The recurrent cervical swelling syndrome.

The objective of this study is to report an overlooked cause of cervical swelling linked to a thoracic duct (TD) intraluminal obstruction. Four consecutive patients underwent supraclavicular fossa echo-colour-Doppler assessment (ECD) because of recurrent spontaneous cervical swelling. In all patients, during the swelling period we documented a TD dilation with hyperechogenic content, resulting undetectable during asymptomatic periods; ECD also allowed an effective differential diagnosis with TD cysts, obstructive malignancy or other causes of cervical swelling. In conclusion, ECD is to be considered an effective tool in cervical swelling and TD anomalies investigation.

[Role of duplex Doppler for superficial "angiomas"]. / Place de l'échodoppler dans les "angiomes" superficiels.

Diagnosis of superficial vascular anomalies, previously called "angiomas", is basically clinical. Ultrasound and duplex Doppler imaging is a simple and helpful tool to confirm the clinical diagnosis and/or to suggest further required imaging modalities. The purpose of this work is to demonstrate the usefulness of duplex Doppler and ultrasound for exploring vessel and soft tissue components of vascular anomalies.

Curative treatment of pelvic arteriovenous malformation--an alternative strategy: transvenous intra-operative embolisation.

OBJECTIVES: Pelvic arteriovenous malformations (AVMs) are difficult to treat. Arterial embolisation is the most common strategy but often has poor results. We report an alternative surgical approach of controlled intra-operative transvenous embolisation with long-term results in seven cases. MATERIALS AND METHODS: Between 1980 and 2008, we treated seven patients (four men, three women, mean age 50 years). Indications were rectal bleeding (one case), urinary tract problems (four cases), oedema of lower limb (one case) and high-output cardiac failure (one case). Four of them had previous operations and three had previous attempts for embolisation. Embolisation of the malformation was performed through the internal iliac vein. This was done after clamping of all the feeding and draining vessels. The agent used was cyanocrylate (one case), Ethibloc (one case) and bone wax (five cases). RESULTS: Mortality was 0%. Complications occurred in two patients (28,5%), one pulmonary embolism and one regressive femoral paresis. Three patients were re-operated for various reasons. The mean follow-up period was 6 years (1-12 years). Symptoms resolved in all patients, while control by computed tomography (CT) angioscan revealed one residual shunt. CONCLUSION: Complete surgical excision of pelvic AVMs is not always possible. Embolisation does not offer a permanent cure. Intra-operative transvenous embolisation of persisting complex AVMs appears to be an alternative approach with good immediate and long-term results. Ethylene glycol appears to be the most suitable agent.

Trust between patients and health websites: a review of the literature and derived outcomes from empirical studies.

With the exploding growth of the web, health websites have become a dominant force in the realm of health care. Technically savvy patients have been using the web not only to self inform but to self diagnose. In this paper we examine the trust relationship between humans and health websites by outlining the existing literature on trust in health websites. A total of forty-nine papers were examined using a meta-analytical framework. Using this framework, each paper was coded for the antecedents and facets that comprise user trust in health websites. Our findings show that there is little consensus regarding the defining characteristics of the construct of trust in health websites. Further research in this field should focus on collaboratively defining trust and what factors affect trust in health web sites.

The psychological burden of an initially unexplained illness: patients with sternocostoclavicular hyperostosis before and after delayed diagnosis.

BACKGROUND: Sternocostoclavicular hyperostosis (SCCH) is a rare, debilitating, chronic inflammatory disorder of the anterior chest wall due to a chronic sterile osteomyelitis of unknown origin. SCCH is largely underdiagnosed and often misdiagnosed. In individual cases it can remain unrecognized for years. The purpose of this study is twofold. Firstly, to evaluate the psychological condition of SCCH patients, both in the sometimes quite extended pre-diagnostic period between first manifestations and confirmed diagnosis of the disease, and in the current situation. Secondly, to investigate the relationships between the pre-diagnostic and the current psychological conditions of confirmed SCCH patients. METHODS: Structured interviews were held with 52 confirmed SCCH patients. Questionnaires were included to assess posttraumatic stress symptoms, social support, aspects of pain, illness perceptions, self-reported health status, and quality of life. RESULTS: SCCH patients reported stronger posttraumatic stress symptoms, more unfavorable illness perceptions, lower health status, and poorer quality of life than healthy individuals and patients with other diseases or traumatic experiences. Psychological distress in the pre-diagnostic period was associated with unfavorable conditions in the current situation. CONCLUSION: SCCH is an illness with serious psychological consequences. Psychological monitoring of patients with unexplained complaints is recommended as long as a diagnosis has not been reached.

Delayed-iatrogenic injury of the thoracic aorta by an anterior spinal instrumentation.

We present a case of a 15-year-old girl who presented to us with an unusual low back pain. About 7 years ago, this patient had corrective surgery for her idiopathic left thoracolumbar scoliosis. Recent surgery revealed a laceration of the posterior wall of the thoracic aorta by an impending screw thread. This injury was repaired by the vascular surgeons and, subsequently, the patient had full recovery without any complications.

[Late occlusion of the subclavian artery proximal to mammary bypass]. / Occlusion tardive de l'artère sous-clavière en amont d'un pontage mammaire. 2 observations.

We report the cases of two patients with an occlusion of the left subclavian artery several years after left internal mammary bypass of the anterior interventricular artery. The effect on the myocardium was only apparent after scintigraphy in one case, and was clinical in the second with angina pain on exertion of the upper limb. Re-implantation of the subclavian artery in the common carotid relieved the signs of myocardial ischaemia. While the internal mammary artery is the conduit of choice for coronary revascularisation because it is not affected by atheromatous lesions, this does apply to the proximal subclavian artery. Stenosis or occlusion here can entail ischaemia in the revascularised myocardial territory. Regular clinical and ultrasound surveillance can detect these lesions.

Coagulation abnormalities associated with extensive venous malformations of the limbs: differentiation from Kasabach-Merritt syndrome.

Confusion in the nomenclature of vascular malformations has been a major obstacle to the understanding of these conditions, so that misdiagnosis and treatment inconsistencies are common. Coagulation abnormalities occurring in combination with venous malformations (VM) have been misdiagnosed as Kasabach-Merritt syndrome (KMS), despite marked differences in clinical features, pathology and treatment. A homogenous group of 24 patients with diffuse limb VM was entered into a retrospective chart review study. The VM affected an upper limb in 12 patients, a lower limb in 10 and both in two. Localized intravascular coagulation (LIC) was characterized by a decrease in fibrinogen (0.5-1 g/l), an increase in d-dimers (2-64 micro g/ml) and presence of soluble complex of fibrin (+ to +++). Platelet counts were normal or slightly decreased. Higher VM severity scores were associated with more severe LIC. A number of events such as sclerotherapy, surgery, bone fracture, prolonged immobilization and pregnancy or menstruation triggered conversion of the LIC to disseminated intravascular coagulation (DIC), with bleeding related to factor consumption and multiorgan failure related to disseminated microvascular thrombosis. Clinical symptoms associated with worsening of LIC were pain, thrombosis and bleeding at wound sites or during surgery. None of the patients had the large ecchymotic and inflammatory tumours seen in KMS. Graded permanent elastic compression with heparin therapy was the only effective treatment. In conclusion, VM-associated LIC is a distinctive lifelong coagulopathy that must be differentiated from KMS, which is characterized by platelet trapping within a vascular tumour of infancy. The treatment of the two conditions is very different.

[Percutaneous angioplasty of the infra-renal aorta. Report of 9 cases]. / Angioplastie endoluminale de l'aorte abdominale sous-rénale. A propos de 9 cas.

Between June 1996 and September 2000, nine angioplasties of the infra-renal aorta were performed in two Surgical Vascular Centers (Hospital Saint-Joseph, Paris, Polyclinic La Baule), in 6 men and three women age ranged from 36 to 72 years (middle age 48 years and 2 months). Eight of these patients presented important stenoses of the middle infra-renal aorta, or in the aortic bifurcation, one of them presented an occlusion, leading to severe intermittent claudication, and rest pain. After endoluminal kissing balloon angioplasty, five aortic stents (five patients), and six iliac primitive arteries stents (in three patients), extended beyond the aorta, were placed. One isolated angioplasty was also performed. All the procedures were performed in the operative room, with good results, except for one patient requiring emergency aorto-bi-femoral by-pass, because of acute leg ischemia, immediately following the procedure. Follow-up was clinical, with Us-Doppler scan, and angiogram in all cases. After 36 months follow-up (4-52), all patients are asymptomatic, with permeable stents. This technique is well-known since 1980, without excessive morbidity. Aortic angioplasty represents the right technique, with good long-term results, for middle or terminal aorta atheromatous stenosis, according to classical aorto-bi-femoral by-passes. Final result depends on associated iliac arteries stenoses.

[Critical ischemia of the leg. A technique for distal anastomosis in a a small caliber artery]. / Ischémie critique des membres inférieurs. Un artifice pour anastomose distale sur artère de petit calibre.

CRITICAL ISCHEMIA OF THE LOWER LIMBS: This type of lesion, which spontaneously progresses to gangrene and amputation, is encountered more and more frequently. Emergency endoluminal revascularization or bypass surgery is required. When conventional endoluminal techniques cannot be used, a distal graft using the autologous saphenous vein is a promising alternative to achieve patent vascularization and salvage the limb. IF VENOUS MATERIAL IS NOT AVAILABLE: Usable venous material is not always available due to varicosities, thrombus formation, small size or previous surgery (stripping, coronary surgery, prior revascularization procedure); rates reported range from 20 to 40%. For such patients, other veins (external saphenous, arm veins, superficial femoral veins) may be useful but are not always appropriate for distal repair. Different prostheses might also be used but again do not always provide improved permeability. Most teams however use a polytetrafluoroethylene stent for revascularization of the distal leg. Different technical improvements favor success of prosthetic bypasses, but when used below the knee, flow remains less satisfactory than with venous bypasses. VEIN CUFFS: This procedure is a common adjuvant technique positioning a venous cuff between the recipient artery and the prosthesis. The cuff avoids the direct contact between the prosthesis and the fragile artery that is often difficult to suture. RESULTS: Several series have demonstrated that the rate of success of vein cuff procedures remains lower than venous bypass procedures, but also that flow is better than with simple femorotibial prostheses. PATHOGENIC HYPOTHESES: The reduction of the neo-intimal hyperplasia observed in experimental models is insufficient to explain entirely the observed in vivo benefit. The fact that the suture is easier to make is one possible reason. Indeed the rate of failure of simple prosthetic bypass surgery is high in the immediate postoperative period. These cases of thrombosis result from technical insufficiencies and are undoubtedly overcome by the use of the venous cuff.

[Blunt force rupture of the thoracic aorta and diaphragm: an unusual association]. / Rupture de l'isthme aortique et de la coupole diaphragmatique droite: une association inhabituelle.

The aim of this study was to report two cases of rupture of the right hemidiaphragm with intra-thoracic liver hernia, associated with a traumatic aortic disruption. These two lesions followed traffic accidents, and were both treated separately. Both patients had a long-term favourable progression. Association of these two lesions is particularly rare: fewer than 50 cases have been previously described in an extensive review of the literature. CT-scan seems to be particularly efficient in diagnosis, even if less efficient than other more specific explorations. The order of surgical management is guided by the physical examination, and especially by abdominal emergency.

Aneurysms of the internal iliac artery: management strategy.

With the widespread use of CT scans, detection and treatment of internal iliac artery aneurysms (IIA) have become more frequent. In the last few years, endovascular repair has been added to the therapeutic arsenal. We reviewed the records of 38 patients treated for 44 IIA between 1987 and 1997 to assess immediate and long-term outcome using various therapeutic methods. Aneurysms were divided into three groups according to the circumstances of treatment. Group I included 25 IIA treated at the same time as abdominal aortic aneurysm (AAA). The morbidity/mortality rate in this group was comparable to that in patients who underwent isolated AAA repair. Group II included 14 IIA treated during follow-up of AAA repair. Most complications in this group were intraoperative. Group III included five isolated IIA not associated with AAA repair. Complications were similar to those in group I. On the basis of this retrospective analysis, we propose a management strategy in which open surgery, endovascular repair, or both are used, depending on the circumstances of treatment.

Embolized ischemic lesions of toes in an afibrinogenemic patient: possible relevance to in vivo circulating thrombin.

Fibrinogen plays a complex role in hemostasis, thrombosis, and vascular disease. Hyperfibrinogenemia is an independent vascular risk factor and dysfibrinogenemia can provoke thrombosis. Afibrinogenemia is usually responsible for hemorrhagic diathesis, and unexpected ischemic lesions are intriguing. We report the case of an afibrinogenemic patient, who at the age of 30 developed ischemic lesions of the feet related to severe stenosis of the iliac and hypogastric arteries. The biopsy of the iliac artery lesion showed an intense myointimal hyperplasia. We performed standard hemostatic analysis and analyzed the activation markers of platelets and coagulation factors and the kinetics of thrombin generation in the patient and in normal control plasmas treated or not with reptilase. Occlusive arterial lesions were attributed to a disruptive hematoma penetrating the vascular lumen. Thrombin concentration after calcium addition increase markedly in the afibrinogenemic patient and in defibrinated normal plasma, as compared to untreated normal plasma. Thrombin-antithrombin complexes (T-AT) were markedly enhanced while F1+2 prothrombin fragments stayed in the normal range. These results suggested activation of coagulation and in vivo circulating thrombin. Thrombin activates the platelets that secrete growth factors for smooth muscle cells and generate the intimal hyperplasia. Recurrent hemorrhage within the vessel wall might induce injury and local thrombin generation. Thrombin not trapped by the clot is available for platelet activation and smooth muscle cell migration and proliferation. The absence of a protective fibrin cap on the intima might account for intima vulnerability and embolization. Afibrinogenemia appears in this paradoxical situation as a vascular risk factor.

Transient relief of abdominal angina by Wallstent placement into an occluded superior mesenteric artery.

A 56-year-old man presented with complete occlusion of the superior and inferior mesenteric arteries resulting in chronic mesenteric ischemia. After a minimal angioplasty a Wallstent was inserted across the superior mesenteric artery occlusion. This produced immediate clinical relief, with a successful angiographic result. Eight months later, an intrastent occlusion with acute bowel infarction was treated in emergency by saphenous vein bypass graft. Despite the death of the patient a few days later from a multivisceral failure syndrome, this method seemed to us feasible in treating a chronically occluded SMA in patients with high operative risk.

[Which indications and techniques for lower limb arteriopathy obliterans and proximal aorto-iliac lesions?]. / Artériopathie oblitérante des membres inférieurs et lésions proximales aorto-iliaques: quelles techniques? Quelles indications?

Atherosclerotic aorto iliac occlusive disease are not the most frequent lesions in the lower limbs. Isolated aortic iliac lesions are often associated with intermittent claudication; critical ischemia with proximal aorto iliac lesions can be due to acute occlusion or associated femoropopliteal occlusive lesions. Preoperative explorations need Duplex Scan, Arteriography and CT Scan to define extensive lesions and wall' calcifications. Endovascular procedures are, in this lesion, safe, effective and permit to delay conventional surgery. The best strategy, today, needs to known endovascular procedures and surgical procedures to obtain the most efficient anatomic result.