[Peroperative angiography in reparative surgery of the lower limbs. Apropos of experience with 1099 cases]. / L'angiographie per-opératoire dans la chirurgie de restauration des membres inférieurs. A propos d'une expérience de 1,099 cas.

The authors report their experience of per-operatory angiography in a series of 1,099 cases over 13 consecutive years. The main interest is the limitation in the rate of early reintervention, which frequently causes morbidity and mortality in this type or surgery. The serial nature of the technique is emphasized, and is most comparable to pre-operatory exploration. The various technical details are specified. Some hemodynamic troubles noted during injection (aortography) contraindicate the method in high-risk subjects. The main indications are, above all, control of restorative acts, but also a per-operatory diagnosis of a lesion, and the assessment of blood stream at a lower level. The results are morphological and the various anomalies discovered are reviewed, with iconography, in relation to each type of surgical act (disobliteration, bypass). In situ bypasses are considered separately. The data are also hemodynamic, and justify the six successive X-ray film technique. Deblocking (embolectomy with a balloon catheter) and endarterectomies were found to give more technical imperfections than bypasses. The rate of extemporaneous corrections tripled during the second period (1978 to 1986), and this was no doubt due to an extension in operative indications (19% versus 6% at the beginning). Dacron bypasses (fibrinous debris) and in situ bypasses (detection of anatomical abnormalities, location of shunts) were more often incriminated in immediate reinterventions than Dardik homografts or PTFE.

[Peroperative measurement of peripheral vascular resistance. Significance for the indications, technic and prognosis of distal bypasses. Apropos of 35 cases]. / La mesure per-opératoire des résistances vasculaires périphériques. Intérêt pour les indications, la technique et le pronostic des pontages distaux. A propos de 35 cas.

The authors report their experience of the per-operative measurement of the "absorption capacity" of a distal vascular network. This constitutes an absolute measurement and provides a reliable per-operative indication of a bypass, and eventually that of surgical reintervention in early thrombosis. The techniques are described with a brief overview of the major physical laws in this field. As a predictive test, the measurement is highly reliable, and a threshold value of 3 PRU was found in the series; beyond this value, all bypasses were thrombotic. A brief survey of the literature considers the theme of peripheric resistances. A table of clinical indications is situated at the end of the study, and is related to values of residual pressure and peripheric resistance. Glossary: R: peripheral resistance PAF: Pressure in femoral artery P: Pressure (mmHg) Pr: residual pressure Rp: Physiological resistance RS: stenotic resistance RC: Resistance due to collateral flow D: Femoral flow d and d': successive variations of flow.

[Are axillo-distal bypasses justified? Apropos of 70 cases over an 8-year period]. / Les pontages "axillo-distaux" sont-ils justifiés? A propos de 70 cas sur 8 ans.

Seventy axillary/distal artery shunts were carried out in 67 patients between 1978 and 1985. Mean age of patients was 71.5 years; 34% had coronary disease, 39% respiratory insufficiency, 12% diabetes and 12% severe renal impairment. Indications for the operation were sepsis in Scarpa's triangle (5 cases) and to save a limb with major ischemic lesions (65 cases including 14 stage III, 28 stage IV and 23 acute ischemic lesions). One-stage operation was performed in 37 cases and a two-stage procedure in 33. In 80% of cases the distal artery was the upper popliteal (11 cases) or lower popliteal (45 cases) artery. In 14 cases the distal artery was either the fibular (6 cases) anterior tibial (4 cases) or posterior tibial (4 cases) artery. Allowing for the context, the results justify this "maximalist" attitude (16% operative mortality, 43 limbs saved at 6 months, 31 at 1 year, 19 at 2 years). Three factors are determinant for permeability of shunts: severity of initial clinical stage, level of distal anastomosis and type of material used.

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.