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

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

[Lymphedema of the lower limbs: CT staging]. / Lymphoedème des membres inférieurs: apport du scanner.

Routinely performed, CT is useful and reliable for staging lower limb lymphedema. We describe methods we utilized. We found in frequency order: skin thickening, subcutaneous tissues area increase in regard the safe limb, perimuscular aponevrosis thickening, fat infiltration: lines parallel to the skin, edematous areas along perimuscular aponevrosis, lines perpendicular to the skin. The lowest fat density is increased on the pathologic side. Subfascial compartment is slightly fattened. We found huge differences between primary and secondary lymphedema for the thigh. Same images may be generated by old or young lymphedema. Rarely useful for positive diagnosis, CT is indispensable for secondary lymphedema staging (initial staging or after a recent increase). It seems us indispensable for any pretherapeutic staging (whole objectively disorders, exact upper limit, infraclinic bilaterality).

[Femoro-popliteal emboli: treatment by manual thrombo-aspiration]. / Embolies fémoro-poplitées: traitement par thrombo-aspiration manuelle.

Acute arterial thrombo-embolic pathology constitutes a common pathology in the elderly population, principally in cases of cardiac arrhythmia. Out study allowed analysis of the results of percutaneous manual thrombo-aspiration as a primary procedure in a series of 25 patients (average age: 73.3 +/- 11.3 years) presenting with a picture of acute femoro-popliteal ischaemia, of supposed cardiac origin. Most of the patients had an arrhythmia with atrial fibrillation (68%), and 88% had grade II ischaemia. The site of proximal occlusion most frequently found was the popliteal axis (22 patients). Thrombo-aspiration was performed in all cases via the common femoral route homo-lateral with the ischaemia, by anterograde approach, after having obtained a diagnostic angiograph of the opposite side. The procedure, with an average duration of 39 minutes, allowed restoration of good quality flow in at least 2 axes subjacent to the occlusion in 23 patients (92%). Besides two failures, two complications (8%) were counted (one Scarpa haematoma and one early re-thrombosis). This good result was sustained long term, with 94% of patients reviewed on average 3 years after the procedure remaining asymptomatic. Manual thrombo-aspiration thus constitutes a technique of choice in the framework of the management of acute infra-inguinal emboli due to its angiographic and functional results on the one hand, and its low morbidity on the other, in a population particularly exposed to the risk of spontaneous and post-operative vascular complications.

[Computerized tomography of 150 cases of lymphedema of the leg]. / Tomodensitométrie de 150 cas de lymphoedèmes des membres inférieurs.

The aim of this work was to evaluate the usefulness of CT imaging to stage lower limb lymphedemas. Between 1992 and 1997, we studied 150 cases of lymphedema, half idiopathic and half secondary. Methods used are described. In decreasing order of frequency, we found: skin thickening, increased subcutaneous tissue surface area compared with the healthy limb, thickening of the perimuscular aponevrosis, fat infiltration: lines parallel to the skin (parallel), edematous areas along the perimuscular aponevrosis, lines perpendicular to the skin (perpendicular). The lowest fat density was increased on the diseased side. The subfascial tissue showed some fat accumulation. These results were compared with findings reported in the literature. There were very major differences between idiopathic lymphedema and secondary lymphedema of the thigh. Similar images were generally generated by new and long-standing lymphedema. Rarely useful for positive diagnosis, CT is indispensable for establishing stage initially or after recent increase and, in our opinion, is essential for pretherapeutic assessment. The CT-scan gives objective evidence of overall disorders, the exact upper limit of the lymphedema, and sometimes reveals infraclinical bilateral involvement.

Transaxial computer tomography of lower extremity lymphedema.

We examined retrospectively 11 patients with isolated unilateral lower limb lymphedema (clinical criteria confirmed by isotope lymphography) using computer tomography. In conjunction with earlier observations, the findings of soft tissue stranding, skin thickening, fat deposition in the epifascial compartment and perimuscular fascial thickening and edema relate to lymph stasis. This noninvasive and relatively simple imaging technique allows analysis of soft tissue changes in leg lymphedema and can be used to evaluate lymphatic insufficiency and its extent as well as document the response to treatment.

[Percutaneous angioplasty of the renal arteries. Long-term results of 222 operations]. / Angioplastie percutanée des artères rénales. Résultats à long terme de 222 procédures.

OBJECTIVES: Determine the relative role of percutaneous angioplasty of the renal arteries in the treatment of renovascular hypertension. METHODS: From September 1984 to June 1993, we performed 222 angioplasties in 196 patients with renovascular hypertension. There were 186 atheromatous stenoses of the renal arteries and 36 fibromuscular dysplasias. Certain patients had associated moderate renal failure but variations in renal function were not considered in this study. RESULTS: The operation was hemodynamically successful in 180 cases (86%) including 165 cases with residual narrowing less than 30% and 27 between 30 and 50%. In 10 cases (4%), residual stenosis was greater than 50%. Complications at the site of angioplasty occurred in 13 cases (6%) including parietal damage (n = 10) due to hemodynamic pressure (n = 4), thrombosis (n = 2), and arterial rupture (n = 1). Mean follow-up in 131 patients was 2 years. Among these patients, clinical success was obtained in 93 (70%) including 12 complete cures (9%) and 81 improvements (62%). Cure of hypertension was better in patients with dysplasia (30% success rate) than in those with atheroma (5% success rate). Rate of clinical cure was higher for lesions of arterial branches (82%) than in main trunks (69%) or ostium (68%). Among the 38 cases of clinical failure (30%) there were 28 angiographically proven cases of restenosis including 16 which underwent redilatation leading to improvement in 6 (38%). CONCLUSION: These findings confirm the efficacy of percutaneous endoluminal angioplasty for the treatment of renovascular hypertension and suggest that this technique should be used as first line therapy.

Long iliac stenosis: initial clinical experience with the Cragg endoluminal graft.

PURPOSE: To determine the feasibility of use of a self-expanding nitinol stent covered with polyester fabric in long iliac stenoses. MATERIALS AND METHODS: In 10 patients with 12 iliac artery stenoses (6-10 cm long [mean, 7.5 cm]), a Cragg endoluminal graft was placed percutaneously after failure of percutaneous transluminal angioplasty. RESULTS: At angiography after implantation of 15 Cragg endoluminal grafts, patency was restored and the dissection flap was eliminated without any residual stenosis in all cases. At 1-13-month follow-up (mean, 7 months), eight patients were asymptomatic, with a mean ankle-brachial index of 0.90 +/- 0.15 (standard deviation). Arterial rupture occurred in one patient, with thrombosis of the artery with the stent within 1 day. In one patient, tight restenosis was seen at the proximal part of the stent. In another patient, moderate restenosis was seen at the distal junction of the prosthesis with the native artery, but restenosis did not occur within the stent. The 6-month primary patency rate of the stent graft was 80%. CONCLUSION: In long iliac artery stenoses, the deployment of the Cragg endoluminal graft is feasible and no short-term complications were seen.

[Results of endoprostheses in the iliac arteries; an experience apropos of 47 implantations]. / Résultats des endoprothèses dans les territoires iliaques; expérience à propos de 47 implantations.

Obstruction or stenosis of the iliac artery was treated by placement of an endoprothesis in 41 patients. A total of 47 lesions was treated. 26 patients had poor results of balloon angioplasty including residual stenosis (7 cases), restenosis post angioplasty (7 cases), and dissection (12 cases). 15 patients had iliac occlusion. The endoprothesis used was a self expandable flexible endoprothesis (Wallstent) in 26 cases and a balloon expandable flexible endoprothesis (Strecker) in 21 cases. Complications included one thrombosis of the endoprothesis occurred immediately after placement, one hematoma. No distal embolization occurred. Patency at the end of the study was 70% at 9 months and 50% at 21 months. Patency was better with the Wallstent endoprothesis (60% at 21 months) than with the Strecker endoprothesis (38% at 21 months). Results was better with lesions of the common iliac artery, and when the indication was dissection or failure of angioplasty. During the 21 months of follow-up 18 occlusions or restenosis occurred. At the end of the study 20 patients (49%) were asymptomatic and improvement was achieved in 9 (22%), the clinical success rate was 71%. One amputation was required.

[Atrophic polychondritis presenting as multiple arterial stenosis. Report of a case]. / Sténoses artérielles multiples inaugurales d'une polychondrite atrophiante. A propos d'un cas.

A case of multiple arterial stenosis is reported in a pattern with atrophic polychondritis. The disease was diagnosed retrospectively nine years after the first vascular signs on the basis of clinical course. Atrophic polychondritis is a rare connective tissue disease with characteristic chondritis. Cardiovascular involvement occurs in one-fourth of the cases during the clinical course leading to poor prognosis. Stenosis of the peripheral arteries has not been reported, to our knowledge, as the inaugural sign in atrophic polychondritis.

[Modern imaging of atheromatous aneurysms of the abdominal aorta]. / Imagerie moderne des anévrismes athéromateux de l'aorte abdominale.

Radiologic imaging advances, during the last decade, deeply modified diagnosis, follow up and preoperative staging of aortic abdominal atheromatous aneurysms. When congenital, infectious and inflammatory aneurysms are rare, atheroma is the most frequent etiology of aneurysms. Ultrasonography is actually very reliable for aneurysms diagnosis. Inexpensive, it is the best exam for early screening in a risk population (arterial hypertension). If ultrasonography is adequate for diagnosis and follow up, two tests are necessary for pretherapeutic staging: arteriography and computed tomography (CT). CT is more accurate than ultrasonography. It is realized just after arteriography without any other contrast media injection. Angiography of aorta and limbs vessels shows the whole arterial system and allows the adaptation of surgical procedure. IRM is more expansive and less accessible, it has not proved it superiority versus CT. It is realized only when CT is unwise (allergy, renal failure). Helicoidal CT will be in the future the best exam to study the whole vascular system and will probably take the place of arteriography and CT.

[Renal artery occlusion: percutaneous revascularization]. / Occlusion de l'artère rénale: revascularisation percutanée.

The value of percutaneous revascularization of acute or chronic occluded renal arteries is demonstrated in 9 cases. Recanalization and dilatation was technically successful in 6 patients. The authors stress the importance of anatomo-radiologic criterion for successful recanalization. This technic is an attractive alternative to surgery specially in short occlusion.

[Proximal tubal obstruction. Treatment by recanalization and transcervical dilatation]. / Obturations tubaires proximales. Traitement par recanalisation et dilatation transcervicale.

Forty-three fluoroscopic transcervical fallopian tube recanalizations were performed in 30 consecutive patients whose infertility was due to proximal tubal obstruction demonstrated by hysterosalpingography and laparoscopy. All had been recommended tubal microsurgery or in vitro fertilization. Thirty fallopian tubes (81 percent) were successfully recanalized, with balloon dilatation in 20 (57 percent). Six intrauterine and one ectopic pregnancies resulted from successful tuboplasty. Six women who did not conceive underwent follow-up hysterosalpingography 6 months on average after tuboplasty; 2 were found to have tubal reocclusion. There was no difference in our results between patients simply recanalized and those in whom recanalization was combined with balloon dilatation. We conclude that transcervical balloon tuboplasty is an effective treatment of infertility caused by proximal tubal obstruction.

[Evaluation of the myocardial ischemic and arrhythmogenic risk of digitalized angiography by venous route. Apropos of a comparative trial of ioxaglate and iopamidol]. / Evaluation du risque ischémique myocardique et arythmogène des angiographies numérisées par voie veineuse. A propos d'un essai comparatif de Ioxaglate et de Iopamidol.

Cardiac tolerance to digital subtraction angiography by venous route (DSAV) was evaluated during a prospective study of a continuous series of 100 patients of both sexes investigated for various arterial diseases, and classified previously as "cardiac" and "non-cardiac". A permanent 12 lead ECE recording by sequences of 3 allowed study of ischemic and rhythmic changes provoked by randomly allocated injections of contrast media, Ioxaglate or Iopamidol. Major cardiac complications were not observed in the 98 patients studied (2 excluded), but in 32.6% auricular extrasystoles (AES) and/or ventricular extrasystoles (VES) were noted and in 19.4% a painless widening of the ST segment of 0.5 mm or more. The and ST widening were more frequent in the VES 40 patients classed as "cardiac" than in the 58 "non cardiac" (35% against 8.6%, p less than 0.01 and 37.5% against 6.9%, p less than 0.001 respectively). The two products did not differ with respect to their effect on frequency of repolarization anomalies, whereas Ioxaglate provoked more VES than Iopamidol (30% against 8%, p less than 0.02). It is concluded that cardiac tolerance to DSAV is good, but that the frequency of VES and painless repolarization ischemic disorders observed, even with only weakly hypertonic contrast media of non ionic type, suggests that their indications be limited and that certain precautions are necessary in cardiac patients.

[Evaluation of cardiac tolerance of intravenous digital angiography]. / Evaluation de la tolérance cardiaque des angiographies numérisées par voie veineuse.

Cardiac tolerance to intravenous digital subtraction angiography (ANVV) was evaluated by a prospective study in a continuous series of patients of both sexes investigated for various arterial diseases and classified initially into "cardiac" and "non-cardiac" cases. Ischemic and rhythmic electrocardiographic modifications were monitored, the contrast medium (PC) used being randomly selected between Ioxaglate and Iopamidol. Of the first 46 patients studied, 40% had had more than one auricular and/or ventricular extrasystole (ES), 18% had painless depression of the ST segment (greater than or equal to 0.5 mm) and 46.7% both effects. In the 17 "cardiac" patients, depression of ST and the ES were more frequent (p less than 0.02 and p less than 0.05 respectively) than in the 29 "non-cardiac" cases. There was absence of difference between Ioxaglate and Iopamidol with respect to frequency of disorders of repolarization, but Ioxaglate appeared to provoke more ES than Iopamidol (respectively 13 of 23 and 5 of 22 cases, p = 0.02). Major cardiac complications were not reported, and it is concluded, after discussion of cardiovascular effects of PC injection, that intravenous digital subtraction angiography is generally well tolerated but requires some precautions in patients with cardiac affections.

[Indications for arteriography for chronic obliterative arteriopathy of the lower extremities]. / Indications des artériographies pour artériopathie chronique oblitérante des membres inférieurs.

The indications of aorto-arteriography and femoral arteriography in the investigation of chronic occlusive arterial disease of the lower limbs, were reviewed in 161 patients with respect to clinical parameters, age, associated risk factors, symptoms, the presence of a femoral pulse and with respect to treatment:revascularisation or not, and level of revascularisation. Ninety-four aorto-arteriographies and 67 femoral arteriographies were performed. Aortography was carried out more commonly in young patients (p less than 0,001) without associated risk factors, with exercise symptomatology (p less than 0,0001) and with reduced or absent femoral pulses (p less than 0,0001). Conversely, femoral arteriography was performed more frequently in elderly patients with associated diseases, in the presence of symptoms at rest and when the femoral pulses were present. The absence of revascularisation was not related to age, symptoms or type of arteriography performed. The level of revascularisation on the other hand, was related to clinical and angiographic parameters. An aorto-femoral revascularisation was performed more commonly in young patients (p less than 0,01) with decreased or absent femoral pulses (p less than 0,001) in whom aorto-arteriography had been performed (p less than 0,00001). The level of revascularisation was not related to clinical symptoms. An algorithm can be elaborated from this data on the respective indications of aorto-arteriography in the investigation of chronic occlusive arterial disease of the lower limbs based on clinical parameters and the therapeutic possibilities.