[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.

[Salmonella enteritidis septicemia manifesting as a suppurated thrombophlebitis]

BACKGROUND

Non-typloid salmonella can cause septicemia and extradigestive disorders in immunodepressed adults. These frequent diseases can be life-threatening.

CASE REPORT

A 76-year-old woman was treated with corticosteroid therapy for 1 year for suppurated thrombophlebitis of the right greater saphenous vein. Weight loss, fever at 41 degrees C and Salmonella enterididis isolated from blood cultures and skin samples led to the diagnosis of septicemia with multiple septic foyers including the venous endothelium and surrounding soft tissue.

DISCUSSION

In Western countries, there has been an uprise in the frequency of low-grade salmonella infections by food poisoning usually causing acute diarrhea. S. enterididis can also cause severe infectious syndromes with multiple septic localizations, main in patients with a compromised immune reaction. In our cases, Salmonella enteritidis septecemia was revealed by an unusual situation. In the literature, inaugural signs usually involve the heart or arteries, but our patient had isolated foyers involving the superficial venous network. This is exceptional especially since there was no iatrogenic venous catheter insult. For our patient, favoring factors were the long-term corticosteroid therapy and altered venous network. The portal of entry could not be clearly identified but the discovery of a sigmoid diverticulosis would be an argument favoring a digestive origin. Medical and surgical management with resection of the necrosed tissues and two adapted antibiotics in a long-term regimen led to a successful outcome.

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.

[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).

[Renal transplantectomy: surgical technics and results. Apropos of 60 patients]

Nephrectomy of a non-functioning renal transplant after renal transplantation is a delicate operation which the authors evaluate on the basis of a retrospective analysis of 62 patients. A review of the literature helps to more clearly define the indications, optimal time of the operation and the operative technique. A subcapsular approach, by simplifying the operation, constitutes an important factor in reducing the operative morbidity in the late forms. "Early" transplantectomies are often more serious because of the recently operated patient's fragile status and immunosuppression, responsible for frequent infectious complications. Transplantectomy should therefore not be delayed once the permanent loss of transplant function has been confirmed.

[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.