[Malignant carotid paraganglioma. A case report]

The most common sites of paragangliomas occurring in the head and neck region are the carotid body and vagal glomus. The clinical course of carotid body paragangliomas is characterized by two modes of development: locoregional growth and distant metastatic dissemination. Few cases of malignant carotid body paraganglioma have been reported in the literature. We report a case managed in the ENT Department of Grenoble university hospital in 1993. A 53-year-old woman presented a bilateral functional (dopamine secretion) carotid tumor, stage II on the right side and stage I on the left side according to the Shamblin classification. Two successive excisions with complete resection were performed without complication. Two years after the second surgical excision, bone and liver metastases were diagnosed and visualized with a Ostreoscan scintigraphy. Clinical course was rapidly unfavorable and the patient died a few weeks later. Malignant forms of carotid paraganglioma are very uncommon and there is no cellular or histological appearance significantly contributing to the diagnosis of malignancy. Clinical findings are the most reliable criteria for malignancy, with the development of distant metastases usually after about 9 years. Long follow-up is essential. Histology in needed to establish the diagnosis of metastasis. A histology specimen may not be possible for a functional paraganglioma. In this case scintigraphy can provide the diagnosis. Malignant forms are more frequent in case of functional paraganglioma, more particularly in case of dopamine secretion.

Management of symptomatic and asymptomatic popliteal venous aneurysms: a retrospective analysis of 25 patients and review of the literature

OBJECTIVE

Popliteal venous aneurysms (PVAs) are an uncommon but potentially life-threatening disease because they can be a source for pulmonary emboli (PE). With the widespread use of venous duplex scanning, PVAs are increasingly found in patients with deep or superficial vein insufficiency, and questions have arisen as to the management of these aneurysms. The purpose of this study was to review our experience in the management of PVAs diagnosed in patients with PE and in patients with chronic venous diseases.

METHODS

Twenty-five patients with PVAs were treated in two centers between 1985 and 1999. There were 20 women and five men, with an average age ranging from 33 to 79 years (mean age, 59 years). Twenty-four percent (6/25) presented with PE, and 76% (19/25) of PVAs were discovered during investigation for chronic venous disease (varicosities, n = 13; post-thrombotic symptoms, n = 6). The diagnosis of PVA was achieved in all cases with venous duplex scanning and phlebography. Aneurysms were located in the proximal popliteal vein (n = 17) and at the saphenopopliteal junction (n = 8). Seventy-two percent (18/25) of PVAs were saccular, and 40% (10/25) had an intraluminal thrombus. Two patients with PE underwent cardiac arrest, with one requiring a pulmonary embolectomy. The Fisher exact test showed a statistically significant correlation between PE and the presence of thrombus (50% vs 7% without thrombus, P =.02). Aneurysms were treated with tangential aneurysmectomy and lateral venorrhaphy (n = 19), resection with end-to-end anastomosis (n = 2), resection with interposition of the greater saphenous vein (n = 2) or the superficial femoral vein (n = 1), and resection with vein transposition (n = 1). Two patients who experienced a PE had an inferior vena cava filter placement before surgical repair of the PVA.

RESULTS

Mean follow-up was 63 months (range, 11-168 months). No operative deaths occurred, and no patient had evidence of a recurrent PE. Postoperative minor complications (20%) included transient common peroneal nerve palsy (n = 2), postoperative hematoma (n = 2), and wound infection (n = 1). Postoperative thrombosis of the surgical repair occurred in three patients, and patency was restored with anticoagulation therapy.

CONCLUSION

Despite its rarity, PVAs should be ruled out with venous duplex scanning in patients with PE and in patients presenting with chronic venous diseases. Because of the unpredictable risk of thromboembolic complications, surgical treatment that is accompanied by a low morbidity rate is indicated in all PVAs. Tangential aneurysmectomy with lateral venorrhaphy is the procedure of choice.

Critical hand ischemia after angioaccess surgery: diagnosis and treatment

Severe hand ischemia is an uncommon complication of angioaccess surgery. Prompt recognition is necessary to prevent finger necrosis and permanent nerve damage. Treatment should relieve symptoms without compromising dialysis access. From January 1989 to September 1999, we treated critical hand ischemia in 23 patients (16 men, 7 women), including 8 diabetic patients with a total of 19 arteriovenous fistulas (AVF) and 4 arteriovenous grafts (AVG). In 21 patients, the symptom was critical ischemia, with finger necrosis occurring in 7 patients. In the remaining two patients, the manifestation was acute ischemia due to venous thrombosis. Four patients required finger amputation. Fifteen patients (65%) had previous AVF on the lateral extremity. The mean number of previous AVF in this group was 2.5 (range, 2 to 6). Various treatments were used for arterial insufficiency (n = 20), including ligation of the fistula (n = 8), distal revascularization-interval ligation (DRIL) (n = 4), bypass (n = 4), sympathectomy (n = 1), ligation of the radial artery (n = 1), medical therapy (n = 1), and banding technique (n = 1). Medical therapy and banding relieved symptoms after thrombosis of the AVF. Through the use of DRIL, healing of finger necrosis (n = 3) and improvement of symptoms (n = 1) were achieved. The findings of this study indicate that severe hand ischemia occurs mainly in diabetic patients with multiple previous AVF and finger arteriopathy. DRIL is the conservative treatment of choice, since it can be used to achieve both symptomatic relief and maintenance of dialysis access.

[Inframalleolar bypass in limb salvage. Late results]

STUDY OBJECTIVE

The objective of this retrospective study was to report the long-term results of distal revascularization at the ankle in patients with critical ischemia.

PATIENTS AND METHODS

From January 1989 to November 1999, 50 inframalleolar bypasses were performed in 49 patients (35 males and 14 females with a mean age of 75 years [range: 51 to 95 years]). Twenty-five patients (50%) were diabetics. All patients presented with critical ischemia of the lower limb. Distal anastomosis was performed at the retromalleolar posterior tibial artery in 28 cases (56%), pedal artery in 20 cases (40%) and distal fibular artery in two cases (4%). Bypasses were performed using a greater saphenous vein (n = 38), a cryopreserved arterial allograft (n = 9), or a PTFE graft (n = 2). A composite graft with greater saphenous vein and arterial allograft was performed in two cases.

RESULTS

There were two early postoperative deaths. One patient presented a blow-out of the distal anastomosis that required bypass ligation and subsequent leg amputation. Early thrombosis of the graft occurred in four cases, leading to major amputation in three cases. No patients were lost to follow-up and mean follow-up was 26.7 months (range: 1 to 86 months). Graft thrombosis occurred in 15 patients and led to amputation in 6 cases. Bypass graft patency rate was 72% and 61% at 1 year and 3 years, respectively, yielding a 80% limb salvage rate at 3 years. The 3-year actuarial survival rate was 53%.

CONCLUSION

Inframalleolar bypasses are a valuable tool in patients with critical ischemia. The lower limb salvage rate is satisfactory in this elderly population. Based on this experience, angiography with good run-off and, when necessary, a surgical approach to verify patency of the arteries at the ankle should always be performed before undertaking a major amputation.

Furosemide inhibits thromboxane A2-induced contraction in isolated human internal mammary artery and saphenous vein

Evidence suggests that, in addition to its diuretic property, furosemide also may exert direct vascular effects. Because thromboxane A2 (TXA2) has a role in the control of vascular tone, we investigated the effect of furosemide on the contraction induced by U46619 (a stable TXA2 mimetic) on isolated human internal mammary artery (IMA) and saphenous vein (SV). Concentration-response curves to U46619 were performed in the absence (vehicle) or the presence of furosemide (0.1-1 mM) on rings of IMA and SV. In addition, the relaxant effect of furosemide (0.1 microM-1 mM) also was evaluated on U46619-precontracted IMA and SV. The participation of cyclooxygenase derivatives was studied by pretreatment with indomethacin. Furosemide (0.1-1.0 mM) caused parallel rightward shifts of U46619 concentration-response curves without affecting the maximal responses in both IMA and SV. Treatment with indomethacin (1 microM) modified neither the inhibitory effect of furosemide on U46619-induced contractions, nor the relaxant effect of furosemide on U46619-induced contractions, nor the relaxant effect of furosemide on U46619-precontracted IMA and SV. In conclusion, furosemide at high concentrations inhibited U46619-induced contraction in human isolated IMA and SV and relaxed U46619-precontracted IMA and SV by mechanisms independent of the release of relaxant prostaglandins. These results suggest that blockade of TXA2 receptors by furosemide may contribute to explaining the therapeutic effects of furosemide in the treatment of severe heart failure.

Long-term results of arterial allograft below-knee bypass grafts for limb salvage: a retrospective multicenter study

PURPOSE

Arterial allografts (AAs) have been recently reconsidered in the treatment of critical limb ischemia when vein material is absent, because of the disappointing results with artificial grafts. The aim of this study was to report the results observed in three centers where AAs were used for infrainguinal reconstruction in limb-threatening ischemia.

METHODS

Between 1991 and 1997, 165 AA bypass procedures were performed in 148 patients (male, 90) with a mean age of 70 years (range, 20-93 years). Indications for operation were rest pain in 54 cases and tissue loss in 111 cases. Mean resting ankle pressure was 53 mm Hg in 96 patients who did not have diabetes and mean transcutaneous pressure of oxygen was 10 mm Hg in 52 patients who did have diabetes. In 123 cases (75%), there was at least one previous revascularization on the same limb. AAs were obtained from cadaveric donors. The distal anastomosis was to the below-knee popliteal artery in 34 cases, to a tibial artery in 114 cases, and to a pedal artery in 17 cases.

RESULTS

At 30 days, the mortality rate was 3.4%; the primary patency rate was 83.3%; the secondary patency rate was 90%; and the limb salvage rate was 98%. During follow-up (mean, 31 months), 65 grafts failed primarily. Causes of primary failure were thought to be progression of the distal disease in 15 cases, myointimal hyperplasia in 16 cases, graft degradation in 10 cases (four dilations, three stenoses, two ruptures, and one dissection), miscellaneous in eight cases, and not known in 16 cases. Primary patency rates at 1, 3, and 5 years were, respectively, 48.7% +/- 4%, 34.9% +/- 6%, and 16.1% +/- 7%. Secondary patency rates at 1, 3, and 5 years were, respectively, 59. 8% +/- 4%, 42.1% +/- 5%, and 25.9% +/- 8%. Limb salvage rates at 1, 3, and 5 years were, respectively, 83.8% +/- 3%, 76.4% +/- 5%, and 74.2 % +/- 8%.

CONCLUSION

AA leads to an acceptable limb salvage rate but poor patency rates. A randomized trial that will compare AAs and polytetrafluoroethylene should be undertaken.

[Fate of the competence of the valvular apparatus of the femoral veins after cryopreservation. Preliminary study]

PURPOSE

The aim of this study was to determine the impact of cryopreservation on the competency of human femoral vein valve.

MATERIALS AND METHODS

Nine superficial femoral veins bearing 24 valves were harvested in brain death patients (5 men, mean age 32 years, range 16 to 63 years). Veins were divided in 24 segments bearing only one valve. Each segments was tested for reflux by using a pressure column filled with heparinized saline. After harvest, vein segments were kept in Belzer solution with antibiotics (gentamycin, colistin, lincomycin and amphotericin B). Histological study was undertaken in a fresh valve segment (n = 9). The remaining segments (n = 15) were stored in 15% dimethyl sulfoxide (DMSO) and cryopreserved in liquid nitrogen vapor for 120 days. Afterwards the 15 cryopreserved vein segments were thawed in 37 degrees C water bath and were studied for mechanical and histological changes.

RESULTS

All the 24 valve segments initially tested were competent. Off the 15 cryopreserved segments only 4 (26%) were found to be non refluxive after cryopreservation. Histological study performed before cryopreservation showed a normal appearance of the vein wall (n = 9). On the contrary after cryopreservation, microscopic examination showed that in the incompetent veins, the endothelium surface was either absent or poor with a marked decrease in elastic fibres.

CONCLUSION

This preliminary study indicates that DMSO cryopreservation must be improved in order to preserve vein valve competency: 26% of the cryopreserved valves remained competent. Histological findings also suggest that elastic fibres play a major role in the failure of the vein competency.

Vascular surgical society of great britain and ireland: mid-term results of arterial allograft below-knee bypasses for limb salvage

BACKGROUND: Arterial allografts (AAs) have been recently reconsidered in the treatment of critical limb ischaemia when vein material is absent, because of the disappointing results with artificial grafts. The aim of this study was to report the results observed in three centres where AAs were used for infrainguinal reconstruction in critical limb ischaemia. METHODS: Between 1991 and 1997, 165 AA bypasses were performed in 148 patients (90 men) with a mean age of 70 (range 20-93) years. Indications for operation were rest pain in 54 patients and tissue loss in 111. Mean resting ankle pressure was 53 mmHg in 96 non-diabetic patients and mean transcutaneous partial pressure of oxygen was 10 mmHg in 52 diabetic patients. AAs were obtained from cadaveric donors. The distal anastomosis was to the below-knee popliteal artery in 34 cases, to a tibial artery in 114 and to a pedal artery in 17. RESULTS: At 30 days, the mortality rate was 3 per cent, primary patency 83 per cent, secondary patency 90 per cent and limb salvage rate 98 per cent. During follow-up (mean 31 months) 65 grafts failed primarily. Causes of primary failure were thought to be progression of the distal disease in 15 cases, myointimal hyperplasia in 16, graft degradation in ten (four dilatations, three stenoses, two ruptures and one dissection), other causes in eight and not known in 16. Primary and secondary patency rates at 3 years were 35(s.e. 9) per cent and 42(s. e. 10) per cent. The limb salvage rate at 3 years was 76(s.e. 8) per cent. CONCLUSION: AAs lead to a good foot salvage rate but poor patency rates. The results are similar to those obtained with polytetrafluoroethylene grafts.

[Evaluation of a clinical and scintigraphic management strategy for cardiac risk before abdominal aorta surgery. Apropos of 982 surgical patients]

The incidence of major cardiac events (death, infarction) is over 5% after programmed aortic vascular surgery. The aim of this study was to evaluate a management strategy of this risk based on the clinical status and targeted indication of myocardial scintigraphy, coronary angiography and myocardial revascularisation. A first phase (1991-1993, 451 patients) confirmed the prognostic value of clinical (age, previous cardiac history, diabetes, hypertension, electrocardiogrammes) and scintigraphic features: the cardiac mortality was 1.25% in patients with a low clinical risk (70.3% of cases) and 4.5% in patients with a high clinical risk (2 factors, 29.3% of cases) (p < 0.01). In the latter group, the mortality was zero after normal myocardial scintigraphy and 7.2% after abnormal myocardial scintigraphy (p < 0.01) and 12.5% in cases with reversible defects (p < 0.01). During the second phase of the study (1994-1997, 531 patients) coronary angiography was performed in patients with a high clinical risk and abnormal scintigraphy (10.9% of cases). This led to a myocardial revascularisation in 3.6% of patients. The cardiac mortality was then the same in the low and high a priori clinical risk: 2.3 and 2.8% (NS). The use of simple clinical criteria enables surgery in the majority of candidates for aortic vascular surgery, scintigraphy being reserved for about one patient in ten with myocardial revascularisation in less than 4% of cases. The operative cardiac mortality then decreases to under 2.5%.

[Venous aneurysm of unusual localization revealed by a pulmonary embolism. Report of two cases]

We report two uncommon cases of venous aneurysm involving the soleus vein and the saphenofemoral junction. Both cases presented with pulmonary embolism. Diagnosis of the venous aneurysm was achieved by Doppler ultrasonography during the evaluation for deep vein thrombosis. Venography showed a large fusiform aneurysm. Both aneurysms were treated by resection and ligation. At follow-up, there was no evidence of recurrent pulmonary embolism. These cases clearly illustrate the risk of pulmonary embolism associated with uncommon localizations of venous aneurysms and the potential for thrombus formation due to the venous stasis. Surgical treatment, as in the case of popliteal aneurysms, is mandatory to avoid such embolic complications.

Functional assessment of human femoral arteries after cryopreservation

PURPOSE

An established method of cryostorage that might preserve the vascular and endothelial responses of human femoral arteries (HFAs) to be transplanted as allografts was studied.

METHODS

HFAs were harvested from multiorgan donors and stored at 4 degrees C in Belzer solution before cryostorage. One hundred eleven HFA rings were isolated and randomly assigned to 1 control group of unfrozen HFAs and 2 groups of HFAs cryopreserved for 7 and 30 days, respectively. Cryopreservation was performed in Elohes solution containing dimethyl sulfoxide (1.8 mmol/L), and the rate of cooling was 1.6 degrees C/min, until -141 degrees C was reached. The contractile and relaxant responses of unfrozen and frozen/thawed arteries were assessed in organ bath by measurement of isometric force generated by the HFAs.

RESULTS

After thawing, the maximal contractile responses to all the contracting agonists tested (KCl, U46619 [a thromboxane A2-mimetic], norepinephrine, serotonin, and endothelin-1) were in the range of 7% to 34% of the responses in unfrozen HFAs. The endothelium-independent relaxant responses to forskolin and verapamil were weakly altered, whereas the endothelium-independent relaxant responses to sodium nitroprusside were markedly reduced. Cryostorage of HFAs also resulted in a loss of the endothelium-dependent relaxant response to acetylcholine. The vascular and endothelial responses were similarly altered in the HFAs cryopreserved for 7 and 30 days.

CONCLUSION

The cryopreservation method used provided a limited preservation of HFAs contractility, a good preservation of the endothelium-independent relaxant responses, but no apparent preservation of the endothelium-dependent relaxation. It is possible that further refinements of the cryopreservation protocol, such as a slower rate of cooling and a more controlled stepwise addition of dimethyl sulfoxide, might allow better post-thaw functional recovery of HFAs.

[Traumatic and iatrogenic lesions of abdominal vessels]

Gravity of abdominal vessels traumatisms is secondary to multiple factors. It depends on the type of injured vessels, aetiology and associated lesions. Between September 1984 and March 1995, 22 abdominal vessel traumatisms in 16 patients (mean age: 39 years) were treated. At surgical exploration, 4 aortic and 2 renal vein lesions, 7 iliac artery and 3 renal artery contusions, 2 superior mesenteric artery dissections; 3 infra-renal vena cava ruptures and 1 superior mesenteric vein dilaceration were found. All lesions were caused by penetrant wounds secondary to firearm or blade injury or secondary to injuries due to ski or traffic accidents. In 5 cases, lesions were iatrogenic. There was no mortality in the post-operative period, 14 patients out of the 16 patients operated on have been followed during a period from 1 to 120 months.

[Renal revascularization from the digestive arteries in the treatment of renovascular hypertension in high risk patients]

Five extra-anatomic hepatospleno- and gastroduodenorenal revascularizations were performed in 5 high-risk cardiac patients. The procedure followed failure of endoluminal angioplasy for osteal stenosis of the renal artery in 4 cases. All patients had a diffuse lesion of the aorta contraindicating direct aortorenal bypass. The indication for surgery was renovascular hypertension poorly-controlled with medical therapy in all 5 patients; 4 patients also had renal failure. There was no mortality in the perioperative period. Blood pressure returned to normal in 50% of the cases, and improved in the other 50%. There was a clear improvement in renal function in all patients.

Glibenclamide inhibits thromboxane A2-induced contraction in human internal mammary artery and saphenous vein

Glibenclamide, like other hypoglycemic sulfonylurea derivatives, is a potent blocker of ATP-regulated K+ channels. In addition, it is reported to inhibit prostanoid-induced contractions of isolated vascular smooth muscle from different animal species. We investigated the effect of glibenclamide on the thromboxane A2-mimetic U-46619 (9,11-dideoxy-9alpha,11alpha-methanoepoxy-prostaglandin F2alpha)-induced contractions in human isolated internal mammary arteries and saphenous veins. In the two vascular preparations, glibenclamide (3, 10 and 30 microM) caused a concentration-dependent shift to the right of the U-46619 contraction-response curve with a reduction, at the highest concentrations, in the maximal responses. This inhibitory effect appears selective for thromboxane A2-induced contractions since glibenclamide (30 microM) did not alter the contraction of internal mammary arteries in response to norepinephrine and of saphenous veins in response to 5-hydroxytryptamine (5-HT) and endothelin-1. However, glibenclamide reduced the endothelin-1-induced contraction in internal mammary arteries. The endothelin-1-induced contractions were similarly inhibited by GR 32191 ([1R-[1alpha(Z),2beta,3beta,5alpha]]-(+)-7-[5-([1,1'-b iphenyl]-4-ylmethoxy)-3-hydroxy-2-(1-piperidinyl)cyclopentyl]-4-++ +heptonoic acid, a thromboxane A2 receptor antagonist. These results suggest that glibenclamide also reduced the endothelin-1-induced contractions by inhibiting a thromboxane A2 receptor-mediated component of the contraction elicited by this peptide. In conclusion, glibenclamide clearly appears to exert a specific inhibitory influence on prostanoid-induced contractions in human internal mammary arteries and saphenous veins.

Infected aneurysms of the infrarenal abdominal aorta: diagnostic criteria and therapeutic strategy

From 1976 to 1994 we performed surgical treatment of 18 infected aneurysms of the infrarenal abdominal aorta. The aneurysm had ruptured in nine patients: into the retroperitoneum in six patients, and into an adjacent structure in three patients (duodenum, inferior vena cava, left renal vein). Two patients had an associated spondylitis. Four patients were in shock at the time of surgical treatment. Six patients (including four patients with Salmonella infection and two patients with spondylitis) had positive preoperative blood cultures. Salmonella was the most common microorganism (27%). Anaerobes accounted for 16%. In situ replacement was performed in 13 patients including three procedures performed under emergency conditions with frank purulent infection. Extraanatomic bypass was performed in five patients. Early postoperative death occurred in two patients (11%) due to septic complications (rupture of aortic anastomosis in one patient and rupture of aortic stump in one patient). All surviving patients underwent prolonged antibiotic therapy for at least 6 weeks. Overall mortality secondary to infected aneurysm was 16%. Infection of the aortic graft occurred in four patients (38%) including two patients with Salmonella infection and one patient with spondylitis. One patient developed a false anastomotic aneurysm 6 months postoperatively and was treated by in situ arterial allograft replacement. Postoperative blood cultures were positive in two patients presenting spondylitis and infection of the aortic prosthesis occurred in one of these patients. In addition to rupture, poor prognostic factors included spondylitis and Salmonella infection that were found to greatly enhance the risk of postoperative graft infection following in situ reconstruction.

Below-knee bypass using fresh arterial allografts for limb salvage: early results

The purpose of this study was to evaluate early results of below-knee bypass using fresh arterial allografts as arterial substitutes for limb salvage. From April 1991 to September 1993, we performed 28 below-knee bypass procedures using fresh arterial allografts in patients without a suitable autologous vein. Allografts were obtained by multiorgan harvesting from brain-dead subjects and preserved at 4 degrees C. Histologic examination of grafts was carried out. Secondary patency at 2 years calculated using the Kaplan-Meier method was 64% (confidence interval [CI] 45%-79%). No signs of graft deterioration or rejection were noted. These preliminary results are encouraging but long-term assessment is needed before expanding the range of application.

[Carotid revascularizations by venous grafting: long-term results]

Carotid artery reconstruction (CAR) may be achieved through a variety of techniques. The method of choice is based upon the patient's symptoms, the diffusion of the atheromatous lesion in the internal carotid artery and the experience of the surgical team that usually deals with these patients. Between January 1987 and May 1995, we performed 185 CAR using saphenous vein graft. The indication for surgery was atherosclerotic occlusive desease in all patients, sixty-two per cent of whom were asymptomatic. In the early postoperative period one patient died of aspiration, two patients suffered a stroke (one major and one minor) and five patients had a transcient ischemic attack due to carotid clamping intolerance. Two late restenosis and two graft occlusions occurred. The cumulative operative morbidity and mortality rate was 1.6%. This series demonstrates than venous grafting for carotid reconstruction yields satisfactory short- and long-term results and is a valuable alternative to endarteriectomy. Follow-up by Duplex-scan revealed no evidence of morphological degradation of the vein grafts.

Additive value of thallium single-photon emission computed tomography myocardial imaging for prediction of perioperative events in clinically selected high cardiac risk patients having abdominal aortic surgery

The present study was designed to prospectively evaluate whether reinjection thallium-201 single-photon emission computed tomography (SPECT) has a significant additive predictive value for occurrence of perioperative cardiac events in clinically selected patients at high cardiac risk undergoing abdominal aortic surgery. Of a group of 517 consecutive patients referred, 134 had > or = 2 of the following clinical or electrocardiographic cardiac risk variables: age > 70 years; history of myocardial infarction, angina, or congestive heart failure; diabetes mellitus; hypertension with severe left ventricular hypertrophy; and Q waves or ischemic ST-segment abnormalities on electrocardiogram at rest. Operation was performed after thallium SPECT study. Twelve patients (9%) had major perioperative events (cardiac death or nonfatal myocardial infarction) and 18 patients had other cardiac events (unstable angina, congestive heart failure, or severe ventricular tachyarrhythmia). Variables correlated with the occurrence of major events were history of myocardial infarction (p < 0.05) and the presence (p < 0.001) and number of segments with thallium reversible defects (p < 0.001). In multivariate analysis, history of myocardial infarction (p < 0.05) and the number of segments with reversible thallium defects (p < 0.001) were independent predictors. When all the cardiac events were taken into consideration, all the previous variables, as well as Q waves and ischemic ST abnormalities on the electrocardiogram, showed significant predictive value in both univariate and multivariate analyses. Furthermore, thallium SPECT imaging has an additive predictive value for major cardiac events over clinical and electrocardiographic risk factors. When performed on clinically selected patients at high cardiac risk undergoing abdominal aortic surgery, thallium SPECT demonstrates significant prognostic value for cardiac events over that provided by clinical variables alone.

[Chronic venous insufficiency 7 to 10 years after partial vena cava interruption with a clip]

In order to test the responsibility of inferior vena cava clips in post thrombotic venous disease, we performed a comparative retrospective study 7 to 10 years after vena cava interruption by clip. Patients were compared with patients matched for sex, age, and prior deep vein thrombosis (same period and same localisation) but without inferior vena cava partial interruption. The results show that 1) functional complaints were significantly higher in the vena cava clip group; 2) valvular incompetency, in the initially thrombosed leg, (tested by scanning duplex) was not different in the two groups: 3) inversely, on the other leg, valvular incompetency was greater in the vena cava clip group. Furthermore this valvular incompetency was principally located at a femoral level, suggesting that the vena cava clip may induce backward thrombosis; 4) complications were independent of vena cava thrombosis.

[Prediction of respiratory complications after surgery of the abdominal aorta]

The most frequent type of complication in patients undergoing aortic surgery is respiratory. Preoperative lung function (PFT) and arterial blood gas measurement (ABG) are often carried out to assess the risk more precisely. The aim of the present retrospective study was to determine which value of lung function test could identify patients who developed such complications. "Receiver Operating Characteristic" (ROC) curves and the area beneath the curve for the diagnosis of respiratory complications were calculated for each variable of PFT and ABG. The greatest Youden index for each variable was chosen as indicative pulmonary function criterion of increased risk of pulmonary complications. One hundred and ninety-five patients (age: 65 +/- 10 years) were included. Respiratory complications occurred in 15% of patients. Respiratory complications increased from 12% if the vital capacity (VC) was > or = 77% of the predicted value to 35% if the VC was < 77% (P = 0.002), and from 10% if the FEV1 was > 76% to 34% if the FEV1 was > or = 76% (P = 0.0005). A decreased PaO2 or increased PaCO2 was not correlated with an increased incidence of respiratory complications. Length of stay in ICU or in hospital were increased when VC or FEV1 were low. Frequency of pulmonary complications was 9% in patients without PFT abnormalities, 16% in patients with either diminished VC or FEV1 and 35% in patients with both lowered VC and FEV1. However, all the areas under the ROC curves were < 0.7 and the sensitivity of the different variables was low. It is concluded that routine preoperative PFT and ABG cannot predict respiratory complications after abdominal aortic surgery.

[Popliteal aneurysm and leg ischemia: surgery first]

The treatment of symptomatic popliteal aneurysms is debated should local fibrinolysis or surgery first be used first? The authors report their experience in the treatment of 90 popliteal aneurysms in 66 patients. In this series were only examined those aneurysms with either acute ischaemia 12 (27%) or sub-acute ischaemia 21 (45%). The treatment of those cases with acute ischaemia was surgical for all, allowing salvage in all cases. Sub-acute ischaemia was treated with either: a surgical bypass with exclusion of the aneurysm in 7 cases, or lumbar sympathectomy in 7 cases, or medical treatment in 6 cases or local fibrinolysis for distal ischaemia in one case only. There was no peri-operative mortality, only one amputation was required (5%) (J Mal Vasc 1994; 19, Suppl. A: pages 150-153).

[Salmonella aortitis complicated by rupture. Diagnostic and therapeutic problems]

We observed a case of aortitis due to Salmonella in a patient with spondylodiscitis. Outcome was fatal despite resection and grafting, extensive drainage and adapted but unsuccessful antibiotic treatment. Based on the literature, suggested treatment for patients with spondylodiscitis includes extra-anatomic bypass combined with resection of the infected tissue and adapted antibiotherapy. In these emergency cases, computed tomography is the most useful exploration and also gives the diagnosis of spondylodiscitis. It is also necessary to identify the infectious agent to adapt the antibiotics.

The femoral artery and flexion of the hip joint

The behavior of the femoral a. when the hip joint passes from the position of extension to the position of flexion at 90 degrees was studied in 13 cadavers, using several methods: anatomic sections, arteriographies or vascular casts. The modifications of the direction and shape of the femoral a. were assessed in the frontal and sagittal planes. They result from a movement combining flexion and torsion of the femoral a. on its axis at 2 different points in its course. The change of direction of the artery in the sagittal plane is the most obvious modification. It corresponds to the displacement and to the inversion of an angle of 45 degrees on the course of the artery. This angle is situated below the level of the inguinal ligament when the hip joint is in extension and above the sartorius m. when it is flexed to 90 degrees. If these modifications are produced in a similar manner in the living subject, they would seem to correspond to the best possible functional adaptation of the femoral a. They may be involved in the genesis of prosthetic aneurysms.

[Intraoperative nitroglycerin: value of determining individual doses: (surgery of the abdominal aorta)]

Thirteen patients requiring infrarenal aortic clamping were studied during flunitrazepam, fentanyl, pancuronium and nitrous oxide anaesthesia. Each awake patient was submitted to a volume loading test to determine the haemodynamic status and his optimal left pre-load. Anesthetic induction was well tolerated. Nitroglycerin was administered by continuous infusion before aortic clamping and we determined the dose necessary to decrease the systemic vascular resistance by 20 per cent. This dose was very variable and needed to be increased in five of 13 patients at the time of clamping. With nitroglycerin, we noticed no significant alteration of MVO2 at clamping. Volume loading allowed good stability at declamping.

Stability of performances of vascular prostheses retrospective study of 22 cases of human implanted prostheses

Twenty-two cases of vascular graft failures (thrombosis, pseudoaneurysm, dilation, infection) were investigated by means of physicochemical, histological, and ultrastructural studies. A general decrease of mechanical resistance to stress of the prostheses was observed. Its magnitude ranged from 2 to 75% of the values of identical virgin prostheses and there was no relation with the duration of implantation. In addition to the breakage of yarn filaments (SEM), migration of fiber debris (histology) was observed in 7 cases. The structure of the polyester molecule had evolved after implantation. A decrease of crystallinity (x-ray diffraction and differential scanning calorimetry) was noted. These observations raise the question of the established stability of vascular prostheses and emphasize the need for further investigations in human graft retrieval programs.

[Value of venous ultrasonic tomography in the screening for unusual emboli-causing foci]

In certain cases of pulmonary embolism, phlebography of the lower extremities remains normal. The study of 219 consecutive cases of pulmonary embolism shows the advantage of venous ultrasonic tomography which, alone, enables to screen the embolic focus in 10% of the cases, either because the phlebographic data are insufficient (5%), or because the embolic focus cannot be reached with phlebography (5%), especially in deep femoral and internal saphenous thromboses. On the other hand, popliteal venous aneurysms, which represent 1% of all embolic foci in this study, are always discovered by ultrasonography. Therefore this technique appears absolutely necessary for the diagnosis of an embolic venous focus.

Semiological analysis of Raynaud attacks

Careful semiological and etiological investigations (including nailfold capillary microscopy) were performed in 120 consecutive patients with Raynaud phenomenon (RP) (December 1983-March 1984) recorded on a standardized form. Complete and reliable data were obtained in 103 cases. The functional severity of the attacks was assessed statistically, after adjusting for etiological groups. The existence of an asphyxial (cyanotic) phase was found the best single criterion for the severity of attacks, but a more complete evaluation was arrived at with the following functional severity score (FSS = 0 to 3): asphyxia (0 or 1)+summer rate of attacks higher than once a week (0 or 1)+involvement of all the fingers (0 to 1). This score was also validated through a multivariate correspondence analysis. FSS was much higher in RP associated with connective tissue diseases (1.73 +/- 0.18) than in primary RP (0.64 +/- 0.14, p less than 0.001). A careful analysis of ischemic attacks is thought to be an important part of etiological and pre-therapeutic evaluation of patients with RP.

[Consumption coagulopathies following peritoneojugular bypass. Prevention by a heparin-antithrombin III combination]

Consumption coagulopathy (CIVD) is a frequent complication of peritoneojugular bypass operation. Preventive treatment applied involves low-dose heparin (1.5 mg/kg/d) to maintain an antithrombin III concentration of at least 65%. Results are evaluated in 6 patients treated by 7 bypass operations. A biologic CIVD developed in 2 cases (29%) but no clinical coagulopathy was observed. This incidence is less than that usually reported, a literature review indicating a biologic coagulopathy in 65% of cases, with clinical evidence in 12.5%. Furthermore, patients with spontaneously elevated AT III levels did not develop CIVD while, in contrast, sufficiently high concentrations of AT III could not be maintained in the 2 patients with coagulopathy. These findings suggest the interest of prevention of a CIVD by the use of this procedure.

[Acute thrombosis of the aortic bifurcation caused by heparin allergy. Apropos of 5 cases]

Five patients with humoral intolerance to heparin developed acute thromboses, with a fatal outcome in two cases from failure to establish the diagnosis, marked sequelae in one case, and recovery without complications in the other two. Accidents of this type may occur in 0.6 p. cent of patients on heparin therapy and are almost always fatal if administration is not discontinued. They result from a severe immunoallergic. Thrombocytopenia which may lead to the formation of arterial clots. Arterial thrombosis during heparin therapy is suggestive of the diagnosis and tests for diminished platelet counts are necessary. Apart from surgery, treatment involves the immediate cessation of heparin therapy.

[Segmental colonic lipomatosis. A case of isolated caecocolonic lipomatosis (author's transl)]

The authors report a case of isolated segmental caecocolonic lipomatosis complicated by infarts. The diagnosis was made from the urgent symptoms and treatment was by simple right colectomy and immediate reconstitution of continuity.