Salvage treatment for venous aneurysm complicating vascular access arteriovenous fistula: use of an exoprosthesis to reinforce the vein after aneurysmorrhaphy.

OBJECTIVES: We report a new salvage technique for treating venous aneurysms (VAs) complicating vascular access arteriovenous fistula (AVF) using externally reinforced venous aneurysmorrhaphy. DESIGN: A retrospective study over a 20-month period from a single centre. PATIENTS: Patients presenting to the vascular surgery department, Bordeaux University Hospital for revision of a vascular access AVF were included. METHODS: Reinforced venous aneurysmorrhaphy consisted in removal of redundant vessel wall followed by reinforcement using an external prosthetic graft. Patency, diameter and flow were assessed by duplex ultrasound at 1, 6 and 12 months after salvage. RESULTS: Thirty-eight eligible patients were identified. Five were excluded because VA was associated with central vein stenosis; the remaining 33 underwent salvage. Indications were rapidly expanding or painful VA in seven cases; VA with frequent bleeding or damaged overlying skin in eight; VA in close relation to a stenosis in two; and VA associated with high-flow rate in 16. Cannulation was attempted after 30 days. Mean follow-up time was 12 S.D. 5 months (range: 4-22). Two repaired AVFs failed. Primary 1-year patency was 93%. No aneurysm or infection occurred. Reduction of high flow was successful in 12 of 16 patients. The remaining four required re-operation. CONCLUSIONS: Reinforced venous aneurysmorrhaphy is effective in controlling venous dilation and achieving patency. Reduction of high-flow rates was not always achieved. Further study is needed to evaluate long-term efficacy of this treatment.

[Laparoscopic management of median arcuate ligament syndrome]. / Traitement du syndrome du ligament arqué médian par voie coelioscopique.

Median arcuate ligament syndrome is a rare disorder resulting from luminal narrowing of the celiac trunk. The classic management of median arcuate ligament syndrome involves the surgical division of the median arcuate ligament fibers in order to decompress the celiac trunk. This has traditionally required an upper midline incision. A few authors have described a successful laparoscopic release of celiac artery compression syndrome. Laparoscopy provides a less invasive, but equally effective method for decompressing the celiac trunk.

[Cerebral vasoreactivity: Concordance of breath holding test and acetazolamide injection in current practice: 20 cases of asymptomatic carotid artery stenosis]. / Étude de la vasoréactivité cérébrale en Doppler transcrânien : évaluation du test d'apnée comparé à l'injection d'acetazolamide en soins courants. Exploration de 20 sténoses carotidiennes asymptomatiques.

INTRODUCTION: Cerebral vasoreactivity (CVR) is the ability of the brain's vascular system to keep cerebral blood inflow stable. Impaired CVR is a risk marker of stroke in patients with asymptomatic carotid stenosis. The gold standard to assess CVR with transcranial ultrasound is acetazolamide (ACTZ) injection. The breath holding test (BHT) might be easier to perform. CVR proved to be efficient in laboratory conditions but not in routine practice. OBJECTIVES: To study the validity of BHT versus ACTZ in routine practice in a vascular exploration unit in patients with asymptomatic carotid stenosis. METHODS: Study of concordance of BHT and ACTZ, to assess CVR in patients consecutively explored on the same day. RESULTS: Eighteen patients with 20 carotid stenosis were included. The temporal window was missing in 20% of cases. Only 11 out of the 20 procedures were analyzed. Concordance was low between BHT and ACTZ to assess CVR (k=0.3714). CONCLUSION: BHT cannot replace ACTZ injection. It might be a first-step test so that ACTZ injection might be avoided if CVR is normal. Our present results must be confirmed by further study enrolling many more patients.

Mild hyperhomocysteinemia and hemostatic factors in patients with arterial vascular diseases.

Mild hyperhomocysteinemia, due to genetic or to environmental factors, is now recognized as a risk factor for premature arterial disease, including peripheral arterial occlusion, thrombotic stroke and myocardial infarction. It is defined by either an increased level of fasting homocysteine or by an increased level after loading with methionine, which is more frequently altered than the former. We studied the hemostatic parameters in 88 patients with premature arterial disease (mean age 43 +/- 11 years). We confirmed previously known hemostatic alterations described in vascular patients when compared to controls, but found that, among patients, some of these parameters were more altered in hyperhomocysteinemic patients. When fasting homocysteine was increased, higher alterations were found in factors VIIIc, von Willebrand and thombin-antithrombin complexes were more elevated. When post-methionine load homocysteine was increased, alterations in fibrinolytic parameters were more pronounced.

Could non steroidal anti-inflammatory drugs be used to potentiate L.M.W.H activity in thrombosis? (Part I).

Heparin fractions are antithrombotic drugs prescribed for preventive treatment but their efficacy must be optimized to permit curative use without side effects. The present study was performed on 144 rats receiving a low molecular weight heparin (L.M.W.H), Fraxiparine, and a non steroidal anti-inflammatory drug (Phenylbutazone), which were injected simultaneously or separately. Neither Phenylbutazone nor L.M.W.H at their lowest dose (1 mg/kg) reduced thrombus size. However, administered together, they produced a significant limitation of thrombus growth. Variation in anti Xa activity limitation was only observed with the highest dose of Fraxiparine alone or in combination with Phenylbutazone (1 mg/kg) corresponding to its antithrombotic effect.

[Blunt trauma to the infrarenal abdominal aorta with neurologic lesions. Case report and review of the literature]. / Traumatisme fermé de l'aorte abdominale sous-rénale avec lésions neurologiques. Stratégie de prise en charge: à propos d'un cas et d'une revue de la littérature.

We report the case of a 31-year-old female involved in a severe motor vehicle accident. The diagnosis of blunt trauma to the abdominal aorta was not retained initially. The patient was referred to our institution when she developed a delayed paralysis of the lower limbs associated with the disappearance of both femoral pulses. Computed tomography evidenced dissection of the infrarenal aorta and NMR ruled out injury to the spinal cord. An aortoiliac endarteriectomy was then performed. Neurological recovery was partial at 3 months. We reviewed the frequency, the mechanisms and the management of blunt trauma to the abdominal aorta.

[Retrospective study of the one-year patency of a cuffed polytetrafluoroethylene Venaflo-type graft placed for venous hemodialysis access]. / Etude de la perméabilité à un an des anses de dialyse en polytétrafluoroéthylène avec chambre d'anastomose veineuse de type venaflo.

PURPOSE: The objective of this study was to determine retrospectively the one year patency of a new polytetrafluoroethylene (ePTFE) graft with a cuff at the graft-vein anastomosis (Venaflo, Bard industries) placed for hemodialysis access. METHODS: From April first 1999 to December thirty first 2001, 37 consecutive patients (56.8 medium age) underwent 39 Venaflo graft for hemodialysis in Vascular Surgery Section from Bordeaux University Hospital. All medical files have been reviewed at the end of the first year following the operation, by consultation or phone call from the referent nephrologist. Six patients deceased with a functional graft before the end of the study. The patency outcomes were calculated with Kaplan Meier life table method. RESULTS: The one year primary patency is 60.03% with a 95% confident interval [43%; 77%] and secondary patency is 83.73% [70%; 96%]. CONCLUSION: The patency of cuffed ePTFE grafts for hemodialysis was satisfactory in comparison with the result of classic ePTFE grafts in the medical literacy. A large prospective multicentric medium term study would be necessary in order to confirm or not these results.

Deterioration of in-situ vein bypasses: anatomic study of 11 cases.

During the follow-up of 130 patients with in-situ bypasses 11 patients were reoperated following the detection of degenerative changes. The lesions found included anastomotic aneurysms (1), diffuse dilatation (2), localized aneurysms (5), stenosis of valve sites (2), and diffuse narrowing (1). The mean interval for the onset of a lesion was eight months. Histologic findings showed fibrous thickening of the intima, replacements of myocytes by collagen in the media, and moderate adventitial fibrosis. With some quantitative differences these changes are similar to those reported in reversed vein bypasses. It is therefore concluded that devascularization of the adventitia, as happens in reversed bypasses, is not an important etiology in the development of degenerative changes. The better patency rate reported for in-situ bypasses is the result of hemodynamic factors, but not because in-situ bypasses are protected from degenerative changes by their intact adventitial supply.