Phosphorus nuclear magnetic resonance evidence of abnormal skeletal muscle metabolism in chronic alcoholics.

Pathophysiologic events leading to rhabdomyolysis in alcoholics are not clearly understood. We examined 18 alcoholic patients (10 with and 8 without a recent history of rhabdomyolysis) and 15 healthy non-alcoholic volunteers by phosphorus nuclear magnetic resonance spectroscopy of thenar eminence muscle. At rest, phosphocreatine, ATP, and pH levels were similar in patients and control subjects. During aerobic exercise, phosphocreatine utilization was greater, pH fell more slowly, and maximum acidosis was less in alcoholics with previous rhabdomyolysis than in control subjects. During ischemic exercise, both patient groups exhibited a significantly slower and smaller decrease in pH than did control subjects. These findings are consistent with impaired muscular glycolysis or glycogenolysis in both alcoholic groups. This metabolic myopathy may contribute to the onset of acute rhabdomyolsis.

Effects of sodium bicarbonate on striated muscle metabolism and intracellular pH during endotoxic shock.

The effects of HCO3Na load on acid-base balance and muscle intracellular bioenergetics have been investigated using 31P-magnetic resonance spectroscopy in an experimental model of endotoxinic shock. Anesthetized, mechanically ventilated, and paralyzed rats (n = 16) were given an intravenous bolus of Escherichia coli lipopolysaccharide (15 mg/kg). When shock was established they were randomly assigned to receive either HCO3Na intravenously (2 mmol/kg in 2 min) or an equimolar saline injection. Lipopolysaccharide induced a significant decrease in the levels of mean arterial pressure (58 +/- 6 vs. 120 +/- 8 mmHg), arterial pH (7.20 +/- .03 vs. 7.35 +/- .01), intracellular pH (6.86 +/- .04 vs. 7.08 +/- .01), a marked hyperlactatemia (7 +/- 3 vs. 1.2 +/- .2 mmol/L) and a drop in the phosphocreatine-inorganic phosphate ratio. In the bicarbonate-loaded rats, mean arterial pressure further decreased whereas it remained unchanged in the saline group. Bicarbonate increased arterial pH and PaCO2 transiently. In the saline group, arterial pH decreased and PaCO2 remained stable. In both groups, intracellular pH and high energy phosphates had a similar evolution. In this model of septic shock, partial correction of arterial pH using HCO3Na did not reduce the metabolic cellular injury in skeletal muscle. Based on these results, HCO3Na may be of limited therapeutic value in severe septic metabolic acidosis.

Effects of epinephrine on hemodynamics and oxygen metabolism in dopamine-resistant septic shock.

The hemodynamic effects of epinephrine were prospectively studied in 13 patients with septic shock who remained hypotensive after both fluid loading and dopamine. Hemodynamic measurements were performed before and one hour after the start of epinephrine infusion. Systolic, diastolic, and mean arterial pressure increased in all patients (p less than 0.01). Cardiac index and systemic vascular resistance increased by 34 and 32 percent, respectively (p less than 0.05), but heart rate and pulmonary vascular resistance remained unchanged. There was a concomitant increase in oxygen delivery (p less than 0.01) and oxygen consumption (p less than 0.05), the magnitude of the latter being related to baseline lactacidemia (p less than 0.01). In view of the generally recognized physiologic goals of septic shock management, we conclude that epinephrine could be an appropriate alternative where fluid loading and dopamine have failed.

Hemodynamic and metabolic effects of rapid correction of hypophosphatemia in patients with septic shock.

STUDY OBJECTIVE: To examine the hemodynamic and metabolic short-term effects of hypophosphatemia correction in patients with septic shock receiving catecholamine therapy. DESIGN: Prospective, single cohort study. SETTING: ICU, university hospital. PATIENTS: Ten patients with septic shock and hypophosphatemia below 2 mg/dL. INTERVENTIONS: Infusion of glucose-1-phosphate solution (20 mmol of elemental phosphorus) for 60 min. MEASUREMENTS AND RESULTS: Hemodynamic, oxygen-derived, acid-base, and electrolyte parameters before and immediately after phosphate infusion. Left ventricular stroke work index increased significantly (22%) from a mean low value of 24 +/- 10 g/m2 without changes in filling pressures. Systolic arterial pressure improved by 12%. Arterial pH improved slightly but significantly. Ionized calcium level slightly decreased within the normal range values. Other parameters remained unchanged. CONCLUSIONS: Severe hypophosphatemia may be considered as a superimposed cause of myocardial depression, inadequate peripheral vasodilatation, and acidosis in septic shock. A rapid correction of hypophosphatemia is well tolerated and may have both myocardial and vascular beneficial effects. The magnitude of the response, however, is variable and unpredictable on the basis of serum phosphorus levels.

Prognosis of stroke patients undergoing mechanical ventilation.

OBJECTIVE: to determine the outcome of stroke patients undergoing mechanical ventilation. DESIGN: retrospective chart review and follow-up telephone interview. SETTING: medical ICU in a multidisciplinary university hospital. PATIENTS AND PARTICIPANTS: 199 stroke patients from 1984-1989 where the final diagnosis was stroke. INTERVENTIONS: all patients were admitted for the need of mechanical ventilation. MEASUREMENTS AND RESULTS: demographic information, previous relevant diseases, stroke type, general clinical and neurological data, biochemical variables, severity of illness were recorded for the first 24 h following ICU admission. A 1-year follow-up was performed, including mortality and functional status of survivors. Of 170 eventually analyzable patients, 123 (72.4%) died during their ICU stay and 156 (91.8%) during the first year. Three variables were independently associated with one-year mortality: Glasgow score < 10 (p < 0.03), bradycardia (p < 0.001), absence of brainstem reflexes (p < 0.0004). CONCLUSION: overall prognosis of stroke needing mechanical ventilation is poor, strongly linked to symptoms of neurological impairment.

Comparison of systemic and regional effects of dobutamine and dopexamine in norepinephrine-treated septic shock.

OBJECTIVES: To compare the effects of dobutamine and dopexamine on systemic hemodynamics, lactate metabolism, renal function and the intramucosal-arterial PCO(2) gap in norepinephrine-treated septic shock. DESIGN: A prospective, interventional, randomized clinical trial. SETTING: Adult medical/surgical intensive care unit in a university hospital. PATIENTS: After volume resuscitation, 24 patients were treated with norepinephrine alone titrated to obtain a mean arterial pressure of 75 mmHg and a cardiac index greater than 3. 5 l/min(-1). m(-2). INTERVENTIONS: Patients were randomized to receive an infusion of dobutamine (n = 12) (5 microg/kg per min) or dopexamine (n = 12) (1 microg/kg per min). MEASUREMENTS AND MAIN RESULTS: Baseline measurements included: hemodynamic parameters, renal parameters (diuresis, creatinine clearance and urinary sodium excretion), gastric mucosal-arterial PCO(2) gap, arterial and mixed venous gases and arterial lactate and pyruvate levels. These measurements were repeated after 1 (H(1)), 4 (H(4)) and 24 (H(24)) h. No difference was found between dobutamine and dopexamine among H(0) and H(1), H(4) and H(24) values for hemodynamics. Dobutamine and dopexamine at low doses had no significant effect on mean arterial pressure, heart rate, cardiac index, oxygen delivery, oxygen consumption and pulmonary artery occlusion pressure. No patients developed arrhythmia or electrocardiographic signs of myocardial ischemia. After 4 and 24 h lactate concentration decreased in the dobutamine group from 2.4 +/- 1 mmol/l to 1.7 +/- 0. 7 mmol/l and 1.5 +/- 0.4 mmol/l, respectively, while it increased in the dopexamine group from 2.3 +/- 1 mmol/l to 2.7 +/- 1 mmol/l after 4 h and returned to baseline values after 24 h (2.2 +/- 0.6). After 24 h the lactate/pyruvate ratio decreased in the dobutamine group from 15 +/- 5 to 12 +/- 3 (p < 0.05) while it was unchanged in the dopexamine group (from 16 +/- 6 to 17 +/- 4). Arterial pH increased in the dobutamine group from 7.35 +/- 0.05 to 7.38 +/- 0.07 (p < 0. 05) while it was unchanged in the dopexamine group (from 7.34 +/- 0. 01 to 7.35 +/- 0.10). The PCO(2) gap decreased after 1 and 4 h in both the dobutamine and dopexamine groups (p < 0.05 with respect to baseline). When looking at individual responses, however, patients from both groups exhibited an increased gastric PCO(2) gap. No difference was found between dobutamine and dopexamine for renal parameters. CONCLUSIONS: In norepinephrine-treated septic shock, low doses of neither dobutamine nor dopexamine caused significant effects on systemic hemodynamics and renal function and both dobutamine and dopexamine inconsistently improved the PCO(2) gap. The present results support the need for individual measurement of the effects of catecholamine on the PCO(2) gap.

Transient non-cardiogenic pulmonary edema following massive ingestion of ethylene glycol butyl ether.

A case of acute poisoning with ethylene glycol butyl ether (EGBE) is reported in a chronic alcohol abuser. On admission the 53-year-old patient was comatose with metabolic acidosis, shock, and noncardiogenic pulmonary edema confirmed by haemodynamic study. Following supportive treatment and haemodialysis the outcome was favorable. The relationship between respiratory failure and EGBE is examined.

Comparison of norepinephrine and dobutamine to epinephrine for hemodynamics, lactate metabolism, and gastric tonometric variables in septic shock: a prospective, randomized study.

OBJECTIVES: To compare the effects of norepinephrine and dobutamine to epinephrine on hemodynamics, lactate metabolism, and gastric tonometric variables in hyperdynamic dopamine-resistant septic shock. DESIGN: A prospective, intervention, randomized clinical trial. SETTING: Adult medical/surgical intensive care unit in a university hospital. PATIENTS: 30 patients with a cardiac index (CI) > 3.51 x min(-1) x m(-2) and a mean arterial pressure (MAP) < or = 60 mmHg after volume loading and dopamine 20 microg/kg per min and either oliguria or hyperlactatemia. INTERVENTIONS: Patients were randomized to receive an infusion of either norepinephrine-dobutamine or epinephrine titrated to obtain an MAP greater than 80 mmHg with a stable or increased CI. MEASUREMENTS AND MAIN RESULTS: Baseline measurements included: hemodynamic and tonometric parameters, arterial and mixed venous gases, and lactate and pyruvate blood levels. These measurements were repeated after 1, 6, 12, and 24 h. All the patients fulfilled the therapeutic goals. No statistical difference was found between epinephrine and norepinephrine-dobutamine for systemic hemodynamic measurements. Considering metabolic and tonometric measurements and compared to baseline values, after 6 h, epinephrine infusion was associated with an increase in lactate levels (from 3.1 +/- 1.5 to 5.9 +/- 1.0 mmol/l;p < 0.01), while lactate levels decreased in the norepinephrine-dobutamine group (from 3.1 +/- 1.5 to 2.7 +/- 1.0 mmol/l). The lactate/pyruvate ratio increased in the epinephrine group (from 15.5 +/- 5.4 to 21 +/- 5.8; p < 0.01) and did not change in the norepinephrine-dobutamine group (13.8 +/- 5 to 14 +/- 5.0). Gastric mucosal pH (pHi) decreased (from 7.29 +/- 0.11 to 7.16 +/- 0.07; p < 0.01) and the partial pressure of carbon dioxide (PCO2) gap (tonometer PCO2-arterial PCO2) increased (from 10 +/- 2.7 to 14 +/- 2.7 mmHg; p < 0.01) in the epinephrine group. In the norepinephrine-dobutamine group pHi (from 7.30 +/- 0.11 to 7.35 +/- 0.07) and the PCO2 gap (from 10 +/- 3.0 to 4 +/- 2.0 mmHg) were normalized within 6 h (p < 0.01). The decrease in pHi and the increase in the lactate/pyruvate ratio in the epinephrine group was transient, since it returned to normal within 24 h. CONCLUSIONS: Considering the global hemodynamic effects, epinephrine is as effective as norepinephrine-dobutamine. Nevertheless, gastric mucosal acidosis and global metabolic changes observed in epinephrine-treated patients are consistent with a markedly inadequate, although transient, splanchnic oxygen utilization. The metabolic and splanchnic effects of the combination of norepinephrine and dobutamine in hyperdynamic dopamine-resistant septic shock appeared to be more predictable and more appropriate to the current goals of septic shock therapy than those of epinephrine alone.

Introduction to hemorheology: theoretical aspects and hyperviscosity syndromes.

Whole blood behaves like a deformable colloidal particle suspension in a macromolecular medium. Pathological variations in the rheological properties of blood and the clinical symptoms they produce form the "hyperviscosity syndromes". The term "hyperviscosity" was originally used for characterising the plasma hyperviscosity observed during macroglobulinemia and it is only recently that the chapter covering hyperviscosity syndrome has been enlarged to describe the syndromes as a state which the increased blood viscosity and increase in flow resistance must be considered as the result of the rheological behaviour of blood taken as a whole (plasma and blood cells). The etiology of hyperviscosity syndromes can be: (a) an increase in total plasma protein levels, or the appearance of a monoclonal protein; (b) the increase in the number of blood cells; (c) the increase in the erythrocyte's internal viscosity; (d) the changes in the erythrocyte's viscoelastic properties; (e) the excessive aggregating tendency of the erythrocytes and perhaps that of the platelets.

Selenium, oxygen-derived free radicals, and ischemia-reperfusion injury. An experimental study in the rat.

Circulatory shock and its treatment have been compared to a whole-body ischemia and reperfusion with activation of oxygen-derived free radicals. A pilot study had suggested a selenium redistribution in this context. To verify this hypothesis, an experimental study was designed. Temporary occlusion of the superior mesenteric artery was performed in 18 male adult Wistar rats using clamping for 0, 10, and 20 min. Hemodynamic and biochemical data were assessed before clamping and 20 min after release of the mesenteric blood flow. After release, mean arterial pressure decreased, plasma lactate increased, and erythrocyte glutathione peroxidase decreased. Plasma and erythrocyte selenium did not change; however, a slight decrease in plasma selenium was observed when related to hematocrit (to take into account the fluid balance). Erythrocyte-reduced glutathione did not change. In contrast, liver and kidney selenium increased, whereas reduced glutathione decreased in kidney, but not in liver after 20 min of clamping as compared to the sham-operated group. These results suggest that, after temporary intestinal ischemia, the changes in selenium and reduced glutathione observed in blood and tissues, like liver or kidney, could be related to a redistribution pattern in selenium metabolism during shock injury.

[Pre-hospital resuscitation and transport of cardiac patients. Apropos of 107 cases of primary transport]. / Réanimation pré-hospitalière et transports des cardiaques. A propos de 107 observations de transports primaires

Report of 107 cases of primary transportation in ambulances especially equipped for coronary patients monitoring. The various delays of admission were studied and the complications occuring during transportation were analyzed, together with the various therapeutic methods applied. On the basis of this personal experience, and to attempt at diminishing the mortality at the acute stage of myocardial infarction, it was advised: --a careful information of the public, --a systematic training of the physicians, --a logic organization of emergency care. Only a coherent set up of fixed and mobile units might result in improvement of the prognosis of the first hours after myocardial infarction.

[Physiopathology and treatment of vascular spasms]. / Physiopathologie et traitement des spasmes vasculaires.

Vasomotricity and tonus of arterial and arteriolar vessels yield to nervous regulation (central and peripheral, hormonal, metabolic) as well as to local myogenic regulation. The main mediators of vasomotricity are catecholamines which, by their alpha and beta effects, have an effect on the second mediator (3'5' AMP) and on calcic exchanges, angiotension, serotonin and prostaglandins which "modulate" vasomotor reactions. Metabolic factors: pH, PO2, PCO2 and electrolytes balance: Na, K, Mg, Ca have to be considered. The role of the metabolism of the wall and the role of red blood corpuscles (ADP) and of platelets (released substances of granules) have to be mentioned. The physiopathology of spasm must take into account topographic variations. One can distinguish spasms by nervous regulation, by catecholamines discharge and by extreme and lasting muscular contraction. Medicines of the spasm can have an effect on the peripheral sympathetic nervous system, catecholamines, the 3'5' AMP and especially on the smooth muscular fibre, more accessorily on red blood corpuscles, platelets and coagulation. Na nitroprussiate and calcium chelating agents are the most active substances to-day.

[Fractionated heparins. The clinician's viewpoint]. / Les héparines fractionnées. Le point de vue du clinicien.

Currently the rapid development of low molecular weight heparins offers the following questions: assessment of such heparins in prophylaxis of thrombo-embolic disease in surgical or medical procedures; comparison with prior, double-blinded, randomized methods of reference like Kakkar's in general, abdominal, genital, neoplastic and especially orthopedic surgery; search of the most effective standardized dose with no reliable biologic data (usual assays are rather complex and concern more activity than efficacy); respect of absolute contraindication but usefulness of these treatments in relative contraindication of high molecular weight heparin; duration, regimen and outcome measures. The most important standpoint concerns the standardized dosage with few or no reliable biologic tests; thus these dosages cannot be adjusted to coagulation assays.

[Hemorheology, hemodynamics and microcirculation. 1]. / Hémorhéologie, hémodynamique et microcirculation. Première partie.

The microcirculation constitutes an ubiquitous vascular network presenting a mesh pattern, and comprising different types of vessels, arterioles, small veins, capillaries, arteriovenous shunts or similar structures, and lymphatics. Many dimensions have to be recognized, or simply mentioned, if one is to understand the hemodynamic and hemorheological particulars of this territory, which differ, in many aspects, from those specific to the macrocirculation (number and length of the vessels, diameter and cross section, intercapillary distance, geometric characteristics, intravascular pressure, pressure gradient, pressure-volume relationship, flow rate, mean velocity of plasma and RBC, velocity profile, local hematocrit, in situ viscosity, kinematic viscosity, wall shearing conditions, local oxygen transport, aggregation and deformability of RBC, leukocyte properties, etc.). The flow rate in capillary tubes and capillary vessels of the living organism varies with many factors, such as proximal hemodynamics, hemorheological characteristics of blood (fibrinogen, macro- and micro-hematocrit), some known effects (Farheus, Farheus Lindqvist), local diameter, the plasma layer which plays the role of the limiting layer, the endothelial film, the wall effect, and so forth. Models of the circulation have been propounded, none of which takes into account the whole of these phenomena due to their great complexity. Hemodynamic and hemorheological interactions provide for a better understanding of certain concepts, such as vascular resistance, hindrance, capacitance, local flow rates, real capillary opening and closing, development of two-directional functional shunts, autoregulation, pressure-volume relationship, critical closing pressure, circulatory current slowing effect, sequelae of intravascular aggregation of formed blood elements.

[Rheologic activation of blood platelets. Preliminary study]. / Activation rhéologique des plaquettes sanguines. Etude préliminaire.

A Couette type coaxial cylinder viscosimeter was used to evaluate the influence of deformation rates up to 20,000/s on blood platelets, in the presence or absence of red cells. Plasma lactate dehydrogenase and haemoglobin levels were determined in order to assess cell lysis and the estimation of beta-thromboglobulin (beta-TG) was considered to be an index of platelet activation. Results for whole blood revealed a change in red cells from 10,000/s upwards, which increased as the rate rose. At the same time, beta-TG rose slowly from the lowest deformation rates then considerably, in relation with the liberation of erythrocytic substances. The rise in LDH and beta-TG levels in platelet rich plasma (PRP) remained small up to 7,000/s approximately, then increased very rapidly, suggesting earlier mechanical and biochemical activation than in whole blood.

[Blood rheology in Raynaud's disease]. / Hémorhéologie des syndromes de Raynaud.

The part played by blood rheological factors in any vasomotor phenomenon is still difficult to define, in relation to its onset, maintenance and possible worsening. A high viscosity may contribute towards a difficulty in flow and viscosity is known to vary in an inverse manner with temperature. Many studies have been published reporting results of rheological investigations in Raynaud's syndromes, but whereas the majority describe both blood and plasma hyperviscosity, others report negative results or those that are interpretable with difficulty. A recent study in 49 patients with Raynaud's syndromes confirmed the presence of elevated blood and plasma viscosity values, particularly in Raynaud's syndromes secondary to other disorders and in digital arteritis. Elevated viscosity levels in "essential" Raynaud's syndromes were significant at low speeds only, suggesting the association of a disorder of erythrocyte aggregation with the properly termed vasomotor disturbance.

[Hemorheology in clinical practice. Introduction to the notion of hemorheologic profile]. / L'hémorhéologie en pratique clinique. Introduction à la notion de profil hémorhéologique.

Although the non-Newtonian characteristics of blood have now been accurately defined, the influence and effect of a hyperviscosity syndrome at the onset of ischemia and in oxygen transport to the tissues remains within the realm of assumptions. Using a simple theoretical approach it can be shown that oxygen transport capacity to the tissues is proportional to the radio H/eta s (where H = hematocrit, eta s = blood viscosity), as long as vascular bed geometry remains constant (with no sign of compensatory vasodilation). With the help of examples, the authors show the changes in oxygen transport as a function of various rheological parameters (red cell aggregation ans deformability). Further, the authors introduce the concept of a hemorheological profile for taking all the hemorheological parameters into consideration and for standardising the presentation of the results for hyperviscosity syndromes.

[Complications of vascular surgery]. / Complications de la chirurgie vasculaire.

Vascular surgery, which in certain life-threatening situations is the only possible therapeutic option, has progressed considerably since its beginning in the 1950s. Because of the constant progression of vascular diseases, this surgery will present, in the forthcoming years, a major public health problem. Because of advances in medico-surgical management, evermore elderly and frail patients can be treated. Perioperative mortality is constantly decreasing, but much progress remains to be accomplished to prevent, avoid or treat, postoperative complications. They are common and serious in these typical patients with cardiovascular diseases (men over 50 years of age, heavy smokers, atheromatous ...). The AA divide these complications into 3 main groups depending on the surgical procedure: abdominal aortic surgery, carotid surgery and arterial and venous surgery of the lower limbs. There is much data on abdominal aortic surgery because these long and complex procedures produce repercussions often involving many systems. The postoperative complications are treated according to the system they involve: cardiovascular, the most serious, respiratory, the commonest, alimentary, neurological, renal, others, as well as combined systems. The AA do not deal with the specific problems associated with cardiac and cardio-thoracic surgery. The AA discuss the different epidemiological findings of the large surgical series published in the 1970s and 1980s. The more recent literature analyses the relationship between preoperative risk factors (atheroma, COAD, hypertension ...), peroperative problems (surgical difficulties, emergencies, massive transfusions, others) and the corresponding postoperative morbidity. Thus a few general outlines of the physiopathology of these different complications emerge. In the light of these notions the few proposed methods will be evaluated in order to improve the preoperative condition of the vascular patient. The AA also review the relevance of the preoperative investigation in patients for vascular surgery. All these measures aim at reducing the incidence and severity of perioperative morbidity.

[Rheologic particulars of venous flow. Physiopathologic consequences]. / Particularités rhéologiques de l'écoulement veineux. Conséquences physiopathologiques.

Hemorheological parameters must be taken into account for a better knowledge of venous flow properties. The postcapillary venules are the region of lowest shear rates and therefore the region of highest whole blood viscosity. Red cell aggregation plays a major role in blood viscosity, especially at low shear rate. This microrheological parameter can be increased in pathological circumstances, including a low capillary flow, venular insufficiency, elevated hematocrit, high levels of acute phase proteins. At the level of the capillaries, microcirculatory stasis leads to a low oxygen supply and consequently to poor metabolic state lowering local ATP levels. As a result, both platelet and white blood cell functions are compromised. Hemorheological studies have shown that both deep venous thrombosis and chronic venous insufficiency are associated with high blood viscosity mainly due to an increased red cell aggregation. This hemorheological vicious circle--stasis promoting hyperviscosity leading to further stasis--could be broken up by therapeutic intervention including hemodilution, fibrinolytic drugs or other specific agents.

[Thrombectomy or thrombolysis in the treatment of proximal phlebitis. Functional long term results]. / Thrombectomie ou thrombolyse dans le traitement des phlébites proximales. Résultats fonctionnels à long terme.

MATERIALS AND METHODS Between 1981 and 1985, 78 iliocaval thrombi were treated by aggressive therapy: 52 surgical thrombectomies were performed by a femoral approach associated, depending on the case, with a caval approach; and 26 iliofemoral thrombi were lysed according to a protocol in which urokinase and plasminogen were used over a 48-h period. Subsequent functional evaluation was based on clinical scoring (0 to 9 points) taking into account functional impairment, edema and trophic disorders. Patency of trunks and the deep valvular state were assessed by Doppler examination and plethysmography. RESULTS In the surgical group, 3 early deaths occurred, only one of which could be attributed to an embolic course. Six weeks after surgery the rate of recurrence of iliac thrombosis was 50% (25% postoperative + 25% secondary). Beyond this period, there were no recurrences of thrombosis. There was a direct, statistically significant relation between the degree of iliac patency and the realization of an ideal thrombectomy on a nonadherent fresh clot. The functional results, assessed after four and a half years of follow-up, are satisfactory (score less than 3) in 80% of patients. The poor results with venous claudication or varicose ulcer all occurred in the case of massive persistent thrombi of the femoral confluence. Valve lesions were signaled in 46% of patients by a massive backflow in orthostatism. In the medical group, a major hemorrhagic complication occurred under urokinase therapy in 11% of patients, including one for whom it was fatal. Sixty percent of patients showed immediate radiological improvement allowing partial or total freeing of a venous confluence. The functional results after 4 years of follow-up were nondisabling in 85% of patients. No leg ulcers were detected. Late iliac patency was low (26%), whereas at the femoral level almost all of the thrombi which remained after lysis became patent again spontaneously. Valve failure was found in 37% of patients. Both groups had very similar late functional results despite rather different anatomical conditions. The iliac patency rate was higher in the surgical group (50% vs 26%), but plethysmographic study showed that in case of therapeutic failure devalvulation was greater after surgery (46% vs 37%).