[Acquired factor XI inhibitor and chronic lymphocytic leukemia]. / Allongement du TCA chez un patient atteint de leucémie lymphoïde chronique : à propos de la très rare découverte d'un autoanticorps antifacteur XI.

Autoimmune phenomena, most frequently autoimmune hemolytic anemia, is a well-known complication of lymphoproliferative diseases. We report a very rare association of a chronic lymphocytic leukemia with an acquired factor XI inhibitor. A 87-year-old man presented with auto-immune hemolytic anemia. He had untreated chronic lymphocytic leukemia for the past three years and renal insufficiency. Before surgical procedure for arteriovenous fistula, we discovered a very prolonged activated partial thromboplastin time (APTT), and an acquired factor XI inhibitor was detected. The patient was successfully treated with immunosuppressive therapy. Among patients with lymphoproliferative disorders the discovery of a prolonged APTT implies to search for rare autoimmune phenomena like acquired coagulation factor inhibitors.

[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.

Endovascular management of axillary artery trauma.

A 17-year-old man was seen with an expanding false aneurysm of the right axillary artery. This was treated by an intraluminal covered-stent introduced through the brachial artery via an 11F sheath. The covered-stent was constructed from a segment of great saphenous vein anchored in the axillary artery by a 29 mm Palmaz stent. Postoperative arteriography and duplex scanning confirmed normal flow through the axillary artery with complete exclusion of the aneurysm. Postoperative recovery was uneventful.

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.

[Abdominal emergencies in type IV ehlers-Danlos syndrome]. / Urgences abdominales du syndrome d'Ehlers-Danlos de type IV.

Ehlers-Danlos syndrome denotes a group of inherited connective tissue diseases comprising nine types. Type IV Ehlers-Danlos syndrome is the most life-threatening form. It is characterized by a type III collagen deficiency resulting in arterial fragility and death from vascular rupture or bowel perforation. This disease involves a col 3A1 gene mutation. We report the case of a 44 year-old woman with type IV Ehlers-Danlos syndrome. The medical history of our patient included bowel necrosis and two vascular ruptures. We indicate data required to establish Ehlers-Danlos syndrome diagnosis and guidelines for patient management.

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.

Ruptured abdominal aortic aneurysm. A ten year experience.

METHODS: During the last ten years, 84 patients treated for ruptured infrarenal aortic aneurysm have been reviewed to evaluate complications and mortality rates, to determine which factors influenced these rates and to identify the means to improve these results. RESULTS: The intraoperative mortality and the overall mortality rates were respectively 21.4% and 57%. The factors which influenced hospital mortality were analyzed. The most important factors were the age, the depth of the initial shock, the volume of blood transfused and the location of rupture. CONCLUSIONS: These factors cannot be controlled by the surgeon and it should be noted that a significant reduction of the mortality rate may be very difficult or even impossible to achieve. These findings support the concept of aggressive elective resection of abdominal aortic aneurysms.

[Surgical treatment of colonic diverticulosis: results of a series of 70 cases]. / Traitement chirurgical des diverticuloses coliques: résultats d'une série de 70 observations.

Results are reported on a series of 70 patients operated upon for colon diverticulosis, surgery being elective in only 23 (32.9%) cases. Global mortality (12.9%), was higher in patients over 70 years of age (P < 0.01) and for emergency cases (17% against 4.3% (NS) after cold surgery). Global morbidity was 20%, the onset of septic complications being influenced (p < 0.01) only by treatment with antiinflammatory drugs. Despite the absence of precise factors predictive of the course of diverticular disease, it should be possible to further improve the very poor prognosis in patients with serious septic complications (Hinchley's stages I to IV) by: prophylactic colectomy in symptomatic diverticulosis, improved evaluation by complementary examinations, notably the scanner, of localized septic complications (stages I and II), with the possible association of guided puncture to avoid the septic areas and to allow performance of a cold colectomy without the need for colostomy. Certain severe septic complications may still develop and these cannot be totally prevented by any therapy. In these cases preference is given to resection of the septic focus using mainly Hartmann's operative techniques. Further studies are needed to evaluate those cases where protected anastomotic resection provides the best results, since in the long term the incidence of re-establishment is higher.