[Endovascular treatment of femoropopliteal arterial occlusive disease]. / Le traitement endovasculaire des lésions artérielles occlusives fémoro-poplitées.

Endovascular treatment established itself last years as the first choice to treat femoropopliteal arterial occlusive disease. It is less invasive than the surgical approach. Endovascular techniques and devices evolution made it efficient. Use of retrograde puncture or re-entry catheters allows to recanalize more complex lesions. Vessel preparation of stenotic or occluded target lesion becomes an integral part of the therapy. Thanks to a lot of multicenter randomized controlled trials, drug eluting balloons took major place in the armamentarium we have, despite strong controversies last months about their safety. Conventional self-expandable stents with or without eluting drug, and vasculo-mimetic stents allow to treat very calcified lesions or dissected lesions through the recanalization procedure. This paper aims to review endovascular technical developments achieved last years to treat femoropopliteal arterial occlusive disease.

Le traitement endovasculaire s'est imposé, ces dernières années, comme le traitement de premier choix des lésions artérielles occlusives fémoro-poplitées. Il est moins invasif que l'approche chirurgicale. L'évolution des techniques endovasculaires et du matériel l'ont rendu efficace. L'utilisation de la ponction rétrograde ou de cathéters de ré-entrée permet de recanaliser des occlusions plus complexes. La préparation du segment artériel sténosé ou occlus fait partie intégrante de la thérapie. Grâce à de nombreuses études prospectives, multicentriques et randomisées, les ballons à élution de drogue ont pris une place importante dans l'arsenal thérapeutique mis à notre disposition, même si leur innocuité a été fort débattue ces derniers mois. Des stents auto-expansibles conventionnels, avec ou sans élution de drogue, et des stents vasculo-mimétiques permettent de traiter des lésions très calcifiées ou disséquées par le processus de recanalisation. Cet article a pour but de revoir les progrès techniques endovasculaires, réalisés ces dernières années, dans le traitement des lésions artérielles occlusives fémoro-poplitées.

[Retroperitoneal cystic lymphangioma treated by sildenafil]. / Lymphangiome kystique rétropéritonéal traité par sildénafil.

Cystic lymphangioma is a rare and benign lymphatic malformation found most often in the first two years of life. Clinical manifestations are diverse and depend on size and site of the lesion. The most frequently affected sites are cervicofacial and axillary areas. The retroperitoneal form is rare. Diagnosis requires imaging but can only be confirmed on the basis of an anatomopathological examination. The treatment of choice is complete surgical removal. However, this is not always feasible due to proximity of vital structures. Some alternative therapies like sclerotic injection and oral drugs like immunosuppressive treatment or sildenafil are described. We report the case of a 62-year-old patient with retroperitoneal cystic lymphangioma successfully treated with sildenafil.

Le lymphangiome kystique est une malformation lymphatique rare et bénigne, découverte le plus souvent durant les deux premières années de vie. Les manifestations cliniques sont diverses et dépendent de la taille et de la localisation de la lésion. Les localisations les plus fréquentes sont cervicofaciale et axillaire. La forme rétropéritonéale est rare. Le diagnostic nécessite un bilan d'imagerie, mais ne peut être confirmé que sur base d'un examen anatomopathologique. Le traitement de choix est l'exérèse chirurgicale complète. Toutefois, celle-ci n'est pas toujours réalisable en raison de la proximité de structures vitales. Certains traitements alternatifs comme la sclérothérapie ou l'administration de traitements oraux tels qu'immunosuppresseurs ou sildénafil sont décrits. Nous rapportons le cas d'un patient âgé de 62 ans avec lymphangiome kystique rétropéritonéal traité avec succès par sildénafil.

[The opportunities of the minimally invasive approach for the cardiovascular and thoracic surgery]. / Apport de l'approche moins invasive en chirurgie cardiovasculaire et thoracique.

There is a continuous growth in the incidence of cardiovascular and thoracic diseases, especially related to the increased life expectancy. Moreover, the quality and efficacy of care for these pathologies are progressing constantly. The evolution of surgery prompts us to develop less aggressive (minimally invasive), although technically more complex, treatment or diagnostic techniques. Pathologies, which until now required heavy surgeries, are managed today in a less invasive way and become therefore accessible to patients even if they are older or in a poor general condition. In this article, we present our experience in the development of the minimal invasive procedures in cardiovascular and thoracic surgery.

Les pathologies cardiovasculaires et thoraciques, au sens large, sont de plus en plus fréquentes, vu l'augmentation de l'espérance de vie, mais elles sont aussi de mieux en mieux prises en charge. En effet, l'évolution de la chirurgie nous incite à développer des techniques de traitement ou de diagnostic moins agressives (mini-invasives) quoique techniquement plus complexes. Des pathologies qui nécessitaient, jusqu'à présent, des chirurgies lourdes se prennent en charge, aujourd'hui, de manière moins invasive et deviennent donc accessibles à des patients en moins bon état général ou de plus en plus âgés. Nous présentons ici notre expérience dans le développement de l'approche mini-invasive en chirurgie cardiovasculaire et thoracique.

Comparison of laparoscopic and open aortobifemoral bypass in the treatment of aortoiliac disease. Results of a contemporary series (2003-2009).

OBJECTIVES: The study objective was to describe and evaluate our single center (University Hospital Liège) experience with totally laparoscopic bypass surgery compared with conventional open surgery to treat aortoiliac occlusive disease. MATERIAL AND METHODS: A retrospective database review of all patients undergoing aortobifemoral bypass for aortoiliac occlusive disease in our center, between 2003 and 2009, was performed. During this period, a total of 251 consecutive patients were identified. Among these patients, 95 underwent totally laparoscopic aortobifemoral bypass (group I) and 156 conventional open surgery (group II). Demographic data, operative data, postoperative recovery data, complications, two-year follow-up, morbidity and mortality were analysed according to the laparoscopic and conventional open group. RESULTS: Patients included 160 men and 91 women. The mean age was 61 years (range, 40 to 88 years) in both groups. Indications for surgery were invalidating claudication in 87%, rest pain in 7%, trophic disorders in 5%, impotence in 1.6% and digestive claudication in 1.2%. Prior to bypass surgery, 11 (11.6%) for the group I and 41 (26.3%) for the group II had undergone one or more abdominal surgical procedures. A transperitoneal and retrocolic approach was preferred in all laparoscopic procedures. Laparoscopic aortobifemoral bypass (LABF) required an operative time of 242 minutes (range, 129 to 465) and open aortobifemoral bypass (OABF), 200 minutes (range, 105 to 430). The mean aortic cross clamping time was 62 minutes in group I and 33 minutes in group II. Mean blood loss was more important in group II (1010 ml) than in group I (682 ml). The average length of hospital stay was 8.1 days for LABF compared with an average of 12 days for OABF. In 21 cases (20%) conversion to open surgery was necessary in the laparoscopic group. Systemic morbidity was significantly higher in the OABF group. Thirty-day postoperative mortality was 2% for group II. There was no hospital mortality in the laparoscopic group. Twenty nine patients were lost to follow-up and the mean follow-up was 23.5 months. CONCLUSION: Analysis of the results shows that laparoscopic aortobifemoral bypass for aortoiliac occlusive disease is a safe procedure. The statistically significant advantages observed in the majority of our patients were decreased blood loss, faster post-operative recovery and shorter hospital stay. In the two groups, late morbidity attributable to the bypass prosthesis was minimal compared with other causes.

[Rupture of a giant external iliac aneurysm six years after an aorto-bifemoral bypass]. / Rupture d'un anévrysme iliaque externe six ans après un bypass aorto-bifémoral.

We report the case of a patient operated on for an aorto-iliac aneurysm with an aorto-bifemoral bypass who presented a metachronous iliac aneurysm rupture, six years later, because of aneurysmal degeneration. We performed bipolar ligation of the external iliac artery and an end-to-end anastomosis of the prosthetic limb to the common femoral artery. We discuss aneurysms of the external iliac artery, characterised by their rarity, their specific morbidity and mortality.

Outlook of non operated type B aortic dissection with special reference to the incidence of degenerative abdominal aortic aneurysm (AAA). One center study.

OBJECTIVES: to determine the value of pharmacological treatment of type B aortic dissection (B AD) in face of new forms of treatment. DESIGN: this is a retrospective study of the period from 1990 to 2000. Files of 81 patients have been reviewed and completed by questionnaires. RESULTS: Two B AD died after admission without any treatment, 10 were operated on with 7 discharged alive (group I); 69 received hypotensive agents and beta-blockers, 65 were discharged alive (group II). Late mortality of the group I is 3/7, not related with B AD. Late mortality after mean follow-up of 56.8 months is 27/65 with 4/27 related to B AD (4 ruptures, 2 operated on). Non fatal secondary surgery amounts 5 in 4 patients. Total B AD aortic events comprise 8/65 patients. Type A AD were operated on successfully (8 : 4 before B AD, and 4 after B AD). Degenerative abdominal aortic aneurysms were present, operated (9) or not (3), in the history of patients and 3 more appear subsequently. At 10 years, actuarial survival is 40% +/- 18. CONCLUSION: in non-complicated cases of B AD, medical treatment is a reasonable choice, provided that a strict follow-up of the thoracic abdominal aorta is performed.

Potential benefits of laparoscopic aorto-bifemoral bypass surgery.

BACKGROUND: This series aims to prove the positive impact of laparoscopic approach in aortofemoral bypass grafting. METHODS: It concerns a retrospective non randomized study comparing 58 consecutive patients treated with laparoscopic procedure (n = 30) and with a standard open procedure (n = 28) in a single center. The different operating times, the complications and the follow-up of these two groups are compared RESULTS: The demographics and angiographic data of the two groups were comparable. Operating time was longer in the laparoscopic group. However, we noticed a significant shorter hospitalisation stay (p < 0.0001) after the laparoscopic procedure with a mean 5.1 days. There was no significant difference of morbidity. CONCLUSION: We suggest that the trans-peritoneal approach is the best way in laparoscopic procedure in term of exposure and ergonomics. Laparoscopic aortofemoral bypass grafting is feasible, safe and effective. Shortening of operating time is observed as surgeon's experience grows.

Amputations in diabetic patients: a plea for footsparing surgery.

The authors observed a rather high rate of primary major amputation (above-knee or below-knee) performed for diabetic foot problems as well as an important revision rate for minor amputations (forefoot or toe) in diabetics. They reviewed their experience in order to compare it with more recent data from the literature, pleading for foot-sparing surgery. From 1993 to 1998, 186 amputations were performed on 146 diabetic patients. The cause of foot ulcers was neuropathy in 43 of them (51 episodes of diabetic foot problems) while in the remaining 103 patients (135 episodes of diabetic foot problems), diabetic macroangiopathy (absent ankle pulses) was on cause. For neuropathic foot problems, amputations were almost minor, resulting in a limb salvage rate of 90%. Only five of these patients (12%) had primary major limb amputation versus 43 of the dysvascular patients (42%). The reasons for major amputation by first intention were extensive tissue loss, intractable infection or non-reconstructible occlusive vessel disease, as judged by the surgeon. A foot-sparing surgery was attempted in 92 dysvascular cases. In only 44 of them, a preliminary vascular repair was performed. Twenty eight percent of the primary toe amputations and 24% of the forefoot amputations required secondary revision to a more proximal level. Minor amputations in case of diabetic neuropathy were characterized by a more favourable outcome: only 14% of the toe and 9% of the forefoot amputations failed. During follow-up, only 63% of the major amputations regained an autonomic walking capability with their prosthesis. Wound healing problems in diabetic foot are mainly due to infection and poor tissue perfusion. An aggressive control of the infection and distal revascularization of calf- or foot arteries, whenever possible, could improve the results of diabetic foot surgery. The poor functional recovery after major amputation (only 63% autonomic gait with limb prosthesis) argues for foot-sparing surgery whenever possible.

[Should we correct stenosis of the superficial femoral artery in a patient with claudication?]. / Faut-il corriger les sténoses de l'artère fémorale superficielle chez le patient claudicant?

Infrainguinal arterial occlusive disease is very common at the age of 60 years or older. It remains often asymptomatic. In one third of cases, it results in claudication. Claudication is a benign symptom that rarely necessitates surgery or endovascular intervention. Physical training and control of risk factors are sufficient in most cases to improve the walking performance. Nowadays, the authors do no longer perform femoropopliteal bypass grafting as a first choice treatment for intermittent claudication. Conservative treatment has gained widespread acceptance for infrainguinal atherosclerosis with moderate ischemia. What is the fate of the claudicant? How effective is exercise therapy? Should we broaden the indications for percutaneous angioplasty? What is the place of femoropopliteal bypass graft for claudication? The authors investigate these different questions by means of an extensive review of recent literature. Based on this review and on international consensus documents, they justify their conservative approach to claudication secondary to occlusive disease of the superficial femoral artery.

[Fibromuscular dysplasia]. / La dysplasie fibromusculaire.

Fibromuscular dysplasia is a rare non-atherosclerotic, non-inflammatory arterial disease. It concerns less than 1% of all occlusive artery lesions, but is more common in young female patients, with a prevalence of 3 to 5% of the arterial lesions in that age group. It mainly attains renal and carotid arteries. The authors discuss the etiopathogeny, the prevalence and treatment of fibromuscular dysplasia. Their own surgical experience with 21 renal and 10 carotid lesions of fibromuscular is exposed.

[Prevention of secondary mortality after type B aortic dissection]. / Prévention de la mortalité secondaire après anévrysme disséquant de type B.

Only few dissecting aneurysms type A survive without surgery. Opposingly, the dissecting aneurysms type B are successfully managed by the medical treatment "anti-impulsion". A personal series is reported, that evidence important cardiovascular mortality in the follow-up in chronic dissecting aneurysms type B; one part of this late mortality is linked to rupture of the thoracic descending aorta. Thus, the prevention of this late mortality depends on a strict follow-up of the characters and dimensions of descending aortic thoracic aorta.

[Resurgence of vein perforation surgery: SEPS (subfacial endoscopic perforator surgery)]. / Résurgence de la chirurgie des veines perforantes: CEPS (chirurgie endoscopique des perforantes sous-fasciales).

The treatment of venous ulcers is a challenge even in this era of modern medicine. The role of incompetent perforating veins in the pathophysiology of venous ulcers has been well documented. Open surgical interruption of incompetent perforating veins (Linton's procedure) may be complicated by important wound healing problems, and has never gained widespread acceptance as a first choice treatment. Recently, an endoscopic technique of subfascial interruption of perforating veins has been developed. This new procedure, with smaller scars and faster recovery, gives promising midterm results. The authors summarize their initial experience with subfascial endoscopic perforating surgery (SEPS) during the last three years (25 cases). They obtained ulcer healing in all cases. At 16 month follow-up, 88% of patients remain ulcer free. Three patients developed a new minor ulceration in the era of lipodermatosclerosis. This less invasive technique is a promising tool in the management of patients with venous ulcer disease.