[Multiple cholesterol embolism mimicking periarteritis nodosa]

Ten men aged 56 to 84 were hospitalized with a diagnosis of periarteritis nodosa, whereas they had multiple cholesterol embolism. The diagnosis was corrected post mortem in the first 3 patients and subsequently in live patients. The particularly misleading clinical manifestations were neurological (polyneuritis in 5 cases, mononeuritis in 1, central nervous system disorders in 3), pulmonary (alveolar haemorrhage in 2 cases, respiratory failure of unknown mechanism in 4) and pericardial (2 cases). Five patients had eosinophilia (more than 500 eosinophils/mm3). The elements that led to the correct diagnosis were the presence of vascular risk factors in all 10 patients (but hyperlipidaemia in only one), severe complications of the atheromatous disease in all cases, a precipitating or aggravating factor in 8 patients (anticoagulant therapy in 7, arteriography in 6) and the finding of purple or necrotic toes (6 cases). Histological (5 cases) and/or ophthalmological (2 cases) evidence was obtained in only 6 patients. Seven patients died 1 to 3 years after the onset of the disorders. Studies on low-density lipoprotein metabolism are in progress to determine the mechanism of clinical manifestations unexplainable by embolism.

[Rupture of abdominal aorta aneurysms. Study of 92 cases operated on over a ten year period (1980-1989)]

From January 1980 to December 1989, 92 ruptured abdominal aortic aneurysms (AAA) were operated upon in emergency at our institution. During the same period, 747 AAA were operated in election or in the absence of rupture. The mean age of patients was 72.8 +/- 9.1 (52-95). There were 81 men and 11 women. Etiology of the AAA was common degenerative in all cases except in one case of aortic dissection and one case of infectious aneurysm. 27 (29.3%) patients presented antecedents of bronchopathy, 31 (33.7%) antecedents of hypertension and 36 (39.1%) antecedents of coronary heart disease. All patients were operated upon under general anesthesia, in two (2.1%) cases through a thoraco-abdominal exposure, in one case through a lombotomy, in one case, using exclusion and an extra anatomic bypass and through a midline transperitoneal laparotomy in all 88 (96.9%) other cases. The mean diameter of the AAA was 9 +/- 3.9 (4-25) cm. The rupture was intra-peritoneal in 26 (28.3%) cases, intra caval in 5 (5.4%) cases, intra duodenal in 2 (2.2%) cases and retro peritoneal in all the other 59 (64.1%) cases. The aorta was cross clamped above the renal arteries in 15 (16.3%) cases, under the renal arteries in 48 (52.2%) cases and at both levels in 29 (31.5%) cases. Surgical treatment consisted in an aorto-aortic tubular graft in 45 (48.9%) cases, a bifurcated aortic graft in 32 (34.8%) cases, an exclusion with extra anatomic bypass in one (1%) case and could not be completed before the death of the patient in 14 (15.3%) cases. There were 56 (60.9%) deaths, 27 (29.4%) in the per operative and 29 (31.5%) in the post operative periods after a mean time of 5.7 +/- 9.2 (0-36) days. The cause of the death was hemorrhage in 25 (44.4) cases, cardiac complications in 28 (50%) cases, renal insufficiency in 1 (2%) case, pulmonary complications in 1 (2%) case and septic complications in one (2%) case. During the period of the present study, rupture of an AAA remained, in our institution as in other institutions an often fatal condition. This condition could probably be avoided with a policy of early detection and surgical treatment.

Arteriovenous fistula of the internal maxillary artery in a child: case report

Direct arteriovenous fistulae supplied by the external carotid artery are unusual. Rarely, congenital fistulae have been described involving the head and neck. We describe the first case of congenital internal maxillary arteriovenous fistula in a child. Balloon embolization is currently considered the method of choice for treatment of direct arteriovenous fistula.

Area-level predictors of use of prenatal care in diverse populations

Patterns and predictors of the use of prenatal care in Hawaii were examined by census tract, taking into account summary measures of socioeconomic status, environmental conditions, and aggregated indicators of pregnancy-related risk characteristics of mothers. The objectives of the study were to identify those census tracts with high levels of inadequate use of prenatal care services; to develop a model, based on census tract characteristics, to explain observed geographic variations in the use of prenatal care services; and to identify for further investigation specific localities with unanticipated patterns of use. Data were drawn from 1980 census reports and vital statistics live birth files for the period 1979-87. Regression analysis was used to develop a model that was able to predict 61 percent of the census tract variation in the percentages of inadequate use of prenatal care services. Increased proportions of mothers of Japanese and other Asian-descent and of adults with more than high school education were associated with low levels of inadequate use of prenatal care services. Increased proportions of high parity-for-age risk and Samoan mothers were associated with higher levels of inadequate use. Census tract maps of actual and predicted percentages and studentized residual values were used to identify areas with high and low rates of inadequate use of prenatal care services. The area-level methods used are believed applicable to health care planning in other areas with ethnically or socioculturally diverse populations.

Dipyridamole-thallium-201 scintigraphy in the diagnosis and prognosis of coronary artery disease in patients undergoing noncardiac surgery

Although most of the published studies using DTS as a preoperative screening test show various shortcomings, the following conclusions can be drawn: 1. DTS should not be used as a routine preoperative test in vascular surgical patients. DTS possesses insufficient accuracy when used in patients without clinical findings suggestive of CAD. 2. DTS may prove more useful in stratifying patients with an intermediate probability of developing cardiac complications. In such a population the test will not offer an "all or nothing" linear results, but rather, when included with the clinical findings and the nature of the surgical procedure, a complex stratification. 3. Because of progress in the perioperative management of high-risk patients, positive findings on preoperative DTS may not correlate perfectly with perioperative cardiac occurrences. 4. Because several factors influence thallium uptake after dipyridamole, DTS does not have perfect specificity, which leads to the prescribing of an excessive number of coronary angiographies. Some patients will be seen as having a false-positive DTS test. 5. The use of DTS as a preoperative screening test leads to cardiac catheterization and hence to revascularization independent of symptomatology. Studies must be undertaken to determine whether this approach will improve short- and long-term patient survival.

Leiomyosarcoma of the inferior vena cava. Experience with 7 patients and literature review

Leiomyosarcoma of the inferior vena cava (IVC) is a rare malignant tumor originating in the smooth muscle of the media. Although rare, it is the most common malignancy in the IVC. One hundred and six cases have been reported thus far in the world literature, usually as isolated case reports. Clinical, radiologic, and therapeutic management and follow-up, including 7 additional cases, have been reviewed and summarized. Clinical manifestations are dependent upon the location of the tumor. The main symptom was a palpable mass for a tumor in segment I, abdominal pain for segment II, the presence of Budd-Chiari syndrome for segment III. Segment II was the most frequent site of leiomyosarcoma of the IVC, alone (n = 41) or with other segments (n = 39). Before laparotomy, clinical recognition was difficult or impossible. Recently, however, newer imaging modalities including ultrasound and CT scan have permitted earlier diagnosis. Metastases, when diagnosed, were either present at diagnosis (n = 20) or appeared as the disease progressed (n = 18). Metastatic disease frequently involved the liver, lung, lymph nodes, or bone. The small number of patients alive without metastases (16/113) must be analyzed all the more carefully because these patients were followed for less than 2 years. When prolonged follow-up is possible, the number of patients alive without neoplastic disease is significantly reduced. We found the prognosis of patients with LMS of the IVC to be poor. Diagnosis was made at autopsy for 27 patients. Among the 86 patients with follow-up information, 59 died within a mean of 16 months, and 26 were alive 25 months after the diagnosis. The main prognostic factor is topography, particularly the highest level of extension of the tumor. The upper-segment tumors have the poorest prognosis. The best therapeutic management is difficult to recommend because most of the cases in the literature did not include a sufficient follow-up. Given the very small number of patients completely free of neoplastic disease after sufficient follow-up, it seems unlikely that leiomyosarcoma of the IVC can now be cured. Patients who received a combination of surgery, radiotherapy and chemotherapy remained free of disease for longer periods. The unanswered question is: what is the best timing for each of these treatments? We recommend diagnosis of leiomyosarcoma of the IVC through biopsy guided by ultrasonography or computed tomographic scan. Therapeutic management should include large doses of chemotherapy preoperatively with or without radiotherapy to reduce tumor size.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical treatment of aneurysms of the thoraco-abdominal aorta]

Surgical treatment of thoraco-abdominal aortic aneurysms, E. Kieffer. Thoracoabdominal aneurysms have a high potential for rupture, that justifies extensive indications for surgery. Mortality and spinal cord injury rates depend on age and general condition of the patient as well as extent and etiology of the aneurysm and the possibility of preoperative visualization of spinal cord arteries.

In situ fresh allograft replacement of an infected aortic prosthetic graft: eighteen months' follow-up

We report a case in which an allogenic aortic graft was used to treat the last one of a series of infectious graft complications. The original operation was a Dacron aortobifemoral bypass for aortoiliac occlusive disease in an institution other than ours. The patient was referred for the treatment of the infection of the prosthetic implant. We inserted a prosthetic bypass from the left axillary to the left deep femoral artery, as well as a crossover autogenous saphenous vein graft from the prosthesis to the right deep femoral artery; in the same operation the infected intraabdominal prosthesis was removed with closure of the proximal aortic stump. Subsequent stenosis of the vein graft made it necessary to insert a prosthetic bypass between the descending thoracic aorta and the two deep femoral arteries. Infection of the last named prosthesis made it necessary to remove it and replace it with a tailored allogenic arterial allograft between the infrarenal abdominal aorta and both deep femoral arteries. The patient had an uneventful recovery as the infection was controlled and both lower limbs were salvaged. Eighteen months later the allograft was patent without any signs of degeneration. Further clinical experience under appropriate conditions may prove the use of allografts effective in the treatment of selected cases of aortic prosthetic infection.

[Long term results of surgery of aortic aneurysms]

During 10 years, between 01.01.80 and 01.12.89, 838 patients have been operated on consequently for a A.A.A. in the vascular surgery department of the Hospital Pitié-Salpêtrière (Paris). Post-operative death was 7.3% (51 patients) among 692 operated on without emergency and 41.7% (60 patients) among 146 patients operated on emergency. The study was undertaken with the 727 surviving patients (86.8%) for the long term follow-up. Only 25 patients (3.4%) were lost out, so 702 patients (96.6%) had complete recalls even to their late death until the fourth trimester 1990. Total deaths, were 172 patients, (24.5%) out of the 702 patients in the follow-up. 60 patients (34.9%) died from cancer, 52 patients (30.2%) from heart disease, 21 patients (12.2%) from C.V.A. (cerebro-vascular-accident), 8 (4.6%) from rupture of aneurysm, 6 (3.6%) from renal insufficiency, 5 (2.9%) from prosthesis infection, 10 (5.8%) died from known reasons, 10 (5.8%) from unknown reasons. All these results were studied according to the "actuarial method" and the conclusions were as follow. The actual survival rate at 5 years was 72.1% +/- 5.6% and the average annual death rate was 5.8%. The factors which have influenced the late death are: a) Patients age: survival rate at 5 years and average annual death rate were significantly different whether the patients were less or more than 70 at the time of surgery. b) Surgical circonstances: late survival was significatively less with patients operated on emergency. c) Cerebro-vascular insufficiency. The average annual rates from cardio-vascular and cerebro-vascular accident were significatively more important in patients which previously had cerebro-vascular insufficiency. This work shows out that cardiac death are slightly overcame by cancer, but these two factors represent almost 2/3 (65.1%) of late death. So it should be important for prevention of late death to screen for lung and E.N.T. cancers. Some authors have proposed for prevention of coronarian accidents extensive use of coronarography and myocardial revascularisation. We prefer more acute screening than aggressive methods for patients with coronary problem who had surgery for A.A.A. and specially when they are less than 70 at surgical time.

Comparison of isoflurane with sodium nitroprusside for controlling hypertension during thoracic aortic cross-clamping

The aims of this randomized study were (1) to determine if isoflurane is effective in controlling blood pressure during thoracic aortic cross-clamping, and (2) to compare its effects on hemodynamics and oxygen transport to those of sodium nitroprusside. Sodium nitroprusside (SNP group, n = 10) or isoflurane (ISO group, n = 10) was started 2 minutes before cross-clamping and was adjusted to maintain systolic arterial pressure as near as possible to preinduction values. The duration of thoracic aortic cross-clamping was 26 +/- 4 minutes in the SNP group and 30 +/- 4 minutes in the ISO group. Administration of isoflurance and sodium nitroprusside was stopped 2 minutes before unclamping. The same anesthetic technique using fentanyl, 6 micrograms/kg, flunitrazepam, 0.02 mg/kg, pancuronium, 0.1 mg/kg, and 50% N2O was used for all patients. At the time of clamping, either isoflurance (maximal expired concentration, 2.5% +/- 0.3%) or sodium nitroprusside (cumulative dose, 11.1 +/- 1.0 mg) was effective in maintaining the systolic blood pressure below 160 mm Hg, whereas the pulmonary capillary wedge pressure did not change. However, only SNP was able to bring the arterial pressure above the cross-clamp back to postinduction levels. During clamping, stroke index values were similar in both groups, but cardiac index increased only in patients receiving SNP. In both groups, at clamping and unclamping, PvO2 was higher than postinduction values, indicating that throughout the study the oxygen needs of the perfused area were adequately met. There was no evidence of acute left ventricular decompensation because pulmonary capillary wedge pressures did not abruptly increase, nor did pulmonary edema occur.(ABSTRACT TRUNCATED AT 250 WORDS)

Reconstructive surgery of the renal arteries in Takayasu's disease

Between 1977 and 1989, 24 patients (19 women and 5 men) with Takayasu's disease underwent renal artery restoration. Mean age was 32.9 years (range 15 to 60 years). All patients were hypertensive and three had moderate, chronic renal failure. Renal artery lesions were unilateral in two patients (8%), bilateral in 17 patients (71%), and unilateral in a solitary kidney in five (21%). Associated lesions of the thoracic or abdominal aorta or both were found in 22 patients (92%). Lesions of the visceral arteries found located in 21 patients (87%) and of the supraaortic trunks in 16 (67%). Initial revascularization of the supraaortic trunks was performed in four patients (17%). Renal artery revascularization was unilateral in 11 patients (46%) and bilateral in 13 (54%). Concomitant aortic reconstruction was performed in 21 patients (87%), visceral artery reconstruction in 17 patients (71%), and supraaortic surgery in seven (29%). One patient who underwent combined aortic and renal artery restoration, and in whom visceral artery involvement had been neglected, died postoperatively of heart failure and intestinal infarction. Three patients were lost to follow-up. Twenty patients have been followed for a mean of 61.3 months (range 4 to 124 months). One patient died at 89 months of intestinal infarction secondary to embolization originating from a false aortic aneurysm. Five repeat renal revascularizations were required in four patients. Hypertension is presently cured in 12 patients (63%), improved in six (31%), and unchanged in one (6%). Even though surgical treatment of arterial lesions in Takayasu's disease often includes complex and repeat revascularization procedures, satisfactory long-term results suggest the use of renal artery reconstruction in this affliction.

[Mechanisms and prediction of hemorrhagic complications during surgery of thoraco-abdominal aortic aneurysms]

This study, including 33 consecutive patients was designed to assess the haemostatic alterations occurring during repair of thoracoabdominal aneurysms. The surgical procedure consisted in Dacron graft replacement of the diseased aorta, using neither cardiopulmonary bypass, nor any shunting technique, nor any heparin. Blood samples were drawn before anaesthesia, before and 30 min after unclamping, and on the first postoperative day. The measured parameters were: haematocrit, platelet count, bleeding, activated cephalin, thrombin and prothrombin times, and concentrations of fibrinogen, factors V, VII, X and II, anti-thrombin III, proteins C and S, fibrin degradation products, D-dimers, alpha 2-antiplasmin, plasminogen, tissue plasminogen activator, plasminogen activator inhibitor, and serum protein. Eight patients developed severe multiple haemorrhages; 3 of them died during the procedure because of uncontrollable bleeding. Although the measured parameters were similar in the "bleeding" and control (n = 25) groups before surgery, there was, before unclamping in the first group, an important increase in activated cephalin and thrombin times, with a fall in concentrations of factor II and V, protein C, fibrinogen, and alpha 2-antiplasmin, and in platelet numbers. After unclamping, these changes worsened further, with an increase in prothrombin time and in fibrinogen levels (0,8 g.l-1), without any increase in fibrin degradation products. Abnormal bleeding started about 30 min after this in all the patients of the "bleeding" group. These changes, involving the fibrinolytic system as well as a fall in concentration of all the coagulation factors, can probably be partly explained by the clamping and unclamping of mesenteric vessels.(ABSTRACT TRUNCATED AT 250 WORDS)

Cutaneous manifestations of Takayasu arteritis. A retrospective study of 80 cases

The aim of this retrospective study is to delineate in Europe the frequency and type of cutaneous manifestations associated with Takayasu arteritis (TA). Eighty patients with TA were analyzed. Symptoms suggestive of Raynaud's syndrome were noted in 11 patients (14%) and could be directly related to large vessel involvement. Other skin lesions were observed in 10 patients (12.5%). Five had acute tender erythematous nodules on the legs with a clinical diagnosis of erythema nodosum; 2 had subacute ulcerated nodules of the legs; 1 had pyoderma-gangrenosum-like ulcerations of the four limbs which resulted from the breakdown of subcutaneous nodules; 1 had lupus-like malar flush, and the last one had urticarial lesions with livedo reticularis. Skin samples were obtained from 4 patients. Three of them agreed that reiterated biopsies be done on recurrent lesions. A granulomatous vasculitis was observed in 2 cases involving hypodermal arterioles in one case and veins in the other. The other pathological findings were septal and lobular panniculitis which can be associated with granulomatous vasculitis. Different histological findings on reiterated biopsies were frequently found. The absence of any other etiology and chronological arguments suggested a relationship between these skin lesions and TA. Tuberculosis was probable in 1 case but apparently was not related to the skin lesions.

[Peri- and postoperative use of low molecular weight heparin in peripheral vascular surgery]

A pilot study has been conducted in ten consecutive patients undergoing femoro-popliteal reconstruction or distal vascular surgery under epidural anaesthesia. Immediately before arterial cross-clamping, enoxaparin (E) (75 anti-Xa IU.kg-1) was injected intravenously (i.v.). During surgery, washing of the saphenous or polytetrafluoroethylene (PTFE) graft has been performed using enoxaparin. Enoxaparin (75 anti-Xa IU.kg-1) was administered subcutaneously (S.C.) 8 hours after the i.v. injection, and then every 12 hours during 10 days. The patency of the vascular reconstruction and the side-effects of E administration were evaluated clinically before and during surgery, then by a daily clinical examination. Echo-Doppler and/or arteriography were also performed preoperatively and on the 10th postoperative day. Haematocrit, platelet count, activated partial thromboplastin time, prothrombin time, thrombin time, fibrinogen and anti-Xa activity were assessed. None of the patients developed venous or arterial thrombosis and all the by-pass grafts remained patient. Only one minor surgical bleeding occurred on the first post operative day, despite anti-Xa levels in the expected range. One patient developed minor haematomas at the injection site. No bleeding was observed. Further randomized studies comparing LMWH and UH are required in order to substantiate these preliminary clinical and biological findings.

Perioperative cardiac complications of surgical repair of infrarenal aortic aneurysms

From 1985 to 1987, 261 patients (241 male, 20 female; mean age 66.5 years, range 38-90 years) were hospitalized for elective repair of infrarenal aortic aneurysms. One-hundred forty seven patients (56%) had coronary artery disease, attested to by past history of myocardial infarction or angina pectoris, electrocardiographic signs at rest, or abnormalities of dipyridamole thallium scintigraphy (performed in 72 patients). Ten patients had coronary arteriography and one patient then underwent aortocoronary bypass. Only two patients were not offered operation. All patients operated on had perioperative monitoring using Swan-Ganz catheters. Forty-five patients (17.5%) had a total of 62 postoperative events related to coronary artery disease. These included 40 cases of myocardial ischemia (15%), 16 cases of left heart failure (6%), and six myocardial infarctions (2%). There were nine (3.4%) postoperative deaths, four of which were due to cardiac causes (1.5%). In spite of the frequency of preexisting coronary artery disease and of intra- or postoperative myocardial ischemia, surgical repair of abdominal aortic aneurysm was not responsible for increased perioperative cardiac morbidity or mortality. In this population of aged patients, abdominal aortic aneurysm repair does not necessitate extending the indications for preoperative coronary arteriography or aortocoronary bypass.

[Arterial manifestations of Behçet's disease. 12 cases]

Out of 196 patients with Behçet's disease, 12 (10 men and 2 women, mean age 34 +/- 7 years) had non-coronary arterial lesions. Behçet's disease was complete in 4 patients. The arterial lesions had appeared 8.6 +/- 8 years on average (20 years at most) after the first sign of the disease. Three patients showed evidence of stenosis or occlusion involving one or several arteries. Eight patients had both stenotic and aneurysmal lesions. One patient had an arteriovenous fistula. Another developed a false aneurysm at the site of introduction of a femoral catheter. Yet another patient developed an anastomotic aneurysm one year after implantation of an abdominal aortic graft. In 2 cases histology showed fragmentation of the media associated with vasculitis of the vasa vasorum. Two patients with pulmonary aneurysm died of massive haemoptysis. In 2 patients combined corticosteroid and cyclophosphamide therapy failed to prevent the development of aneurysmal lesions. Phlebitis was associated with arterial involvement in 7 patients. Comparison between patients with or without arterial lesions showed no significant difference in time of onset of Behçet's disease, sex, main clinical features and presence of HLA B5. Aneurysmal lesions respond poorly to medical treatment, and surgery is mandatory. Since recurrence at the site of anastomosis is possible, prolonged monitoring is required.

[Baroreflex activity in carotid endarterectomy during general anesthesia]

The baroreceptor reflex was studied in eleven patients, aged 69 +/- 6 years, scheduled for carotid endarterectomy under general anaesthesia. Nine were hypertensive. The anaesthetic protocol was the same for all the patients: premedication with morphine and scopolamine, induction with 5 mg.kg-1 thiopentone, 6 micrograms.kg-1 fentanyl and 0.01 mg.kg-1 pancuronium bromide. All the patients were intubated and ventilated with a mixture of nitrous oxide and oxygen. Fentanyl, 100 micrograms, was routinely given at the time of incision. Baroreflex sensitivity was tested using Smyth's method, with a bolus of 75 micrograms trinitrin and plotting changes in heart rate against those in systolic blood pressure. Electrocardiogram, invasive arterial blood pressure and airway pressure were simultaneously recorded. PaCO2 and PaO2 were measured during arterial clamping. The tests were carried out before clamping, 2 min later and 10 to 20 min after the last injection of fentanyl. In the seven patients for whom clamping lasted more than 15 min, a further test was carried out after administration of 0.4 +/- 0.05 vol% halothane (Datex analyser) for 5 min. During anaesthesia, baroreflex sensitivity was low (1.8 +/- 0.3 ms.mmHg-1). After clamping, there was only a significant change in Pasys, with no changes in heart rate or blood gas values (129 +/- 8 mmHg before clamping; 167 +/- 12 mmHg after clamping; n = 8; p less than 0.01). After halothane administration, the sensitivity slope decreased, but not significantly. Moreover, halothane decreased the R-R intervals (1140 +/- 84 after clamping; 963 +/- 76 under halothane; n = 6; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Preoperative spinal cord arteriography in aneurysmal disease of the descending thoracic and thoracoabdominal aorta: preliminary results in 45 patients

Between 1985 and 1988 45 patients with descending thoracic or thoracoabdominal aortic aneurysms underwent selective arteriography of the intercostal and lumbar arteries to delineate preoperatively the artery of Adamkiewicz and the thoracic radicular artery. Identification of these vessels failed in five patients (11%), was considered complete in 31 patients (69%) and incomplete in nine (20%). Selective arteriography classified these patients into four groups: groups A and B--the artery of Adamkiewicz arose respectively above and below the zone of operation; group C--the artery arose directly from the segment to be operated; and group D--origin could not be determined. All 30 patients in group C underwent a spinal cord revascularization procedure (complete in 20 cases, incomplete in 10). Spinal cord complications occurred in 9/45 patients (20%). No spinal cord complications occurred in groups A and B; their incidence was 5% in group C when revascularization was complete, and 50% when revascularization was incomplete; and 60% had complications in group D (p less than 0.01). Spinal cord complications were more frequent (p less than 0.05) when the artery of Adamkiewicz arose from an intercostal or lumbar artery obliterated at its aortic origin but filled through collaterals or when spinal cord circulation was interrupted for more than 45 minutes. This study confirms the importance of preserving arterial supply to the spinal cord during repair of descending thoracic and thoracoabdominal aneurysms. The information obtained from spinal cord arteriography allows the prediction of complications and informs the choice of the appropriate surgical technique.

Improvement of diaphragmatic function by a thoracic extradural block after upper abdominal surgery

The effects on diaphragmatic function of a thoracic epidural block were assessed in 13 patients after upper abdominal surgery (UAS). Lung volumes and tidal changes in chest wall circumferences and gastric (delta Pgas) and esophageal (delta Pes) pressures were measured pre- and postoperatively. Volume displacement of the abdomen divided by tidal volume (delta VAB/VT) and delta Pgas/delta Pes were taken as indices of the diaphragmatic contribution to tidal breathing. These respiratory variables were obtained in the postoperative period, before and after epidural injection of 0.5% plain bupivacaine to achieve a block up to the T4 segment. UAS was constantly associated with a decrease in VT, delta VAB/VT, delta Pgas/delta Pes, and forced vital capacity (FVC). Epidural block was associated with an increase in VT, delta VAB/VT, and FVC. delta Pgas and delta Pgas/delta Pes returned to their preoperative values. It is concluded that: 1) diaphragmatic dysfunction observed after UAS is partially reversed by thoracic epidural block; and 2) that inhibitory reflexes of phrenic activity arising from the abdominal compartment (abdominal wall and/or viscera) could be involved in this diaphragmatic dysfunction.

Traumatic rupture of the thoracoabdominal aorta

We report a case of traumatic rupture of the thoracoabdominal aorta that was successfully repaired 3 days following the accident. Associated lesions included rupture of the left renal and celiac arteries. This rare lesion should be suspected in the victims of violent hyperextension of the body with or without a fracture of the dorsolumbar spine. Aortography is diagnostic. Whenever possible preoperative angiographic visualisation of the spinal cord arterial supply should be performed.

Pathophysiologic study of chronic infarcts with I-123 isopropyl iodo-amphetamine (IMP): the importance of periinfarct area

Seventeen chronic cerebral infarcts were investigated by a highly sensitive, dedicated brain single photon emission computerized tomography system using 123I-isopropyl iodoamphetamine (IMP) and 133Xe. IMP uptake was measured 10 minutes, 2 hours, and 5 hours after injection, and regional cerebral blood flow was measured with 133Xe. In 4 cases a positron emission tomography system was used to measure the rCBF and the regional metabolic rate of oxygen with C15O2 and 15O2. The results obtained allowed us to identify 2 abnormal zones. One, the "central area," was characterized by a severe decrease in IMP uptake and rCBF averaging 34% and 46% respectively and by a hypodense image on the x-ray computerized tomography scan. The second, the periinfarct or "peripheral area" was characterized by a moderate decrease in IMP uptake and regional cerebral blood flow averaging 13 and 19% respectively; this area extended around the central area and had a normal density on computerized tomography scan. The IMP hypofixation of the peripheral area observed at the 10th minute tended to disappear at the 5th hour. The volume of this area was often found to be quite large, covering more than 30% of a hemisphere whereas the central area did not exceed 25%. Volume appeared to be correlated with the neurological status of the patient. The nature of the peripheral area is not established with certainty. It may be caused by deafferentation of areas not directly affected by the ischemic insult and/or selective ischemic neuronal loss. The results stress the important role played by the peripheral area, which may be useful in establishing the prognosis and evaluating the efficacy of therapy in individual stroke cases.

[Leiomyosarcomas of the inferior vena cava]

Leiomyosarcoma of the inferior vena cava in a rare tumor which is predominantly seen in women. The symptomatology is non specific and depends mostly of the segment of the vessel which is involved. Radiologic approach for correct preoperative diagnosis is based on ultrasonography, computed tomography and inferior vena cavography. The best treatment is en bloc resection of the mass associated with pre and post-operative chemotherapy. Although the tumor is slow-growing, the prognosis is poor and the average survival is less than two years, due to local recurrence and metastases.

Exclusion-bypass for aneurysms of the descending thoracic and thoracoabdominal aorta

From October 1973 to April 1985, 81 patients with aneurysms of the descending thoracic or thoracoabdominal aorta underwent surgery. Eight (10%) of these patients were treated by exclusion-bypass. The aneurysm was located in the descending aorta alone in five cases, and in the descending thoracic and thoracoabdominal aorta in three cases. In all cases, the proximal anastomosis of the bypass was performed on the ascending aorta. The site of the distal anastomosis was the supraceliac aorta in two cases, the infrarenal aorta in three cases and the iliac arteries in three other cases. Exclusion was bipolar, at each end of the aneurysm, in six cases, and unipolar, ie. proximal interruption only, in two cases. Two patients died during the first postoperative month, one of rupture of the distal portion of the aortic arch, the second, after onset of secondary paraplegia. There were no other spinal, cardiac or cerebral complications. One patient died three months postoperatively of intercurrent pulmonary infection. The five other surviving patients whose mean follow-up period is 48.1 +/- 25 months, are alive and enjoying good health. Resection and grafting as advocated by Crawford, is the usual treatment proposed for aneurysms of the descending thoracic and thoracoabdominal aorta. Exclusion-bypass may however be preferred in the following cases: elderly patients with compromised respiratory status, aneurysms of the descending thoracic aorta, either voluminous, of infectious origin or associated with aneurysm of the infrarenal abdominal aorta.

Intravenous digital subtraction angiography in Takayasu's disease. A report of 32 cases

IVDSA appears to be a reliable method and should therefore be considered as a first step examination when Takayasu's disease is suspected. The simplicity and safety of the method provide a rationale for the use of this technique in Takayasu's disease. Therapeutic decisions can usually be obtained without further radiological investigation, and conventional arteriography has to be performed only when data obtained with IVDSA are insufficient. In these rare cases, conventional arteriography aims at the investigation of a particular area. The site of arterial puncture can be precisely guided by IVDSA.

[Takayasu's disease. Value of digital intravenous angiography. 44 cases]

Forty-four patients with Takayasu's arteritis were explored by digital intravenous angiography either for diagnostic purposes and pre-therapeutic assessment (n = 29) or immediately after surgery (n = 15). There were 36 women, 6 men and 2 children; mean age was 31 years. The contrast medium (mean volume 140 ml) was injected into central (74%) or peripheral (26%) veins. No other angiographic exploration was contemplated in 24 patients selected for medical treatment. Among 15 patients destined to surgery or percutaneous angioplasty, 13 were operated upon without further angiography and 2 underwent arteriography since the distal vascular bed beyond the major lesions could not be evaluated adequately. Data obtained from post-operative evaluation (n = 15) were satisfactory, with 1 failure in this group. Digital intravenous angiography seems to be reliable enough to be used as first examination in patients with suspected Takayasu's arteritis. The procedure is well tolerated and can be repeated for optimum determination of the operation date. Arteriography can now be reserved to those rare cases where digital angiography has failed; it can then be limited to the study of a specific territory, the site of puncture being located by digital angiography.

Roles of fentanyl and nitroglycerin in prevention of myocardial ischemia associated with laryngoscopy and tracheal intubation in patients undergoing operations of short duration

The purpose of this study was to evaluate intravenous nitroglycerin given during induction of anesthesia as a means for prevention of myocardial ischemia and hemodynamic changes associated with induction, laryngoscopy, and intubation, in patients with stable angina scheduled for vascular operations of moderate duration. Forty-six patients were randomly assigned to receive either fentanyl, 3 micrograms/kg (group 1, n = 6), fentanyl, 8 micrograms/kg (group 2, n = 20), or fentanyl 3 micrograms/kg plus a continuous intravenous nitroglycerin infusion, 0.9 microgram X kg-1 X min-1 (group 3, n = 20), in addition to thiopental-pancuronium anesthetic induction, prior to laryngoscopy and intubation. The criteria for recognizing myocardial ischemia were the following: horizontal or downsloping ST segment depression equal to or greater than 1 mV, and/or ventricular arrhythmia, on CM5 recording. In group 1, myocardial ischemia occurred during laryngoscopy and intubation in four patients, and mean blood pressure (MBP), heart rate, and mean pulmonary wedge pressure (PCWP) increased significantly (P less than 0.05). Despite greater stability in MBP and heart rate in group 2, myocardial ischemia still occurred in four patients (not significantly different from group 1). Nitroglycerin added to low-dose fentanyl (group 3) produced significant reduction in myocardial ischemia (1/20) when compared with group 1 (P less than 0.01), and significantly greater stability in PCWP during laryngoscopy and intubation in comparison to groups 1 and 2. In patients with stable angina undergoing operations of short duration, the use of nitroglycerin infusion and low-dose fentanyl significantly decreases the incidence of myocardial ischemia associated with induction of anesthesia and tracheal intubation.

Gunshot pellet embolus to the middle cerebral artery

A 24-year-old man sustained a gunshot wound to the upper right hemithorax and neck, with injury to the subclavian and carotid arteries. A cerebral artery pellet embolus resulted in contralateral hemiplegia. The injured vessels were repaired, but the middle cerebral artery pellet was left undisturbed. Neurologic improvement occurred. Fifteen cases of foreign body embolus to cerebral vessels are reviewed and the management of this unusual injury is discussed.

[Digitized intravenous angiography in Takayasu's disease. Apropos of 44 cases]

Forty-four patients with Takayasu's disease were investigated by digitised intravenous angiography (DIVA) during a diagnostic and pretherapeutic work up (N = 29) or at surgery (N = 15); the aim of this retrospective study was to assess the role of DIVA in the investigation of this condition. The patients were 36 women, 6 men and 2 children; the average age was 31 years. The intravenous injections were performed in a central vein in 74% and in a peripheral vein in 26% of patients; the average amount of contrast medium injected was 140 ml per investigation (32 g of iodine %). Depending on the site of the lesions, the distribution of the 43 successfully investigated patients was as follows: Type I: 13 (20%), Type II: 6 (14%), Type III: 12 (28%), Type IV: 12 (28%). In the group of patients managed medically (N = 14) no other angiographic investigations were considered. In the group with an indication for surgery or percutaneous angioplasty (N = 15), the procedure was carried out without further angiography in 13 cases; in 2 patients the imaging of the distral vessels was inadequate and complementary angiography was required. All postoperative controls (N = 15) but one were satisfactory. These results show that DIVA is sufficiently reliable for it to be considered as an investigation of first intent in patients with suspected Takayasu's disease. The investigation is well tolerated and can be repeated when necessary to determine the optimal time for surgery. Arterial angiography should seem only to be indicated when the venous approach has failed, which was rare in this series.

[Hemodynamic effect of the clamping of the carotid in the surgically treated coronary patient]

To determine both the incidence of myocardial ischaemia and haemodynamic response to carotid cross-clamping in coronary artery disease, 30 patients undergoing carotid endarterectomy were studied with a clear history of effort related disabling angina pectoris. Myocardial ischaemia was detected by a recording of lead CM5 of the electrocardiogram. A radial arterial and a thermodilution pulmonary catheter were inserted to obtain haemodynamic measurements before and after carotid cross-clamping and unclamping. Anaesthesia was induced with increments of thiopental, fentanyl 6 micrograms X kg-1 and pancuronium. Additional fentanyl (2 micrograms X kg-1) was injected before skin incision and before carotid cross-clamping. Carotid cross-clamping results in a significant increase in both mean arterial blood pressure and capillary wedge pressure. Two patients experienced myocardial ischaemia with ST segment depression during carotid cross-clamping. Nitroglycerin infusion led to the improvement of ST segment depression. When halothane was additionally administered to patients who developed hypertension in response to carotid cross-clamping, arterial blood pressure returned to normal value. These results indicate that carotid cross-clamping increases determinants of myocardial oxygen demand and may cause myocardial ischaemia in patients suffering from angina pectoris.

[Coronary involvement in Takayasu's disease. Apropos of 3 cases, of which 2 were surgically treated, and review of the literature]

Coronary arteries like other branches of the aorta may be involved in Takayasu's disease. This complication is not rare (7% of cases) but appears to be relatively unappreciated. Three new cases are reported of main coronary artery disease, two of which were treated by coronary bypass surgery. A review of the literature of 1 130 cases of Takayasu's disease revealed 86 cases with coronary involvement, 33 of which were confirmed anatomically and 15 by coronary arteriography. The clinical manifestations, angina and/or myocardial infarction, were present in 5% and 3% respectively, of patients with Takayasu's disease. They may be the first sign of the disease and, in some cases, the only symptomatic arterial localisation. The coronary lesions are either ostial, a direct complication of the aortic disease, or on a main vessel, usually proximal. Histological studies show typical changes of stenosing inflammatory panarteritis involving mainly the media and adventitia. Thrombosis and secondary atheromatous plaques may be observed. Aneurysms are rare. Apart from cases with typical ostial lesions, the coronary angiographic appearances are not specific, but some features are suggestive of the diagnosis; the occurrence in young women; the presence of associated peripheral arterial lesions, their localisation and grouping; their radiological and/or histological characteristics. The spontaneous prognosis of these proximal lesions is usually poor and justifies surgical revascularisation by coronary bypass. Six patients, including two in this series, have been treated surgically. The associated aortic lesions may pose special technical problems which we discussed. The relatively high incidence of coronary involvement in Takayasu's disease and its often unexpected revelation by myocardial infarction or sudden death, suggest that coronary arteriography should be undertaken more often during investigation of the arterial lesions of these patients. Takayasu's disease should figure prominently amongst the causes of coronary artery disease in young women.

[Persistent sciatic artery. Apropos of a case, review of the literature ]

A case is reported of bilateral persisting sciatic arteries: complete on the right side but incomplete on the left, revealed by the onset of a distal embolism on the right side treated by exclusion and a right femoropopliteal shunt operation. The observation of this further case in France led to a review of the literature which demonstrated the rarity of this congenital anomaly, which usually however represents the only vascular axis to the lower limb, and the frequency of aneurysmal transformations with subsequent complications that are best treated by ligature combined with a femoropopliteal shunt.

Arteriovenous fistulae of the internal iliac vessels

Seven patients with arteriovenous fistulae of the internal iliac artery are reported. Ages varied from 6 to 50 years (mean 32 years). Cutaneous angiomata , leg oedema and pain was present in 4 cases each, bleeding in 2 cases whilst only one was asymptomatic. Only 1 patient had cardiac insufficiency. In six patients the lesion was a congenital malformation but in one it was posttraumatic. Arteriography both global and selective, intravenous pyelography and cardiac output are routine. Recently, pelvic computerised tomography has been most helpful. Embolization is recommended in all cases with surgery within 24 hours unless the lesion is very extensive and considered to be inoperable. Repeat embolization is used for recurrence or very extensive lesions. Results were good in five patients; in two patients the results were clinically good but control angiograms showed a recurrence.

"Redo" surgery for late aorto-femoral graft occlusive failures

Experience of late failures of Dacron aortofemoral grafts is presented; about 70 cases observed during the past eight years on whom 105 subsequent operations were performed. One third of these patients were first operated upon by another surgical team. During the same period, 850 patients were submitted to reconstructive surgery of the abdominal aorta and iliac arteries either for atherosclerotic or for aneurysmal disease. It appears that conservative procedures like thrombectomy of the occluded limb are often insufficient, impossible, inappropriate or dangerous, even after restoration of a good deep femoral outflow. On the other hand, aggressive restoration of limbflow is generally necessary, with other various and ingenious direct or indirect reconstructive techniques for restitution of a good inflow and outflow. These techniques are usually successful (85%) and gain time against the major etiology of these late failures viz the development of atherosclerotic disease.

[Inferior caval syndromes. Apropos of 45 cases]

The authors report their experience with 45 cases of inferior vena cava thrombosis. Diagnosis was delayed for an average of 55 days. One-third of cases were revealed by an embolic complication. Inflammatory diseases were the most common causes (Behcet disease: seven cases, systemic lupus erythematosus: 5 cases). Malignancies accounted for 20% of cases. Abnormalities of coagulation were uncommon: antithrombin III deficiency in one patient and protein C deficiency in another. Estrogen-progestogen combinations could be incriminated in 4 cases. Outcome was fatal in 20% of cases, usually as a result of the underlying disease. Functional status was good in two-thirds of patients without malignancy followed up for an average of 27 months. In 14 patients a clip was inserted to ensure total (3 cases) or partial (11 cases) interruption of vena cava blood flow because of a free thrombus and/or recurrent pulmonary embolism. Three patients had thrombectomy. After clip insertion two embolisms were recorded, one of which occurred in the immediate post-operative period.

[Peroperative vascular accidents during orthopedic surgery. Apropos of 55 cases]

The functional or vital prognosis may be affected by the rare vascular accidents resulting from orthopedic operations. During a 10 year period (1970-1980), 55 vascular lesions were observed in 40 patients, and were either arterial (40 cases) or venous (15 cases) in type. Vascular injuries in 9 cases were due to spinal operations (cervical, lumbosacral or herniated disc arthrodesis), in 7 cases to shoulder operations (recurrent dislocation, excision of first rib), in 9 cases to hip surgery (prosthesis, plate and screws, fractured acetabulum), and in 15 cases to operations on the lower limbs (osteosynthesis of femur or tibia, meniscus operations, etc.). Emergency operation was necessary in 18 cases because of a hemorrhagic or ischemic syndrome, all other cases except three requiring secondary surgery for false aneurysms, arteriovenous fistulae, or residual ischemia. Four patients (10%) died, three following hip surgery, and 8 developed complications. The frequency, mechanism, diagnostic and therapy of these lesions are discussed.

[Myocardial ischemia and carotid surgery. Holter study of 21 severe coronary patients. Preventive effect of intravenous trinitrin]

Cervical carotid artery surgery is increasingly being performed in elderly, polyvascular, high risk patients, some of whom have severe coronary artery disease. Is this right? The effects of this almost routine surgical procedure from the technical point of view were analysed with respect to the coronary lesions. 1. A retrospective study of coronary events occurring in the peroperative or immediate postoperative period and at short term was carried out in 367 patients aged over 70 years old (average 73,4 years) undergoing 424 cervical carotid artery procedures with a particularly high coronary risk. 2. A prospective study of ischemic ECG changes occurring in the period between induction of anaesthesia and the 4th postoperative day was performed by Holter monitoring in 21 patients with severe coronary artery disease. The mortality and morbidity observed were very low and could be further reduced by certain anaesthetic and pre-and postoperative techniques. In particular, prophylactic intravenous trinitrin (0,5 to 1,5 gamma kg/min) was most effective in protecting the myocardium in 15 patients with severe angina (classes III and IV of the NYHA classification). The authors conclude that the surgical result depends mainly on the neurological status of the patients, the best results being obtained in asymptomatic patients (stage 0) or those having suffered transient ischemic attacks (stage 1). The global mortality and morbidity rate was less than 2 p. 100 in those groups. On the other hand, long-term survival depends mainly on the severity of the coronary artery disease.

[Leiomyosarcoma of inferior vena cava. A new case. Surgical management (author's transl)]

The authors report on a new case of leiomyosarcoma of the inferior vena cava, to add to the sixty five cases already mentioned in the literature. The patient had been suffering from subcostal pains for 12 years, and an adenomyoma of the gall bladder was diagnosed. The tumor was discovered in the course of a cholecystectomy. The vena cava was resected and ligated below the renal veins. After describing the case, the authors go on to review the literature and stress the fact that the prognosis, which is often severe, could be improved by earlier diagnosis.

[Superior vena cava syndrome: a rare complication of endocavitary cardiac pacing]

The superior vena cava syndrome is an exceptionally rare complication of endocavitary cardiac pacing, asymptomatic venous thrombosis being much more common. Two cases wee observed as late complications of pacemaker implantation. In the first case the clinical signs regressed with the development of a collateral circulation under heparin therapy after failure of fibrinolytic drugs. In the second one, the severity of the superior vena cava syndrome and the poor quality of the collateral circulation led to the implantation of a Gore-Tex prosthesis. This surgical bypass led to a rapid and complete regression of the clinical signs. It would seem to be a valuable alternative when anticoagulant therapy fails.

Carotid artery surgery in patients over 70 years of age

Between 1965 and 1979, 934 patients underwent 1,057 operations for extracranial carotid stenosis at this institute, and over a recent 30-month period 463 patients underwent 511 operations of this type. This number is equal to the total of operations performed during the years 1965-1976. The increase in the frequency of carotid artery surgery has been more marked in patients of over 70 years. The percentage of elderly patients has increased from 17.5% to 27% in the recent period. In the latter group of 511 operations, results were good in 93.17% of cases, while there was a mortality rate of 1.95% (1% of which were directly related to the surgery), in 1.95% the neurologic condition deteriorated and in 3.13% there was no change. In the first period the mortality rate for patients over 70 years of age was 7.69%. In the second it was 3.27% (1.63% of which were due to non-neurologic causes), 4.09% deteriorated, in 2.18% there was no change and good results were obtained in 90.46%.