Quantitative, histological and ultrastructural studies of peripheral nerve in arteriosclerotic non-diabetic patients.

The superficial peroneal nerve was taken from 12 arteriosclerotic non-diabetic patients just after amputation of a leg. Preparations of teased fibers were performed in 8 cases. Specimens were studied by light and electron microscopy in all cases. Histograms of myelinated fibers in transverse semi-thin sections showed that depletion of myelinated fibers varied from case to case, with no selective vulnerability in either the large or the small diameter group. There was a dramatic loss of myelinated fibers in only one case. No real nerve infarct was observed. In most cases, regions of Wallerian-like degeneration were prevalent; however, myelino-axonal changes were severe only in a few cases. Axons with organelle aggregates were seen in some cases. Figures of segmental demyelination were not numerous in this series. Unmyelinated fibers were also damaged, and the degree of involvement differed from case to case. Pathological changes observed in this study confirm the relative resistance of peripheral nerve to ischemia.

Late reoperations after aorto-iliac restaurations.

(1) Late thrombosis after aorto-iliac revascularisations are infrequent when the operation is correctly performed and controlled by intra-operative angiography. (2) Reoperation after thromboendarterectomy is a difficult procedure requiring great care in the aortic approach. (3) Reoperation after thrombosis of a prosthetic graft is much easier as far as dissection is concerned, usually the upper part of the former prosthesis may be kept, which renders the procedure very much easier. (4) The distal anastomosis should be realised distally to the sclerotic block surrounding the femoral bifurcation. (5) In case of poor risk patients, it is better to use extra-anatomical bypasses, and if necessary, one must be able to sacrifice a limb for a life. Mortality rates are high in our series. It may be due in part to a too much optimistic pre-operative evaluation and selection of our patients, in the first years of our experience.

Postoperative evaluation of in situ saphenous vein bypass with technetium-labelled albumin microspheres.

Technetium-labelled serum albumin microspheres have been used to study arteriovenous shunting in in situ saphenous vein bypasses. Their diameter (15 micron) enables the microspheres to be trapped at the capillary level, either in the limb or in the lungs, according to the extent of arteriovenous shunts. The observed shunting ranged from practically nothing to 90%. The worst distal activity counts as well as the worst scintigraphic aspects (giving a qualitative view of the nutritional circulation of the limb) were found in patients with poor intraoperative arteriographic evaluation of run-off. Persisting clinical inconvenience due to fistulas was only found in patients with over 60% shunting. No patients, even those with up to 90% shunting, had any evidence of ischemia. Arteriovenous shunting would thus seem well tolerated to a certain extent, and the ligation of major arteriovenous fistulas is to be recommended.

[Predictive value of the reactive hyperemia test as an indicator for lumbar sympathectomy]. / Valeur prédictive du test d'hyperémie réactionnelle dans l'indication de sympathectomie lombaire.

Seventy-five patients had a lumbar sympathectomy for chronic arteritis of the lower limbs. This study was done to assess the predictive value of Hillestad's test (potential of vasodilatation) and that of the deep breath test (sympathic stimulation), realised by digital strain gauge plethysmography. Were considered a success the patients with claudication who doubled their walking distance and those with rest pain or gangrene who suffered no more or healed. Globally speaking, 49% were a success. A positive response to Hillestad's test was followed by an 83% overall success rate. For claudicants with femoropopliteal lesions the predictive success rate was 95% with a positive Hillestad's test, against 60% globally; for patients with rest pain or gangrene or with distal lesions the success probability was around 60% if Hillestad's test was positive. A negative response to Hillestad's test was always followed by a failure in diabetics. A better predictability ought to be obtained with the adjunction of a deep breath test.

[Assessment of cicatrisation potential in arteritic patients by means of an isotopic method employing technetium 99 m to measure cutaneous perfusion pressure (author's transl)]. / Evaluation d'un potentiel de cicatrisation chez l'artéritique intérêt de la mesure de la pression de perfusion cutanée par méthode isotopique au technétium 99 m.

Cicatrisation potential was assessed in arteritic patients by an isotopic method employing technetium 99 m to measure cutaneous perfusion pressures. Pressure threshold-values obtained showed that cicatrisation was absent when pressure was below 35 cm of water, that infectious complications developed in half of the cases with values between 35 and 65 cm, and that cicatrisation generally occurred at values above 65 cm.

[Digestive hemorrhage caused by seromuscular erosion of the wall of a section of the small intestine at the level of an aortic prosthesis implanted 5 years earlier]. / Hémorragie digestive par érosion séro-musculeuse de la paroi d'une anse grêle au niveau d'une prothèse aortique mise en place cinq ans auparavant.

A new paraprosthetic enteric fistula case between the small bowel and the body of a Dacron aortobifemoral prosthesis is presented. That complication happened five years after the initial reconstruction and the fistula does not interest an anastomotic site. A process is rare (22 published cases); if symptomatology is often less important than complete fistulas, surgical therapy must be aggressive to be effective.

[Reproducibility of venous occlusion plethysmography. Value of a computerized system of calculation]. / Reproductibilité de la pléthysmographie à occlusion veineuse. Intérêt d'un système de calcul automatisé.

The manual interpretation of identical occlusive venous plethysmography curves by different technicians is subject to a wide variation. The object of this study is to verify this state of affairs and to propose an automatic calculation of the different parameters usually used: the percentage volume increase (delta V), the time taken to half empty (t V/2) and the maximal venous outflow (MVO). We compared the variations, due to the operators, in the measurement of the parameters characterising identical curves obtained by occlusive venous plethysmography. Sixty curves from 30 patients, were photocopied and each was measured independently by four different operators. The results were compared with the measurements obtained automatically from a micro-computer connected to the plethysmograph. The measurements of the percentage volume increase and the time taken to half empty differed among the operators and the computer by less than 2%. However, the maximal venous outflow was subject to very large variations amongst the operators (up to 60%). This uncertainty is due to the operators choice of the point on the curve where the tangent is measured. The micro-computer, by fixing this point at 0.3 second after releasing the cuff allows a standardisation of this parameter.

[Hemorheologic study of different forms of vasomotor acrosyndromes]. / Etude hémorhéologique au cours des différentes formes d'acrosyndromes vasomoteurs.

Hemorheologic disorders are a frequent finding in circulating blood during vascular diseases (arterial disease of lower limb, cerebrovascular accidents). They participate in thrombogenesis and tissue ischemia production, and also in microcirculatory disturbances as shown by behavior in microvessels of red cells with decreased hereditary deformability (sickle cell anemia). Active alterations in erythrocyte rheology have also been demonstrated during vascular diseases in relation to inflammation: cell-protein inflammatory reaction, action of leukocytes. Therapy should be adapted for these microcirculatory disorders by suitable specific clinical trials.

[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.

[Value and limitations of venous blocks using reserpine in acrosyndromes of the upper extremities]. / Intérêt et limites du bloc veineux à la réserpine dans les acrosyndromes du membre supérieur.

A block Bier technique using a one milligram Reserpine injection has been applied to ten patients with severe Raynaud's phenomenon (six of them had digital gangrene). Six patients have been improved and three have completely healed. This method must only be applied to severe cases and may be used as a pretherapeutic test in upper sympathectomy.

[Study of the muscular perfusion of the lower limbs using thallium 201 scintigraphy before and after lumbar sympathectomy in 13 patients]. / Etude de la perfusion musculaire des membres inférieurs par scintigraphie au thallium 201 avant et après sympathectomie lombaire chez treize patients.

Scintigraphy with 201-Thallium is a useful method for exploring muscle circulation in lower limbs of patients with arteritis. Comparative values with time can be obtained by studying respective isotopic activity ratios of the thigh, calf and foot. Unilateral isolated lumbar sympathectomy was performed in 13 patients for arteriopathy of the lower limbs (7 claudications, 4 isolated trophic disorders, 1 thrash-foot and 1 juvenile arteriopathy). Investigations included clinical and arteriographic explorations and functional tests (Doppler, distal pressure, digital plethysmography and 201-Thallium muscle scintigraphy) before and after operation. Pathology of the sympathetic chain was determined in each case. Short-term (2 weeks) follow up examinations gave data showing absence of correlation between the operative procedure and scintigraphy results. Muscle perfusion was improved in only 3 cases: one presented paradoxical improvement contralateral to the sympathectomy, while no change from the pre-operative values was recorded in 9 patients. The findings raise questions concerning the reproducibility of the scintigraphic method, and also confirm the pathogenic hypothesis by which lumbar sympathectomy has only a limited effect on muscle circulation.

[Evaluation of arteriovenous shunts following venous by-pass with the saphenous vein in situ. A suggested approach (author's transl)]. / Evaluation des shunts artério-veineux dans les pontages veineux par saphène in situ élaboration d'une attitude.

An isotopic method employing microspheres of serum-albumin of a mean diameter of 15 microns was used to study the problem raised by the development of arteriovenous fistulae following saphenous by-pass in situ, enabling measurement of shunt flow and qualitative evaluation of the distal bed. Shunt blood flow varies greatly from practically negligible quantities to a maximum of 90%. Comparing data from angiography during operation with these data showed a parallel between the worst angiographic appearances, the poorest scintigraphy images, and the most marked shunts. Sustained clinical manifestations of the fistulae were apparent in shunts of over 60% only. Signs of ischaemia were absent, even in shunts taking 90% of by-pass blood flow. Arteriovenous fistulae induced by by-pass operations employing the saphenous vein in situ appear, therefore, to be relatively well-tolerated. Ligature of the most important, preferably proximal, collaterals is nevertheless recommended, to reduce disturbing side-effects as far as possible, and loss of flow to the distal arterial bed in cases with very large fistulae.

[Contribution of immunology to the differentiation of arteritis in young persons. Apropos of 2 cases]. / Apport de l'immunologie au démembrement des artérites du sujet jeune. A propos de 2 observations.

The authors report two observations of T.A.O. placed under the heading of "Systems Affections" after the discovery of immunologic abnormalities. Vascular troubles in L.E.A.D. and generalised sclerodermis are, apart from the Raynaud Syndrom, exceptional. They oriente specially towards a T.A.O., and in absence of caracteristic symptoms, they retard the diagnosis of a connective. The reader is reminded of the characteristics of the "Buerger Affection" which must no longer be considered as unique anatomoclinic entity, due to modern immunologic and phlebologic exams.

[Anatomo-clinical correlations after the treatment of iliocaval phlebitis with a 1-year follow-up]. / Corrélations anatomo-cliniques après traitement des phlébites ilio-caves avec un an de recul.

Clinical results and anatomical findings on isotopic angiography, after a minimum follow-up period of one year, were compared in 32 patients treated for iliocaval venous thrombosis. Therapy had involved: iliofemoral thrombectomy alone (8 cases), iliocaval thrombectomy and retroperitoneal clip (10 cases), a clip alone (5 cases), fibrinolysis and heparin therapy (3 cases), heparin therapy alone (6 cases). Overall clinical results were considered as being good in 26 patients and poor in 6, whereas permeability of the main venous axis was confirmed by isotopic phlebography in only 5 cases. There appears to be a total lack of parallelism between clinical results and anatomical findings following treatment of these recent iliocaval phlebitis cases.

[In situ venous bypass using the great saphenous vein: analysis of the 5 year outcome of 129 procedures]. / Pontages veineux in situ par veine saphène interne: analyse des résultats a 5 ans a propos de 129 interventions.

One hundred and twenty nine in situ vein bypasses have been reviewed with a five year follow-up. Cumulative patency rates at five year are 71% (+/- 21%) for above-knee femoro-popliteal bypasses, 69% (+/- 11.5%) for below-knee anastomosis and 94% (+/- 35%) when distal anastomosis is performed on tibial or peroneal vessel. Global cumulative graft patency rate is 71% (+/- 9.4%). It is 72% (+/- 11%) in limb salvage.

[Efficacy of an extract of Ginkgo biloba in the treatment of chronic obliterating arteriopathies of the lower limbs in stage III of Fontaine's classification]. / Efficacité de l'extrait de Ginkgo biloba dans le traitement des artériopathies oblitérantes chroniques des membres inférieurs au stade III de la classification de Fontaine.

UNLABELLED: A controlled trial of Ginkgo biloba extract in injectable form (Tanakan 50 mg, a lyophilizate for parenteral use) was carried out versus a placebo as a preoperative medical treatment of stage III (Fontaine classification) chronic occlusive arterial disease of the lower limbs (with pain in decubitus). The 64 men and women patients in this multicenter study (32 in each group) were over 18 years of age and had a cultural and intellectual level as well as a physical condition allowing them to play an active role in the experiment (self-evaluation of pain). During 8 days they received two daily infusions of 500 cc of normal saline solution containing either 100 mg of Ginkgo biloba extract or a placebo of identical appearance. During this period, anticoagulants were authorized; hemodilution, vasoactive drugs and platelet anti-aggregates were forbidden; pentazocine (Fortal, 50-mg tablets) was allowed at the patient's request. Pain was rated according to a visual scale, with each patient marking a point between two extremes ("maximum imaginable pain" and "total absence of pain") 100 mm apart. A questionnaire based on that of Melzack (McGill Pain Questionnaire) completed this qualitative as well as quantitative self-evaluation of pain. The results of these questionnaires were assessed on the basis of 4 scores, each determined by the patient's choice among 3 evaluation figures. The chi square, Student and Wilcoxon tests were used for statistical analysis. RESULTS: The two randomly-composed groups with Ginkgo biloba extract and a placebo were comparable (Table I). Analysis was based on 55 observations (26 in the extract group and 29 in the placebo group).(ABSTRACT TRUNCATED AT 250 WORDS)

[Electric stimulation of the spinal cord in arterial diseases of the legs. A multicenter study of 244 patients]. / La stimulation électrique médullaire dans les artériopathies des membres inférieurs. Une étude multicentrique chez 244 patients.

From January 1985 through January 1990, 244 patients (168 males, 76 females, mean age: 69 +/- 14 years) received epidural spinal cord stimulation for the treatment of advanced, nonreconstructable, peripheral vascular disease of the lower limbs due to atherosclerosis in 180 patients, atherosclerosis and/or diabetes in 49, and thromboangiitis obliterans in 15 patients: previous surgery included 101 bypass-grafts in 70 patients, 51% of which below the knee, and 117 sympathectomies in 113 patients as the last resource in face of distal peripheral vascular disease of the lower limbs. Mean ankle-to brachial systolic pressure ratio was .31 +/- .34 on symptomatic limbs; due to pain and advanced disease, walking capacity was assessed in only 151 patients, either on treadmill in 25, or in a metered corridor in 126; angiogram of the lower limbs was performed in every patient unless one not older than three months was readily available; pain at rest was assessed after an analogical scale; partial transcutaneous oxygen tension was measured on the dorsum of the fore-foot of 77 symptomatic limbs (mean: 13.35 +/- 14 mmHg). According to clinical and functional evaluation, 18 patients had exertional ischemia (group I), 87 had permanent ischemia with pain at rest and no tissue loss (group II), and 139 had chronic tissue loss (group III), including 93 ischemic ulcers (mean surface: 3.7 cm2, mean duration: 3.5 months) in 88 patients, 27 limited gangrene, and 24 previous limited non-healing distal amputation. After temporary spinal cord stimulation at T12-L1 level (mean duration: 9 +/- 4 days) with a percutaneous quadripolar electrode lead had allowed for selection of responders, 212 patients received an implantable neurostimulator.(ABSTRACT TRUNCATED AT 250 WORDS)

[CY 222, a very low molecular weight heparin, in the curative treatment of deep venous thrombosis. Apropos of 95 cases. Clinical and phlebographic results]. / Le CY 222, Héparine de trés bas poids moléculaire dans le traitement curatif des thromboses veineuses profondes. A propos de 95 observations. Résultats cliniques et phlébographiques.

Efficacy of a very low molecular weight heparin, CY 222, in the treatment of deep venous thrombosis of lower limbs was evaluated in a prospective clinical trial instituted in November 1984. CY 222 was administered as subcutaneous injections of 0.03 ml.kg-1 daily (750 anti-Xa U.kg-1.d-1) as 3 divided doses over a minimum of 10 days. Efficacy was rated as a function of clinical and phlebographic criteria. The group of 95 patients treated was a heterogenious one: 38% medical, 62% surgical, and 48% of the total group had partial interruption of vena cava previous to study. The period between first clinical manifestations of the deep thrombosis and therapy varied between one day and 3 months (mean: 1 1/2 days). Clinical symptomatology significantly and globally regressed in 88% of the patients. Comparisons between phlebographic findings at start and end of treatment are expressed using Arnesen's score (cf. table).

[The use of labelled albumin microspheres in the study of arteriovenous shunting in varicosities of the lower limbs (author's transl)]. / Utilisation de microsphères d'albumine marquées dans l'étude du shuntage artério-veineux des varices des membres inférieurs.

The greater proportion of oxygen in the blood circulating in veins of the lower limbs bought to attention the possibility of pre-capillary arteriovenous shunting. The intra-arteriel injection of Technetium labelled serum albumin microspheres enables one to quantify arteriovenous shunts greater than 25 microns. The authors made a comparative study of arterio-venous shunting by blood gases analysis and isotopic techniques in twenty patients. The results seem to deny the existence of arteriovenous shunts in the genesis of essential varicose veins in the lower limb.