Necrotizing fasciitis of the lower limb after venous surgery: cases studies and a review of the literature

We report 2 cases of necrotizing fasciitis following stripping of the long saphenous vein and phlebectomy of varicose collateral vessels. The first one concerns a 42-year-old man who presented with a left thigh postoperative infection, evolving despite oral antibiotic therapy. Urgent surgical exploration proved an extensive necrosis consistent with necrotizing fasciitis. Wide excision of the necrotic tissue was performed. Under intravenous antibiotic therapy, local wound care and hyperbaric oxygen therapy, the patient's condition improved. The second case concerns a 60-year-old man with cardio-vascular disease and diabetes. He was transferred in our institution 7 days after surgery for an infection in the right thigh and septic shock. Immediate surgical exploration showed extensive necrotizing fasciitis of the thigh, popliteal fossa and latero-posterior compartments of the leg. Muscle necrosis of the right leg was also observed. A right supra-condylar amputation was performed. The patient improved under antibiotherapy and hyperbaric oxygen therapy.

Do surgical distal bypasses still play a role in the treatment of critical limb ischemia?

AIM

The treatment of critical limb ischemia is at present very controversial. In fact surgery using different grafts (venous or prosthetic) is in competition with percutaneous angioplasty. Progresses of endoluminal techniques brought certain authors to think that angioplasty is now the first treatment of critical limb ischemia. The aim of the study hereby is to compare our results of distal venous bypasses to the results obtained in literature with venous or other grafts and to those of the percutaneous angioplasty.

MATERIAL AND METHOD

In this retrospective study of 113 operated cases between January 2003 and December 2006 by four surgeons, 21 cases are excluded considering the lack of data. Among the remaining 92 cases, the average age is 68.1 years. Men represent 79.4%. Comorbidities include: COPD 55.4%, coronary artery disease 60.9%, diabetes 44.6%, dyslipidemia 66.3% and dialysis 9.8%. Surgical revision was necessary in 29.4%. There were 30.4% stage III limb ischemia and 62% stage IV. Acute ischemia was present in 7.6% of patients. The proximal anastomosis of the bypass is femoral except for 13 cases. The outflow artery is always sural or even more distal.

RESULTS

Perioperative mortality is of 2.2% (two cases). The average follow up was of 26.2 months (0.16-64). Eleven patients required subsequent amputation. The primary patency at 1, 3 and 5 years was respectively of 82.1%, 70.6% and 55.9% while limb salvage was respectively of 87.4%, 85.9% and 85.9% at the same intervals.

CONCLUSION

Comparing our results to those of the literature for venous or prosthetic bypasses and distal angioplasties, we remain convinced of the high efficiency, on the long run, of infra-popliteal venous bypass grafts. Meanwhile, recent data on distal angioplasties are promising and in constant progress.

Spontaneous renal artery dissection in an otherwise healthy male

Dissection of a renal artery is rare and, in most cases, associated with underlying arterial diseases. Spontaneous renal artery dissection (RAD) is exceptional. We report the case of a young and otherwise healthy man with an isolated dissection of the right renal artery without any obvious origin. Diagnosis was made by angiography. He received medical treatment and rapidly recovered. Renal artery dissection can be misdiagnosed because its clinical presentation may be confusing. Selective renal angiography is essential to evaluate the extent of the dissection and the suitability for repair. Control of the hypertension and renal function preservation are the two main goals of the treatment. The place of surgical repair remains unclear because of the poor results on hypertension improvement and high complication rate.

Pituitary apoplexy after aortic abdominal aneurysm surgery: a case report

Pituitary apoplexy (PA) occurring after surgery is a rare but life-threatening acute clinical situation following extensive haemorrhage or necrosis within a pituitary adenoma. Pituitary apoplexy has been reported to occur spontaneously in the majority of cases or in association with various inducing factors. One of the pathophysiological mechanism that has been postulated is the fall of arterial blood pressure inducing ischaemia followed by infarction of the pituitary gland. We report a case of pituitary apoplexy following aortic abdominal surgery. To our knowledge, this has not been previously reported. A 73-year old man complained of headache and diplopia. At clinical examination, he presented a right oculomotor nerve palsy. Magnetic resonance imaging (MRI) showed a haemorrhagic sellar mass. In our case, intraoperative hypotension could have been the precipitating factor. Diagnostic and therapeutic measures are discussed.

Emergency endovascular treatment of an acute traumatic rupture of the thoracic aorta complicated by a distal low-flow syndrome

We report the case of a patient who suffered major trauma following a motorcycle accident that resulted in multiple fractures, bilateral hemopneumothorax, pulmonary contusions, and an isthmic rupture of the aorta with a pseudoaneurysm compressing the descending aorta. This compression was responsible for distal hypotension and low flow, leading to acute renal insufficiency and massive rhabdomyolysis. Due to the critical clinical status of the patient, which prevented any type of open thoracic surgery, endovascular treatment was performed. An initial stent-graft permitted alleviation of the compression and the re-establishment of normal hemodynamic conditions, but its low position did not allow sufficient coverage of the rupture. A second stent-graft permitted total exclusion of the pseudoaneurysm while preserving the patency of the left subclavian artery.

[Selective intra-arterial perfusion of the cancerous breast: quantitative study]

Mammary tissue diffusion of a radioactive marker (Pertechnetate-Tc99m), intravenously or selectively and intraarterially injected, has been studied in 15 breast cancers; a considerable increase of that diffusion with co-injected degradable starch microspheres has been demonstrated. A clinical application of these techniques should be soon considered.

[Microvascularization of the cancerous breast: therapeutic perspective?]

The aim of this study is to try to answer these two questions: is an intra-arterial chemotherapy of breast cancer technically possible? would such a treatment present a clinical interest? to this purpose, 12 tumoral breasts have been studied from a vascular, anatomic and arteriographic point of view; two of them were moreover subjected to scintigraphic and pathologic studies. The results seem to be encouraging, and studies are continued to specify different parameters of this therapeutic approach; then, the possibility of a clinical trial could be considered.

[Preoperative selection for lumbar sympathectomy using a mixed hyperemia test]

The decision to perform a lumbar sympathectomy in cases of severe distal arteritis should be made according to an objective selection method. The mixed active hyperemia test meets that condition.

[Importance of the Limberg triple flap in the surgical treatment of cancer of the breast in the male]

Two cases of male breast cancer are presented. The patients underwent a modified radical mastectomy with immediate closure of the defect using a triple L-shaped transposition flap. We briefly recall the behaviour of these tumors and the applied surgical principles to define better the value of this plastic procedure. A variety of surgical plastic techniques are described and compared. The triple L-shaped Limberg flap, very well adapted to the treatment of male breast cancer, is described in detail. The results are gratifying both from the plastic and cancerologic view-point.

Role of thymidine kinase in the inhibitory activity of 5-substituted-2'-deoxyuridines on the growth of human and murine tumor cell lines

Twenty-four 5-substituted 2'-deoxyuridines have been evaluated for their inhibitory effects on the growth of three human lymphoblast cell lines (Namalva, RAji and TK- (thymidine kinase deficient) Raji) and these inhibitory effects were compared to those for two murine leukemia cell lines (L1210/0 and L1210/BdUrd). The latter was selected from the parental L1210/0 cell line by its ability to grow at high concentrations of 5-bromo-dUrd and could also be considered as TK-. There was a close correlation between the inhibitory effects of the deoxyuridine analogs on Namalva, Raji and L1210 cells: the correlation coefficient (r) for log ID50 (median inhibitory dose) for L1210 cell growth, on the one hand, and log ID50 for Namalva or Raji cell growth, on the other hand, was 0.902 and 0.929, respectively. There was also a strong correlation (r = 0.936) between the log ID50 values for the two human lymphoblast cell lines. However, there was no significant correlation (r less than 0.40) either between the log ID50 for the TK- Raji cells and the parental TK+ Raji cells, or between the log ID50 for the TK- L1210/BdUrd cells and the parental TK+ L1210/0 cells. We may conclude therefore, that (i) the murine leukemia L1210 cell system is predictive for the growth-inhibitory effects of 5-substituted 2'-deoxyuridines on human lymphoblast cell lines, and (ii) the antitumor cell activity of the 5-substituted 2'-deoxyuridines is, to a large extent, dependent on the thymidine kinase activity of the tumor cells.

Antiviral, antimetabolic, and cytotoxic activities of 5-substituted 2'-deoxycytidines

Various 5-substituted 2'-deoxycytidines, including 5-bromo-dCyd, 5-iodo-dCyd, 5-nitro-dCyd, 5-ethynyl-dCyd, 5-propyl-dCyd, (E)-5-(2-bromovinyl)-dCyd, and (E)-5-(2-iodovinyl)-dCyd, were evaluated for their antiviral and antimetabolic properties in primary rabbit kidney (PRK) cell cultures and for their inhibitory effects on murine L1210 cell proliferation. All dCyd analogues proved to be selective inhibitors of herpes simplex virus (HSV) replication: 5-bromo-dCyd, 5-iodo-dCyd, 5-nitro-dCyd, and 5-ethynyl-dCyd were more selective in their anti-HSV activity than were the corresponding 5-substituted 2'-deoxyuridines, whereas 5-propyl-dCyd, (E)-5-(2-bromovinyl)-dCyd, and (E)-5-(2-iodovinyl)-dCyd were as selective as their dUrd counterparts. The dCyd analogues were also less cytotoxic (for both PRK and L1210 cells), as could be monitored by inhibition of either cell proliferation or host-cell DNA synthesis (incorporation of radiolabeled precursors). Of all 5-substituted 2'-deoxycytidines tested, the (E)-5-(2-halogenovinyl) derivatives emerged as the most potent and most selective inhibitors of HSV (Type 1) replication.

Comparative efficacy of antiherpes drugs against different strains of herpes simplex virus

A large variety of antiherpes compounds was compared for their inhibitory activity against laboratory strains and clinical isolates of herpes simplex virus (HSV) type 1 and type 2. From studies performed in primary rabbit kidney cell cultures, six, E-5-(2-bromovinyl)-2'-deoxyuridine, E-5-(2-iodovinyl)-2'-deoxyuridine, 5-vinyl-2'-deoxyuridine, 2'-fluoro-5-iodoaracytosine, acycloguanosine, and 5-iodo-2'-deoxycytidine, emerged as the most potent and selective antiherpes agents. For HSV type 1, the 50% inhibitory doses (ID50) were 0.008, 0.012, 0.018, 0.017, 0.04, and 0.06 micrograms/ml, respectively; those for HSV type 2 were 1, 2, 0.1, 0.05, 0.04, and 0.3 microgram/ml, respectively. These compounds did not inhibit host-cell metabolism or replication of vaccinia virus except at concentrations 100--10,000 times greater than the ID50 for any HSV. All were significantly less inhibitory for a thymidine kinase (TK)-deficient mutant of HSV type 1 than for normal strains, suggesting that phosphorylation by virus-induced TK was required to produce specific inhibition of HSV replication.

(E)-5-(2-bromovinyl)-2'-Deoxyuridine in the treatment of experimental herpes simplex keratitis

IDU (5-iodo-2'-deoxyuridine), BVDU [(E)-5-(2-bromovinyl)-2'-deoxyuridine] and placebo ointments were studied for their effects on experimental herpes simplex (type 1) keratoconjuncitivitis in rabbits. When treatment was begun 65 h after virus inoculation, both BVDU and IDU prevented development of keratitis. Both BVDU and IDU were also effective in suppressing the severity of conjunctivitis, and in this respect, BVDU proved significantly better than IDU. When treatment was started 110 h after virus inoculation, BVDU proved significantly better than IDU in promoting healing of established keratitis.