Treatment of lymphorrhea with exposed or infected vascular prosthetic grafts in the groin using sartorius myoplasty.

Thirteen myoplasties using the sartorius muscle were performed on 12 patients from 1980 to 1985 for "healing problems" in the groin with subjacent synthetic grafts. Persistant aseptic lymphorrhea was the indication for 4 patients. In 3 other cases, bacterial cultures from the wound were positive. In 2 other patients there was clinical evidence of sepsis with purulent discharge from the wound and an exposed graft. In 3 cases myoplasty was used as a preventive measure after reoperation on patients in poor general condition. Follow-up extends from 3 to 54 months. There was only one recurrence observed at 19 months which was successfully treated by segmental resection of the infected graft and insertion of a new prosthesis through the obturator canal. No recurrence was observed among the other patients as judged by clinical observation and biological tests for inflammation, echotomography, CT scan and indium scintigraphy. The treatment of choice for an infected prosthesis should be removal of the graft and extra-anatomic bypass in the majority of cases. However in some situations, excision of the wound and myoplasty using the sartorius muscle may be of some value and needs further evaluation.

Endovascular repair of iliac artery aneurysm with Endoprosystem I: a multicentric French study.

Due to their position deep in the pelvis, the classical surgical treatment of iliac artery aneurysm leads to a high morbidity and mortality rate. The transfemoral percutaneous repair of these aneurysms is now possible thanks to a new device the endoprosystem I from "Mintech". We began in 1994 a study including radiological, cardiac and vascular centers all of them skilled in endovascular procedures. 27 patients entered the study: 1 patient died, 2 attempt failed and 2 presented leakage: the immediate failure rate was then 18.5%. For the late result (min 6, Max 19, mean 12 months) we had 1 thrombosis treated by surgery, 1 restenosis treated by PTA. We did not see any polyester dilatation or reactivation of aneurysm at the scan control at one year. We conclude that the percutaneous treatment of iliac aneurysm is possible and safe but we need long term result to validate the method.

[Comparative study of short and medium-term results of angioplasty and bypass in severe or unstable angina pectoris caused by isolated stenosis of the anterior interventricular branch]. / Etude comparative des résultats à court et moyen terme de l'angioplastie et du pontage dans l'angor sévère ou instable par sténose isolée de l'IVA.

This retrospective non-randomized study deals with 146 patients subjected to revascularization procedures for severe or instable angina pectoris due to isolated stenosis of proximal or middle anterior interventricular artery, without myocardial infarction in the anamnesis. The patients were divided into two comparable groups: group A (74 patients) treated by an aorto-coronary bypass saphenous vein graft; group B (63 patients) subjected to transluminal coronary angioplasty. None of them presented an associated cardiopathy. The patients were controlled after 10.4 months (group A) and 9.1 months (group B); a physical stress-testing was performed according to the same protocol in the two groups, and control coronarography in group B. The evolution was characterized by one death in each group and a more frequent incidence of infarction (6.7%) in group A than in group B (2.7%, p = NS). The symptomatology in both groups was comparable: 12.1% in group A and 9.1% in group B was free of symptoms. Also the stress-testing yielded similar results: a negative and maximal in 43.6% in group A and 56.4% in group B. When positive at the control (in 27% of group A and 36% of group B) the threshold of appearance of ischemia was delayed only in group B. Thus even if the functional results are comparable in the two groups, the risk of infarction is less after angioplasty, in return, however, for 23% of recurrent stenoses.

[Congenital subclavian steal syndrome. Apropos of 14 cases. Review of the literature]. / Le vol sous-clavier congénital. A propos de 14 observations. Revue de la littérature.

Fourteen cases of the congenital subclavian steal syndrome are presented with a review of 99 cases in the literature. This abnormality is usually asymptomatic and a fortuitous finding (clinical: asymmetric blood pressure; radiological: investigation of an associated cardiovascular malformation). The possible malformations are numerous and may be diagnosed by angiography: however, they can be suspected from three simple investigations, clinical examination indicating the side of lower blood pressure, chest X-ray and barium swallow. Seventy one per cent congenital subclavian steal syndromes are associated with a right-sided aortic arch, the steal being then almost always left-sided via a left subclavian artery anomaly. In this group, a left subclavian artery isolated from the aorta represents about a half of the cases. A cardiac malformation is present in one out of two cases and a patent ductus arteriosus uniting the left subclavian artery and the left pulmonary artery is observed in one out of four cases. Twenty nine per cent of congenital subclavian steal syndromes are associated with a left-sided aortic arch. In these cases the abnormalities usually involve the aortic arch (57% of cases) or a right or left subclavian artery. Therefore, in this group, there is no preferential side for the subclavian steal which can be right, left or bilateral. These abnormalities usually only require medical surveillance. When they become symptomatic, vertebro-subclavian revascularisation is justified. The presence of a subclavian steal may have surgical implications: it is important to exclude a subclavian steal before performing a Blalock anastomosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Arteriovenous fistula caused by spontaneous rupture of an aortic or iliac aneurysm in the iliocaval venous system. Apropos of 2 cases]. / Fistule artério-veineuse par rupture spontanée d'un anévrysme aortique ou iliaque dans l'axe veineux ilio-cave. A propos de 2 observations.

The authors report two cases of arteriovenous fistula due to spontaneous rupture of an aortic or iliac aneurysm into the iliocaval venous axis. This is a rare complication of atheromatous aneurysm (less than 4% of ruptured aneurysms), often difficult to diagnose as the clinical presentation may be obscure. Although aortography is the reference diagnostic investigation, color Doppler ultrasonography enabled visualisation of the arteriovenous communication and provided an accurate diagnosis in one recent case. Treatment of these aortocaval fistulae is always surgical. The prognosis and immediate operative mortality depend mainly on the presence of an associated retroperitoneal rupture.

[Traumatic tricuspid insufficiency. Apropos of 2 cases]. / Insuffisance tricuspide traumatique. A propos de 2 observations.

The authors report two cases of tricuspid regurgitation by a ruptured anterior papillary muscle secondary to non-penetrating thoracic trauma. In the presence of suggestive clinical and electrocardiographic abnormalities (systolic murmur, right heart failure, right bundle branch block), echocardiography confirmed the tricuspid regurgitation, showed its mechanism and excluded any other intracardiac lesions. Tricuspid annuloplasty was performed in both cases because of the persistence of failure or degradation of the patient's clinical condition. Peroperative echocardiography was used to judge the quality of the surgical repair in both cases. Traumatic tricuspid regurgitation is a rare condition and the diagnosis is often delayed. Echocardiography is the investigation of choice and guides treatment which is essentially valvular repair in symptomatic patients.

[Durability of the Carpentier-Edwards porcine bioprosthesis in aortic or mitral positions. 10 years' results on 458 surgically treated cases]. / La durabilité des bioprothèses porcines de Carpentier-Edwards en position aortique ou mitrale. Résultats à dix ans sur 458 opérés.

458 patients with a Carpentier-Edwards porcine bioprosthesis (aortic (Ao): 169, mitral (Mi): 289) operated between January 1975 and December 1981, were studied during the first trimester of 1987. Forty seven patients underwent an associated operation. The total follow-up was 3,001 patient-years with a maximum follow-up of 11.4 years and a mean follow-up of 6.5 years. Only 5.6% of patients were lost to follow-up. The patients were aged between 20 and 80 years. The actuarial 9-year survival rate was 69.2 +/- 6.3% for aortic prostheses and 79.6 +/- 3.9% for mitral prostheses. The principal cause of valve failure, appearing with a considerable frequency after 5 years, was primary tissue degeneration which alone represented 67.8% of the causes of valve failure. The rate of absence of valve failure, for all causes combined, was 77.8 +/- 5.9% for the aortic position and 74.9 +/- 4.9% for the mitral position. The actuarial rate of absence of primary tissue degeneration at 9 years was 79.7 +/- 4.1% for aortic prostheses and 75.2 +/- 4.4% for mitral prostheses. The frequency of tissue degeneration decreased with increasing age, representing 2.9%, 1.9% and 1.5% patient-years respectively for the age-groups: 20 to 39 years, 40 to 59 years and 60 to 80 years. However, this difference was not statistically significant. Tissue degeneration was the principal cause for reoperation (n = 59) with an operative mortality of 7.8%.

Graphology for the diagnosis of suicide attempts: a blind proof of principle controlled study.

To evaluate the ability of two graphologists and two practising internists not trained in graphology to differentiate letters written by subjects who have attempted to commit suicide by self-poisoning and healthy volunteers, we performed a maximal blind controlled study vs. healthy volunteers. Forty fully recovered patients who had attempted to commit suicide and 40 healthy volunteers wrote and signed a short letter or story not related to the parasuicide or their mental health status. The evaluators classified the 80 letters as 'suicide' or 'no suicide' in an intention-to-treat analysis. Letters expressing sadness were subsequently excluded for a per-protocol analysis. Correct diagnosis of suicide and of healthy controls was made in, respectively, 32 of 40 and 33 of 40 letters by the graphologists and in 27 of 40 and 34 of 40 letters by the internists. After the exclusion of 12 letters expressing sadness, the sensitivity, specificity, positive predictive value and negative predictive value were, respectively, 73, 88, 81 and 82% for the graphologists and 53, 89, 80 and 71% for the internists. Both classified the letters with significantly more effectiveness than chance (p < 0.001) with no statistically significant difference between the two groups of evaluators. We concluded that graphological analysis is able to differentiate letters written by patients who attempt suicide from those written by healthy controls. This technique shows an acceptable degree of accuracy and could therefore become an additional discharge or decision-making tool in Psychiatry or Internal Medicine.

Subclavian artery aneurysm secondary to a cervical supernumerary rib in a child.

A case of subclavian artery aneurysm secondary to a cervical supernumerary rib is reported in a 9-year-old boy. Such a complication in a cervical rib has never been reported in so young a child. The risk of inserting inextensible prosthetic material in a growing child led to regular supervision instead of an early surgical cure.

[Malignant pheochromocytoma. A case report in a 10-year-old boy with vertebral metastasis]. / Phéochromocytome et problèmes de malignité. A propos d'un cas de phéochromocytome malin avec invasion vertébrale.

This is a case report of a malignant pheochromocytoma in a 10 years old boy with attacks of abdominal pains, diarrhea, visual difficulties and hypertension. No familial history was noted. At that time, a large functionally active and extraadrenal tumor was surgically removed just above the diaphragm. 3 years later, a retroperitoneal active recurrence required a 2nd operation. Then, a vertebral invading obliged to resect almost the whole T 12 and to stabilise the rachis with a double osteosynthesis, by a posterior and anterior approach. Although this may represent compression and invasion of the bone rather than a true metastasis, the authors think that the clinical course demonstrates malignancy. They emphasize the fact that the acceptance of strict criteria should help to overcome much of the confusion regarding the diagnosis of a malignant pheochromocytoma. It is generally accepted that such a diagnosis cannot be made in the absence of metastases, irrespective of the histologic picture. The technical problems of peri-neural surgery are also discussed.

Persistent sciatic artery: case report, anatomy, and review of the literature.

We report the case of a 64-year-old woman with an aneurysm of a left persistent sciatic artery presenting with arterial insufficiency from distal embolization. Treatment was exclusion of the aneurysm and femoropopliteal bypass after distal embolectomy with a Fogarty balloon catheter. We reviewed 71 cases in the literature to define characteristics of this anomaly which has many synonyms: including persistent sciatic artery, persistent axial artery, ischiopopliteal trunk. The persistence of the sciatic portion of the embryonic dorsal axial artery and failure of development of anastomoses with the ventral femoral network results in the anomaly. The persistent sciatic artery was "complete" in 75% of cases. In this configuration, it arises from the internal iliac artery, leaves the pelvic cavity through the lower part of the greater sciatic foramen caudad to the pyriformis muscle, reaches the posterior compartment of the thigh and continues as the popliteal artery. In 35% of cases, the artery is aneurysmal with a pulsatile mass in the buttock or a complication of the aneurysm. Arteriography required for diagnosis of the mass leads to discovery of the anomaly in many cases. The treatment of choice is exclusion followed by femoropopliteal vein bypass.

Transluminal recanalization of occluded iliac arteries: a surgical experience.

The purpose of this study was to evaluate the feasibility of transluminal techniques in an unselected group of patients and to assess long-term outcome in successful procedures. All patients in whom iliac artery recanalization was attempted were included in this study. Patients with an occluded prosthesis or recent embolism were excluded. A total of 37 patients were studied. Assessment of the success or failure of the procedure was based on the results of control arteriography. Recanalization was deemed successful in 31 patients. This study demonstrates that transluminal recanalization of occluded iliac arteries by a surgeon is indeed feasible. Primary patency was 66% at 24 months. The potential risk, however, is long-term restenosis. Thus follow-up examination every 6 months is recommended including pressure index measurements after exercise and color Doppler ultrasonography of the recanalized zone.

Use of ipsilateral greater saphenous vein as a valved transplant in management of post-thrombotic deep venous insufficiency: long-term results.

Incompetence of the deep venous valve is a common feature of post-thrombotic deep venous insufficiency. Various surgical techniques have been proposed to treat reflux. In this study we describe long-term results of a novel transposition technique using the ipsilateral greater saphenous vein. From 1984 to 1994 we used this procedure to treat 16 patients including 10 men and 6 women with a mean age of 56 years (range: 25 to 76 years). In all 16 cases the indication for surgery was incapacitating pain associated with recurring ulceration in 9 patients. From the results of using this technique we conclude that transposition using the ipsilateral greater saphenous vein is safe and effective with good mid-term results, especially for pain. For ulcers the primary success rate was 55% but this increased to 84% with proper surveillance and treatment of secondary insufficiency of the superficial venous system.

End-to-side aortoprosthetic anastomoses: long-term computed tomography assessment.

Fifty-two asymptomatic patients underwent routine computed tomographic evaluation of aortobifemoral bypass grafts implanted end-to-side on the aorta five to 10 years after operation. Anteroposterior diameters were measured at the level of the stem and the limbs of the graft, the aortoprosthetic anastomosis, and the infraanastomotic aorta. The stems of the prostheses were found to be dilated between 30 and 110% (mean 58%) of initial values. The limbs of the graft were dilated between 15 and 150% of initial values, the mean being 52%. The anteroposterior diameter of the aortoprosthetic anastomosis measured between 27 and 48 mm with a mean of 32 mm. Eight patients (15%) had an anastomotic false aneurysm. The aorta distal to the prosthetic anastomosis was completely occluded in 48 cases (92%). A mural thrombus was encountered at the level of the aortoprosthetic anastomosis in 21 (40%) patients. These findings raise questions as to the possible role of side-to-end aortoprosthetic anastomoses in the genesis of anastomotic dilatations, false aneurysms, intraprosthetic thrombosis, and thrombosis of the branches of aortofemoral bifurcation prosthetic grafts.