneurysm in a 9-year-old girl due to Staphylococcus aureus infection of an umbilical arterial catheter inserted at birth. After resection-anastomosis of the iliac artery the postoperative course was uneventful and hemodynamic data remain normal at 2 years. A review of the literature indicates that the prognosis of infective aortoiliac aneurysm is poor in children, except when the aneurysm is located solely in the iliac artery. Arterial continuity should be restored as late as possible after infection using a technique consistent with normal growth of the artery in the child.

[Role of surgery in the treatment of dissections of the extracranial internal carotid artery. Apropos of a case, review of the literature]. / Place de la chirurgie dans le traitement des dissections de l'artère carotide interne extra-crânienne. A propos d'un cas, revue de la littérature.

The authors report about one operated case of spontaneous dissection of the extracranial internal carotid artery close to the bifurcation. The persistence of a floating thrombus in a 60% stenosis after a six-week treatment with heparin led to establishing the indication for surgery. The surgical indication remains exceptional, considering the natural history of dissections and the frequency of repatency of the arterial lumen. This type of surgery is mainly for sequellae such as stenosis, thrombi or saccular aneurysms, whose emboligenic potential leads to operating (exeresis and graft on the internal carotid artery) if the anatomical location of the lesion makes it possible.

[Crossed ilio- and femoro-femoral revascularizations. Apropos of 50 cases]. / Revascularisations ilio et fémoro-fémorales croisées. A propos de 50 observations.

Results are reported after a mean follow up of 3 years (max: 8 years) of cross-over ilio- and femoro-femoral revascularizations performed in 50 patients for severe arterial disease of lower limbs. Mean age of the patients was 62 years. Operative mortality was nil and immediate permeability 98%. Five year actuarial curves showed a survival rate of 76%, and a permeability of 71% globally and of 85% in patients under 55 years of age. Limb conservation rate was 90% (amputations). Tolerance and reliability of these cross-over revascularizations are discussed, and precise details given of the anatomic and functional conditions of the donor limb that allow use of the method, the technique involved and the associated procedures on the donor arterial axis and the place of this cross-over type of surgery. It is concluded from analysis of the literature and the author's personal experience that ilio- or femoro-femoral bypass surgery is a well tolerated rational procedure. Its indication of choice is for iliac thromboses (arterial or prosthetic) in elderly patients exposed to the risk of an anatomic repair, but its use is also justified in young patients for aortic sparing by avoiding immediate performance of an aortofemoral revascularization.

Pulmonary uptake of Tc-99m-Labeled methylene diphosphonate in a patient with a parathyroid adenoma.

Intense diffuse uptake of Tc-99m-labeled methylene diphosphonate was seen in both lungs of a patient submitted to surgery for a primary parathyroid adenoma. Five scans performed over the 3 yr following the operation showed persistence of lung uptake despite restoration of normal blood calcium concentration. Mild chronic renal failure caused by the hypercalcemia also persisted postoperatively. The present case confirms that pulmonary uptake of bone tracer can occur asymptomatically when both hypercalcemia and renal failure are present. Lung uptake of a bone tracer probably reflects tissue deposition of hydroxyapatite rather than of amorphous structures. Correction of the hypercalcemia failed to resolve the abnormal scan pictures.

[Barotraumatic rupture of the esophagus : a case report (author's transl)]. / Rupture barotraumatique de l'oesophage. A propos d'un cas.

A case of barotraumatic rupture of the thoracic esophagus with a favorable outcome is reported, and the 12 cases found in the published literature reviewed. Mortality was 3 out of 5 in unoperated cases, and only 1 out of 7 in the patients treated by surgery. This emphasizes the need for early diagnosis, thoracotomy for esophageal repair, drainage by-passing digestive secretions, and parenteral feeding, this constituting the best guarantee in the fight against mediastinitis.