Patency of direct revascularisation of the hypogastric arteries in patients with aortoiliac occlusive disease.

OBJECTIVES: Various indications for internal iliac artery (IIA) revascularisation have been reported. Revascularisations for gluteal ischaemia and buttock claudication remain controversial and uncommon. The objective of the study was to assess the patency of direct conventional revascularisations (CRs) of the IIA in patients with aortoiliac occlusive disease because few studies have focussed on this specific topic. MATERIALS AND METHODS: The charts of all patients who underwent CR of the IIA, between August 2000 and January 2009, were retrospectively reviewed. We recorded for each patient preoperative vascular work-up. All patients were tested for patency on January 2009. A computed tomography (CT) scan was requested if the duplex scan casts any doubt with regard to patency. If non-patent, the last date for confirmed patency was kept for the analysis. Functional outcomes at the proximal level were also collected. RESULTS: We studied 40 patients with occlusive disease. Buttock claudication was observed in 27 patients (66%), including eight (20%) in whom these symptoms were isolated. The 13 other patients had distal claudication or rest pain and documented proximal ischaemia, justifying the IIA revascularisations. We performed 44 conventional direct revascularisations of the IIA concomitant to aorto- or iliofemoral bypasses in these patients. The overall postoperative patency rate was 89%. Five early occlusions of the IIA remained asymptomatic. The median duration of follow-up was 39 months (3-86 months). The survival rate was 95% at 1 year and 86% at 5 years. The primary patency rate of the IIA was 89% at 1 year and 72.5% at 5 years. Buttock claudication disappeared in 23 of the 27 patients (85%), who were symptomatic at the proximal level prior to surgery. CONCLUSION: Direct IIA concomitant revascularisation has an acceptable patency rate in patients undergoing aorto- or iliofemoral bypasses for occlusive disease. When feasible, this technique appears to be safe for the treatment and prevention of buttock claudication.

Overestimation of moderate carotid stenosis assessed by both Doppler US and contrast enhanced 3D-MR angiography in the CARMEDAS study.

PURPOSE: To evaluate the agreement and diagnostic accuracy of Contrast enhanced magnetic resonance angiography (CE-MRA), Doppler ultrasound (DUS) and Digital subtraction angiography (DSA) in the assessment of carotid stenosis. METHODS: DUS, CE-MRA and DSA were performed in 56 patients included in the Carotide-angiographie par résonance magnétique-échographie-doppler-angioscanner (CARMEDAS) multicenter study with a carotid stenosis ≥ 50%. Three readers evaluated stenoses on CE-MRA and DSA (NASCET criteria). Velocities criteria were used for stenosis estimation on DUS. RESULTS: CE-MRA had a sensitivity and specificity of 96-98% and 66-83% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 94% and 76-84% respectively for carotid stenoses ≥ 70%. The interobserver agreement of CE-MRA was excellent, except for moderate stenoses (50-69%). DUS had a sensitivity and specificity of 88 and 75% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 83 and 86% respectively for carotid stenoses ≥ 70%. Combined concordant CE-MRA and DUS had a sensitivity and specificity of 100 and 85-90% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 96-100% and 80-87% respectively for carotid stenoses ≥ 70%. The positive predictive value of the association CE-MRA and DUS for carotid stenoses ≥ 70% is calculated between 77 and 82% while the negative predictive value is calculated between 97 and 100%. CE-MRA and DUS have concordant findings in 63-72%, and the overestimations cases were recorded only for carotid stenosis ≤ 69%. CONCLUSION: Combined DUS-CE-MRA is excellent for evaluation of severe stenosis but remains debatable in moderate stenosis (50-69%) due to the risk of overestimations.

[Anatomical study of the superficial cervical plexus: application to the prevention of the postoperative sensitive facial deficits]. / Étude anatomique du plexus cervical superficiel: application à la prévention des déficits sensitifs faciaux postopératoires.

INTRODUCTION: The cervical surgery can be complicated of postoperative facial sensory deficits, in particular in using the anterior presternocleidomastoid approach. The purpose of this study was to specify the routes and the links of nerves involved in these sensory deficits (great auricular nerve and transverse cervical nerve with the goal, to deducing, if possible, some modifications of the surgical practices to prevent the deficits. PATIENTS: Ten dissections of the superficial cervical plexus, on preserved anatomical subjects, were made from February till May 2009. Nerves and whole superficial venous network were dissected on all along their route to be able to make several measures of distances and angles. All the data were computerized treated by spreadsheet. RESULTS: The transverse cervical nerve appeared from the posterior edge of the sternocleidomasoid (SCM) muscle in 7.46 ± 1.81 cm s (5,1-10,0) of the clavicle, with an angle of 108.3 ± 8.15° (93-120). Its halving terminal branches was made in 2.92 ± 1.76 cm s (0,4-5,2) of the posterior edge of the SCM muscle, with an angle between these two branches of 74.0 ± 36.8° (40-120). The great auricular nerve appeared from the posterior edge of the muscle SCM in 8.96 ± 1.85 cm (6.4-12.0) of the clavicle, with an angle of 64.5 ± 23.39° (35-110), which modified secondarily to measure 39.5 ± 6.15° (27-45) in the middle of the SCM muscle. At this level, the great auricular nerve and the external jugular vein were almost parallel (1.3° of average difference) and the distance that separated them was 2.24 ± 0.79 cm (0.8-3.5). CONCLUSION: Our study gave us a precise description of the superficial cervical plexus. All the measures allowed the establishment of the routes and the links of these structures to propose peroperating actions to prevent these facial sensory deficits.

[Morphological anatomy of the cranial nerves in their cisternal segment (III-XII)]. / Anatomie morphologique des nerfs crâniens dans leur portion cisternale (du III au XII).

One hundred brains (first injected in cerebral arteries and veins with latex neoprene or India ink and studied under optic magnification) illustrate this anatomic chapter concerning the microsurgical anatomy of the cisternal segment, the neurovascular relationships, and the blood supply of the IIIrd to the XIIth cranial nerves.

Surgery of the pretransversal vertebral artery: indications and results.

AIM: The aim of this study was to evaluate our results with elective vertebral arteries surgery, to emphasize the indications of such revascularization and to compare it with previous larger studies. METHODS: The medical records of all patients who underwent a pretransversal vertebral artery (VA) revascularization between 1990 and 2004 at our University Hospital were retrospectively reviewed. RESULTS: Forty patients, with a mean age of 60.5 years, met the criteria for VA surgery and accounted for 4.2% of the vascular surgeries involving the brain. Seventeen (42.5%) patients presented with vertebrobasilar insufficiency of hemodynamic origin, 16 (40%) with embolism, and 7 (17.5%) had no neurological symptoms. Direct vertebrocarotid reimplantation was the main procedure performed. No death or stroke occurred preoperatively or during the perioperative period. Mean follow-up was 31 months. Overall survival was 86.9% at 3 years and the primary patency rate was 97.5% at 3 years. CONCLUSION: Our study confirms the good results achieved by the pretransversal conventional VA surgery. This surgery remains few in number despite the fact that about 25% of ischemic strokes occur in the vertebrobasilar region. Vertebrobasilar signs should be better recognized to avoid performing this type of procedure merely based on imaging criteria.

[Spinal destruction caused by chronic contained rupture of an infra-renal abdominal aortic aneurysm]. / Erosion vertébrale par rupture chronique d'un anévrysme de l'aorte abdominale sous-rénale.

The erosion of the lumbar vertebral bodies by a chronic contained rupture of an infra-renal abdominal aortic aneurysm is a rare event. Chronic contained rupture can cause diagnostic difficulties as there are many clinical presentations, such as: back pain, sciatic pain or an expansive abdominal mass. The diagnosis is sometimes made following an incidental finding on radiological examination. Currently a CT scan is the gold standard diagnostic tool. The outcome following urgent surgical or endovascular repair is equivalent to that of an elective aneurysm repair. We report a case of a 59 year old man admitted for septic rupture of a cutaneous fistula resulting from a false aneurysm in the left groin. Pre-operative CT scan revealed a 6 cm abdominal aortic aneurysm, with chronic contained rupture. This had caused bone erosion of the vertebral body of the third lumbar vertebrae.

Infra-stellate upper thoracic sympathectomy results in a relative bradycardia during exercise, irrespective of the operated side.

OBJECTIVE: Removal of accessory fibres coming from the sub-stellar thoracic chain to the heart during infra-stellate surgical upper thoracic sympathectomy (ISS) may be responsible for a decreased heart rate to workload relationship during exercise following surgery. We hypothesised that heart rate would decrease not only following right ISS. METHODS: We performed repeated bicycle incremental exercise tests in 11 control subjects (26.9+/-9.5 years, 61.4+/-12.4 kg, 167+/-10 cm), and 11 patients (29.8+/-10 years, 59.3+/-12.0 kg, 168+/-7 cm) referred for bilateral ISS: results are mean+/-standard deviation. Surgery was performed at two distinct times allowing to study the consequences of unilateral and bilateral sympathectomy to confirm whether a significant relative bradycardia was constant and dependent on the operated side. RESULTS: For control subjects, test durations were 13.55+/-3.29, 14.09+/-4.01 and 13.00+/-3.26 min and heart rates were 187+/-7, 187+/-8 and 186+/-7 beats min(-1) at the first, second and third test, respectively. Although time to exhaustion was comparable to controls and unchanged between tests: 12.32+/-2.87, 12.3+/-2.90, 12.33+/-3.76 min, heart rate at maximum exercise decreased significantly from 176+/-16 to 164+/-15, and 148+/-15 beats min(-1), before, following unilateral and bilateral ISS, respectively. The operated side did not allow for the prediction of the effect of unilateral sympathectomy. CONCLUSIONS: Patients should be informed of the exercise bradycardia resulting from ISS, although clinical tolerance seems excellent in endurance exercise. Contrary to previous reports at rest, during exercise no right-sided dominance was observed. These findings are consistent with reports of random distribution of sub-stellate cardiac fibres from anatomical studies.

Subclavian steal syndrome and flow-related aneurysm. Another reason to treat.

A 48-year-old woman presented with a symptomatic right subclavian steal syndrome due to proximal subclavian artery stenosis. Anatomically the innominate artery was absent. Collateral circulation followed the vertebro-vertebral pathway with reversal of blood flow in the ipsilateral vertebral artery. There was also multiple dilated intervertebral collaterals and an associated saccular aneurysm on one of them. Surgical carotid-subclavian transposition permitted relief of clinical symptoms, disappearance of collateral circulation and subtotal regression of the aneurysm. This spontaneous evolution confirmed the role of high-flow in the pathogenesis of some aneurysms and the habitually good prognosis of flow-related aneurysms with correction of the cause. Arteriography still appears essential in diagnosis, pretherapeutic assessment and sometimes post-treatment evaluation in subclavian steal syndrome.

[Aneurysm of the superior gluteal artery]. / Anévrysme de l'artère glutéale supérieure.

We report the case of an aneurysm of the superior gluteal artery that occurred more than ten years after a pelvic trauma. The diagnosis of this uncommon condition is sometimes difficult because of the predominant neurologic symptoms. Rupture can be life-threatening. The patient was treated by an embolization; thereafter a surgical procedure with control of the internal iliac artery and an endoaneurysmorrhaphy was performed. The main characteristics of this pathology are indicated.

[Long-term evolution of a thoraco-abdominal cryopreserved arterial allograft]. / Evolution à long terme d'une allogreffe artérielle cryoconservée en position thoraco-abdominale.

We report a case of thoraco-abdominal pseudo-coarctation which developed late after implantation of a cryopreserved arterial allograft. The allograft was placed in a thoraco-abdominal position to treat an aorto-esophageal fistula after colonic esophagoplasty. Follow-up was free of complications for eight Years. The pseudo-coarctation was discovered during the evaluation of hypertension. Surgical treatment involved transdiaphragmatic bypass between the thoracic and infra-renal abdominal aorta. Arterial pressure immediately returned to normal. Twelve Months later, the patient is alive and well with normal blood pressure. A review of the literature revealed rare cases of arterial allograft with a description of the long-term outcome.

[Isolated plantar venous thrombosis. Report of a case]. / Thrombose veineuse plantaire isolée. A propos d'un cas.

We report the case of a patient with isolated plantar thrombophlebitis as a post operative complication of saphenectomy. Risk factors such as prolonged bed rest, perioperative inflammation and surgery of the greater saphenous vein itself should be considered. Moreover multiple episodes of superficial venous thrombosis had already occurred as complication of the superficial venous insufficiency. Literature on this unusual outcome is lacking. Ultrasound imaging revealed this superficial thrombosis. Usual echographic signs (non compressible vein, hypoechogenicity of the vessel lumen) can be found. The main problem is to differentiate veins from adjacent tendinous structures. Slow mobilisation of the toes and comparative analysis on contralateral foot are helpful. Thrombosis of the plantar veins must be considered as a possible diagnosis of unexplained plantar unilateral pains. Development of ultrasonic investigations and knowledge of its occurrence could further improve its diagnosis.

[In situ thrombolysis in the treatment of venous thrombosis of effort in the arm]. / Thrombolyse in situ dans le traitement des thromboses veineuses d'effort du membre supérieur.

From March 1989 to March 1993, six athletic patients were treated in our institution by thrombolytic therapy for acute effort axillary-subclavian vein thrombosis in thoracic outlet syndrome. Mean age of these patients was 20 (range 14 to 27). An in situ infusion with urokinase (2,500 U/kg/h) and Heparin (100 U/kg/12 hours) was given during 64 hours (Range 14 to 72). Phlebography showed a complete reperfusion in three cases (the treatment began within an average period of 5.6 days), partial reperfusion in two cases (the treatment began within an average period of 8.5 days). In one case there was no reperfusion on phlebography: treatment began within an average period of 15 days. For this patient, a venous axillo-jugular bypass graft was performed. In all cases, there was no bleeding complication. A trans-axillary first rib resection was done three months later. Mean follow up was 31 months (range: two to 51 months). All patients recovered their previous physical status. Echo-Doppler exam showed normal subclavian vein flow in four cases, partial occlusion in one case and a total occlusion of the subclavian vein flow in one case. In this last case, the thrombolytic therapy failed to restore the permeability of the subclavian vein. Bypassgraft was patent. Axillary-subclavian vein thrombosis seen within a period of seven days should be treated by local thrombolytic therapy using urokinase and heparin.

[Severe and distal ischemia of the upper limb. Results of a surgical follow-up of 11 years in 34 patients]. / Ischémie distale sévère du membre supérieur. Bilan d'un suivi chirurgical de 11 ans chez 34 patients.

The aim of this retrospective study was to evaluate etiology, frequency and prognosis of the distal and severe arterial diseases of the upper limb treated in a vascular surgical unit. Between Jan. 1986 and Jan.1997, 34 patients, 22 males and 12 females, mean age 56 years (range 30 to 87 years) were followed in the vascular and thoracic surgical unit in Angers. Follow-up was 100% complete. Each patient was explored by selective angiography of the upper limb due to the critical characteristic of ischemia.19 patients (56%) had tissue loss. Among multiple etiologies, arteriosclerosis was found in 32% of the cases. When medical treatment was unsuccessful, a thoracic sympathectomy was attempted in 50% of the cases, and 21% of the patients had direct arterial surgery. Nine deaths, due to initial pathology, occurred during follow-up. Eight digitalis amputations were carried out whose two directly because serious necrosis. Severe arterial diseases of the upper limb represented 6, 4% of critical limb ischemia treated during this same period. At time, this study showed arteriosclerosis preponderance over systemic diseases, and the seriousness of cases referred to a vascular surgical center after unsuccessful medical treatment (J Mal Vasc 1999; 24: 368-372).

[Surgery of the proximal vertebral artery. Indications and results]. / Indications et résultats de la chirurgie de l'artère vertébrale pré-transversaire.

OBJECTIVES: The purpose of this study was to: 1) detail the clinical presentations of diseases requiring revascularization of the vertebral artery and recall the guidelines of the 1975 Ad Hoc committee; 2) identify the explorations needed to detect vertebro-basilary insufficiency; 3) define operative indications since no consensus has been reached. PATIENTS AND METHODS: We reviewed retrospectively the files of 34 patients who underwent revascularization of the vertebral artery between January 1990 and December 2000. RESULTS: Surgery of the vertebral artery accounted for 4.6% of our vascular surgery cases involving the brain. Fifty percent of the cases of vertebro-basilary insufficiency were caused by hemodynamic disorders and 26.5% by embolism; 23.5% of the patients had no neurological sign. The most frequent neurological signs were vertigo (44%), balance disorders (41%), long pathway involvement (32%). Vertebro-basilary reimplantation was performed in 76% of the cases. There were no cases of stroke and no deaths during the early postoperative period. There was one case of asymptomatic thrombosis. Mean follow-up was 33.6 months with no patients lost to follow-up. Overall survival was 85.29% at 3 years with patent arteries in 97.06% of the cases at 3 years. CONCLUSION: Our series is in agreement with others reported in the literature, emphasizing the good outcome achieved after vertebral artery surgery. Surgery helps improve signs of vertebro-basilary insufficiency with little operative risk. This surgery is rarely indicated but must be recognized. One must also resist the temptation to "treat images".

Persistent carotid-vertebrobasilar anastomoses: how and why differentiating them?

The persistent carotid-vertebrobasilar anastomoses (PCVBA) can be explained by an interruption of the vertebrobasilar system (VBS) embryogenesis. We present two very rare cases of persistent anastomoses: a hypoglossal artery and a type I proatlantal artery, insisting on the angiographic criteria allowing differentiation. After a brief review of the embryogenesis of the VBS, we describe the different types of persistent anastomoses (hypoglossal, type I and II proatlantal, trigeminal and otic arteries). We will insist on the potential risks, not well-known, but typical of each anastomosis. PCVBA usually are incidental findings but imaging follow-up may be required since aneurysms may develop.

[Prevention of hemorrhagic complications in the lateral retinacular section of the patella. A study of the lateral arteries of the knee applied to the prevention of knee hemarthrosis]. / Prévention des complications hémorragiques de la section du rétinaculum patellaire latéral. Etude des artères latérales du genou appliquée à la prévention des hémarthroses du genou.

PURPOSE OF THE STUDY: Arthroscopic lateral retinacular release is one of the most employed procedures for patellar chondromalacia. A literature review show a complication rate of 10 to 18 p. 100 of postoperative hemarthrosis. This work aims to study the vessels anatomy of the lateral side of the knee in order to find anatomical landmarks allowing to avoid or coagulate them. MATERIAL AND METHODS: Thirty-three cadaver knees were dissected. Measures were made related to the lateral superior genicular artery and the lateral inferior genicular artery. A study using tracing-paper was also carried out. The main part of the work was more descriptive, studying anastomosis between the different arteries and veins location. RESULTS: Concerning the lateral superior genicular artery, measure analysis showed that this artery was always cut in lateral patellar retinaculum. This artery never runs more than one centimeter proximally to the base of patella, which is too insufficient to escape from lateral retinacular release. We noted the possibility of locating 90 p. 100 of lateral superior genicular arteries in a minimal distance of 15 mm, in front of the lateral proximal angle of the patella. Concerning the lateral inferior genicular artery, only a few arteries, protected in the meniscal wall in its early course, can remain intact. Two thirds of these arteries are very vulnerable running across the lateral side of the knee. The study of the tracing-papers confirmed topographic study measurements. The descriptive study emphasized the number and the importance of anastomoses between these different arteries. Each artery is flanked by two large satellite veins, which also attribute a veinous origin to a possible bleeding. DISCUSSION: The topographic study of the lateral inferior genicular vessels shows that their course varies. It seems necessary to avoid their division by performing the standard anterior lateral inferior arthroscopic portal proximally to these vessels. This can be realized at the beginning of the procedure through cutaneous transillumination. The lateral superior genicular vessels are always cut. They are nevertheless reachable through a small lateral incision of about 10 mm, distally to the lateral superior angle of the patella. 90 p. 100 at least of these arteries could be coagulated in such a way. We also emphasize the use of classical methods for the prevention of excessive venous bleeding, such as a compression dressing. CONCLUSION: Following this anatomical study, we suggest, as a supplementary precaution, a selective hemostasis of the lateral superior genicular vessels through a small incision associated with the location of the lateral inferior genicular vessels by cutaneous transillumination.

[Vascular complications during surgery of lumbar disk herniation. Apropos of 3 personal cases and 37 cases from a national investigation]. / Accidents vasculaires au cours de la chirurgie de la hernie discale lombaire. A propos de 3 cas personnels et de 37 cas colligés dans une enquête nationale.

Three personal cases of iatrogenic vascular complications (two arterial wounds and one arteriovenous fistula) induced by lumbar herniation surgery led to a French national investigation among vascular and neurosurgical units where 37 other such cases have been discovered over 10 years (1984-1994). In 23 cases, the initial symptomatology was collapses by arterial (22 cases) or venous (one case) hemorrhage requiring emergency vascular repair surgery; in 17 cases an arterio-venous fistula was found in a period varying from a few hours to 5 years after surgery; it was revealed by cardiac failure, lower limb edema or abdominal thrill. Among the 40 cases, 77% occurred at the L4-L5 level; the mortality was 5%, and the morbidity was 27%. Origin, causes and prevention are discussed.

[Arterial vascularization of the foot. Its importance in operations of revascularization of the lower limb]. / Vascularisation artérielle du pied. Son importance dans les interventions de revascularisation du membre inférieur.

Vascularization of the foot was studied using 50 intraoperative arteriograms on single legs and 50 cadaver injections. Arterial vascularization was shown to depend on supramalleolar anastomoses, the primary plantar arch and secondary arches. Anastomotic routes are essential for the permeability of femorotibial bypasses and cicatrization of distal trophic lesions when only one tibial artery remains permeable and must be revascularized.