Late type IIIb endoleak after endovascular aneurysm repair: case report and review of the literature

PURPOSE

To report a case of type IIIb endoleak developed six years after endovascular abdominal aortic aneurysm repair (EVAR).

CASE REPORT

A 75-year-old man underwent successful Talent™ stent-graft positioning to treat a 53 mm abdominal aortic aneurysm. Subsequently the patient did well and yearly routine control computerized tomography (CT) was unremarkable. Six years later the patient suddenly developed abdominal pain irradiating to the back. An emergency angio-CT showed the presence of a type IIIb endoleak arising from the main body of the endograft. There weren't signs of fissuration or rupture. Aneurysm diameter was 85 mm as compared to 52 mm on a CT performed ten months earlier. The patient underwent successful positioning of an aorto-monoiliac endograft followed by the occlusion of the controlateral limb and a femoro-femoral crossover dacron bypass graft. Three months later the patient presented again because of the sudden onset of abdominal pain. On angio-CT aneurysm size was increased up to 11 cm. A distal type I endoleak was found and treated by placing an iliac extension to the right external iliac artery. After uneventful postoperative course the patient was discharged in good general conditions. Control angio-CT done after six months showed the complete exclusion of the large aneurysm sac.

CONCLUSIONS

Type IIIb endoleaks can be safely treated by endovascular positioning of an aorto-monoiliac stent-graft followed by the occlusion of the controlateral limb and a femoro-femoral crossover dacron bypass graft. Continuous surveillance after EVAR is mandatory.

[Current aspects of cerebral protection in carotid surgery: update]

The goal of cerebral protection in carotid surgery is to reduce postoperative central neurological complications and thus reduce morbidity-mortality of carotid endarterectomy. With improving understanding of the mechanism leading to neurological complications, means of achieving cerebral protection have been developed. Preoperative evaluation of the ischemic risk is based on the neurological examination and on computed tomography and magnetic resonance imaging findings. The possibilities of arterial supply during carotid cross-clamping can be recognized with the help of arteriography, transcranial Doppler or angio-MRI. Selective or systematic use of an intraluminal shunt and preoperative heparin therapy are the main methods used for cerebral protection. The risk of early postoperative stroke can also be reduced by careful preoperative anatomic control to detect any technical failure. Discussion on the usefulness of monitoring cerebral function during the procedure is closely related to the experience of the surgical team. The only method currently accepted by all surgeons is the use of stents during carotid angioplasty to achieve cerebral protection.

[Carotid endarterectomy using eversion. One year radiologic results]

A prospective study was done in 100 patients operated on for a stenosis of the carotid artery by the eversion endarterectomy method of Van Maele (section-eversion-anastomosis) between January 1994 and August 1995. Ten patients were operated on bilaterally (thus, 110 procedures). The distribution of the patients was as follows 81 males and 19 females, mean age 71 years. Clinically, 50 patients were asymptomatic, 44 stage I, 2 stage II and 4 stage III. Arteriography of these patients showed 42 stenoses greater than or equal to 90%, 56 stenoses between 70 and 90% and 12 ulcerated plaques (according to the ESCT measurement standards). Concerning the supra-aortic vessels, 24 lesions of the vertebral-subclavian branches and 21 lesions of the intra-cerebral vessels were observed. Five endarterectomies out of the 110 (5.4%) could not be performed by this eversion method because of the immediate poor technical result before angiography. At the end of the procedure digital angiography was performed for all the patients who underwent an eversion endarterectomy (105 cases). Six images of the internal carotid artery presenting stenoses less than 30% were observed at the level of the implantation site. Two narrow stenoses of the distal part of the endarterectomy made the interposition of a PTFE graft necessary in 20% of the cases, a secondary procedure was necessary after the peri-operative angiography 2 implantations of PTFE in the internal carotid artery, 8 additional endarterectomies of the external carotid artery, 11 infiltrations with Papaverine. The immediate post-operative results were 1 death after hemiplegia, 1 hemiplegia with sequelae (mortality/morbidity approximately 2%, i.e. 2/103 eversions), 3 regressive hemipareses. Angiographic follow-ups after 1 year were performed on 100 out of 110 operated carotid arteries. With regard to the internal carotid artery, 4 patients showed a stenosis less than 30%, 1 patient a 50% stenosis, 1 patient a pre-occlusive stenosis making an operation with the interposition of a PTFE graft necessary (restenosis rate after one year 2%). All the patients followed after one year remained asymptomatic. Eversion endarterectomy is possible for the majority of the atheromatous stenoses of the carotid artery (5.4% were not possible for technical reasons). We find this method not appropriate when a shunt must be placed. Immediate results are comparable to those of classical surgical endarterectomy with or without patching. The restenosis rate at 1 year in our series is 2%. This technique provides an excellent anatomic result by peri-operative angiography and can especially be adapted to stenoses with excess of length of the carotid artery.

Morphologic assessment of abdominal aortic aneurysms by spiral computed tomographic scanning

PURPOSE

The aim of this study was to seek a relationship between the morphologic features of abdominal aortic aneurysms and the feasibility of endoaortic grafting.

METHODS

Between June 1995 and January 1996, 86 patients were prospectively studied with contrast-enhanced spiral computed tomographic scans, which provided 35 parameters concerning the aorta and iliac arteries. Four groups were established according to the diameter of abdominal aortic aneurysms: group A, 40 to 49 mm, 36 patients; group B, 50 to 59 mm, 26 patients; group C, 60 to 69 mm, 10 patients; and group D, greater than 70 mm, 14 patients.

RESULTS

There was a correlation between the diameter and length of the aneurysm (p < 0.0001) and between aneurysm diameter and length of the proximal neck (p < 0.001). Presence of a proximal neck or a distal neck was more frequent in groups A and B than in groups C and D (p < 0.01). The feasibility of endovascular grafting was estimated at between 50% and 61.6% and was higher in groups A and B than in groups C and D (p < 0.01).

CONCLUSIONS

This study has shown an inverse relationship between the diameter of the aneurysm and the length of the aortic neck (correlation coefficient, -0.3640, p < 0.001). The diameter of an aneurysm was the most useful of the 31 parameters measured in predicting the feasibility of endoaortic grafting, estimated at 71% for aneurysms less than 60 mm in diameter and 37.5% for aneurysms greater than 60 mm in diameter (p < 0.01).

[Endovascular treatment of abdominal aorta aneurysms using the Stentor device. Preliminary experience]

PURPOSE

The aim of this report is to describe our experience with the Stentor device for endovascular treatment of the abdominal aortic infrarenal aneurysms also extending to the bifurcation and the common iliac arteries. Stentor is a thermal memory (Nitinol) self-expanding graft, covered by an external 0.1 mm Dacron material.

METHODS

Between December 1994 and July 1995 endoluminal repair of infrarenal aneurysmal disease was undertaken in 6 patients at high surgical risk. The lesions include 2 infrarenal abdominal aorto-aortic aneurysms, 2 infrarenal abdominal aortic aneurysms extended to the common iliac arteries and 2 false aortic aneurysms in patients with previous aorto-bifemoral graft. Straight grafts were implanted in 4 patients and bifurcated in 2. Repair was done in the operating room using general anesthesia. The endograft was placed through remote arteriotomies and advanced under fluoroscopic guidance to his predetermined site. Three-dimensionally reconstructed spiral CT scan and arteriography were performed before the procedure for a preoperative accurate measurement for endograft preprocedural adaptation in length and diameter.

RESULTS

All endografts were successfully deployed. Intraoperative arteriography at the end of the procedure revealed a distal "leak" into an aneurysmal common iliac artery, due to diameter mismatch, in a bifurcated device. There was no instance of embolism or graft migration. No patient required conversion to an open operation. There were no instances of embolism or graft migration. No patient required conversion to an open operation. There were no coagulative disorders. Minor complications were: groin haematoma (1), fever (1), intestinal paralysis (1), pelvic pain (1). Follow-up with spiral CT-scan and echo color-Doppler confirmed normal blood flow through the graft in 5 patients and persistence of distal leak in 1 patient.

CONCLUSIONS

These preliminary results demonstrate the accuracy of implantation and device's adaptability to the particular anatomy of the aneurysmal aorta and iliac arteries. Proximal fixation to the aortic wall, secure seal at the proximal and distal fixation point present the critical aspects of this new surgical technique. More detailed preoperative measurements of aneurysmal disease are required rather than for traditional surgery. Presently we prefer to treat the no operable patients with this endovascular technique in relation with shortness of the follow-up.

Aneurysms of anomalous splenomesenteric trunk: clinical features and surgical management in two cases

Aneurysms of the splenic artery that anomalously arise from a splenomesenteric trunk are a rarity. Aneurysmal disease of visceral arteries is found in only 0.2% of the general population. The celiac trunk and superior mesenteric artery (SMA) are involved in less than 10% of all visceral aneurysms. Although rupture seems to occur in 20% to 22% of patients, the related mortality rate can rise as high as 100%. Anomalies of the celiac trunk and SMA, more common than previously claimed, include the splenic artery arising from the SMA, which occurs in only 1% of patients. We present two cases of young patients who had 4-cm aneurysms behind the pancreas that involved an anomalous splenic artery. The first patient required dissection of the entire splenopancreatic bloc through a transverse abdominal incision to excise the aneurysm and repair the SMA. The second patient was treated by the classic approach, through a median incision and by entering the mesenteric root. There do not seem to be reports of similar cases, except for two cases of aneurysms involving the celiomesenteric trunk. The cause of these aneurysms can be attributed to mesenchymal alterations during the embryonic formation of aortic collateral branches. A correct surgical approach to splanchnic aneurysms calls for awareness of potential vascular variations of the arteries and their collateral pathways.

In vitro testing of six inferior vena cava filters: filtering efficiency and pressure measurements

The purpose of this study is to compare in standarddised ex vivo conditions the performances of six percutaneous vena cava filters available on the European Market.

METHODS

We use a mock circulation with polyethylene beads simulating clots to objectively determine the filtering efficiency of the different devices. We measured pressure at contact points with the wall of the tube simulating vena cava, and also gradient of pressure induced by the empty and full filter. Statistical analysis of the data obtained (at least 100 measurements for each filter) showed great consistency in the response of a given filter to the different conditions of mock circulation.

RESULTS

The Greenfield Filter, which served as the reference, was compared to the other models. Its filtering efficiency was acceptable as was that of the L.G. Filter. The Cardial Filter and Vascor Filter were the most efficient. The Antheor Filter and the Filcard Filter performed poorly.

CONCLUSION

The mock circulation give reliable and reproducible data on the filtering efficiency for a device but ease of placement and clinical studies must be taken into account for the choice of the filter.

Interruption of the inferior vena cava using the Vascor filter: preliminary series of 51 cases

Between February 1991 and October 1991, vena cava filters made of Vascor (Toulon, France) were inserted into 51 patients. The male:female ratio was 29:22 and mean age 74 (range 45-94) years. Diagnosis of thrombophlebitis was established by venography in 48 patients (94%) and ultrasonography in three (6%). Thrombosis was unilateral in 49 patients and bilateral in two, involved the pelvic veins in 38 (75%) and the leg veins in 13 (25%). Of the 51 patients, 17 (33%) presented pulmonary emboli and 12 (24%) had waving supracrural clots. The Vascor umbrella filter is a two-stage stainless-steel device with attachment tabs for anchoring and centering. It can be placed either percutaneously using a 7-gauge French introducer via the jugular, subclavian or brachial vein or surgically. In the present series, placement was achieved percutaneously via the jugular vein, in 49 cases (96%) and surgically in two (4%). Postoperative and follow-up examinations included coagulation tests, Doppler ultrasonography and abdominal radiography. In the immediate postoperative period, one patient developed a pneumothorax which was treated by pleural drainage and five died from cancer within the first month after placement. There were no postoperative accidents and no patient had recurrent embolism. In three patients, the filter tilted 30 degrees and in one caval thrombosis was identified. Follow-up examinations were performed in 46 patients, with a mean duration of 12 months. Ten patients have died. Caval thrombosis occurred in two patients (4%) but proximal migration of the filter and recurrence of pulmonary embolism have not been observed.

[The evolution of iliac artery surgery: vascular endoprostheses]

The Authors report their experience about vascular endoprostheses in iliac arterial stenoses and thromboses. Results are discussed in relation to technical difficulties and indications. The comparison between classic vascular surgery previously used, and the endovascular procedures recently adopted, leads the Authors to assert the validity of this last technique. However the need of precise indications based on radiological and angioscopic findings is stressed.

[In vitro bench tests of caval umbrella filters]

Seven ombrelles percutaneous cava filters, now available, are tested on hydraulic testing ground. Measurements are concerned with the blocking function of filters and pressure changes induced in the cava flow and the cava track wall of the testing ground. A statistical analysis of the results (100 measurements per filter) shows homogeneous reactions of each filter when faced with different situations imposed by variations of the testing ground. Greenfield's filter, a reference, is compared with other models. This one and the L.G. filter show satisfactory filtering qualities. Two other filters, Cardial and Vascor, offer a highest filtering power. Other models give poor filtering results.

[Vascular endoprosthesis. A new indication in the surgery of the iliac artery]

We have used endoprosthesis (Palmaz Schatz) after balloon angioplasty of iliac arterial stenoses or thromboses, in order to increase the immediate patency and to prevent the recurrence of stenosis. Our series gathers 24 patients operated with endovascular procedures over a period of 2 years: 22 men, 2 women--extreme ages 42 to 78 years, average age 63.5 years--Clinical stage: 22 at stage I, 1 at stage III, 1 at stage IV. Arteriographic findings: 8 primary iliac lesions (6 stenoses and 2 thromboses), 11 external iliac lesions (stenoses). All these lesions were atheromatous. One of them had recurred after angioplasty. Usual technique: balloon angioplasty of the stenosis, assessment on a fluoroscopic screen and angioscopy of the result, decision to insert the Palmaz Stent if defects are seen on the image. Repatency of impassable lesions with a YAG laser was carried out in 2 cases. The indication of an endoprosthesis was established on the basis of the radiological image in 17 cases, of the angioscopic image in 4 and systematically in 10 cases of recurrence of stenosis, iliac thrombosis or associated surgery. Associated surgery: 2 femoropopiteal bypass grafts, 3 femorofemoral bypass grafts, 1 deep plasty, 1 superficial femoral recanalization with laser, 1 lymbar sympathectomy. Postoperative results: 1 death due to MI (78-year-old diabetic woman), 1 thrombosis treated with femorofemoral bypass. Middle-term results: after 6 to 24 months, average time lapse 13 months. The comparison of the ankle pressure indices and of the pre- and postoperative sonographic findings shows an indisputable hemodynamic improvement.

The role of omentopexy in the prevention of femoral anastomotic aneurysm

In our experience the incidence of anastomotic aneurysms (AA) after prosthetic bypass varied from 0.3 to 0.7% depending on location; it was 5 times higher at aortobifemoral anastomoses (77/3146; 2.44%) than aortic anastomosis (8/2173; 0.37%) (p less than 0.005). In the inguinal region the incidence of femoral AA (FAA) is the same as elsewhere when the prosthesis is placed in front of the inguinal ligament (axillo-femoral anastomoses, 1/200; 0.5%; femoro-femoral anastomoses 1/270; 0.37%). However when the prosthesis is placed behind the ligament, the incidence of FAA rises to 2.44% (77/3746). In our opinion, this difference is due to adherence between the prosthesis and the ligament during hip movement. When the hip is in extension, tension is placed on the prosthesis and the adjacent arterial junction causing the wall of the artery to tear. The sutures almost always remain intact. In an effort to avoid this problem, we have developed a technique that consists of enlarging the passage of the prosthesis by partial section of the inguinal ligament and then wrapping the prosthesis with a free non pedunculated segment of omentum from above the femoral anastomosis down to the healthy segment of the femoral artery which, being elastic, can stretch. The omentum acts as sheath that reinforces the anastomosis. To evaluate this technique we assessed our patients operated upon for aortobifemoral (or aortofemoroiliac) bypass into two groups. Group A included 115 patients operated on by the same surgeon using the new technique (October 1981 and December 1984). There were 111 men and 4 women (mean age: 59.7 years). Mean follow-up was 7.36 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Stroke prevention during carotid surgery in high risk patients (value of transcranial Doppler and local anesthesia)

In a series of 114 cases, carotid surgery was performed under local anesthesia by cervical block in order to assess cerebral status. Preoperative transcranial Doppler was used to select high risk patients for shunting. Intraoperatively brain function was checked by carotid arterial blood pressure monitoring and transcranial Doppler. No stroke occurred during the procedure. Postoperatively two deaths (1.8%) occurred, one due to intracerebral hemorrhage and one to a late myocardial infarct. The predictive value of both transcranial Doppler and stump pressure monitoring for shunting was 97% respectively. In combination, the two methods provided 100% protection. During the same period, 1406 patients underwent carotid surgery under general anesthesia. Carotid surgery stroke can be prevented either by using transcranial Doppler together with carotid stump pressure monitoring when the procedure is performed under general anesthesia or by operating under local anesthesia.

Pre- and intraoperative transcranial Doppler: prediction and surveillance of tolerance to carotid clamping

We report 91 patients (mean age 70 years) operated upon, prospectively for a total of 100 carotid revascularizations (nine bilateral). Eighty-five of these patients had pre-, intra-, and postoperative transcranial Doppler investigations. Preoperatively, these 85 patients (92 procedures) were classified into two groups based on the results of their Doppler examinations: Group A (65 patients, 72 procedures), those who did not require an intraoperative indwelling shunt and Group B (20 patients, 20 procedures), those who did. The shunt was inserted only when the mean stump (back) pressure was less than 50 mmHg after cross-clamping. Group A all had satisfactory collaterality with a functional anterior and one or two posterior communicating arteries. Group B had no communicating arteries (anterior or posterior) identified by transcranial Doppler. In 17 of 20 patients in this group, the stump pressure was less than 50 mmHg and a shunt was placed. The overall prediction based on Doppler examination of whether or not patients would need a shunt during operation for the two groups A and B (i.e., 92 procedures) was correct in 95.6% (88/92) of cases. Moreover, six hemodynamically significant stenoses (four in the cavernous portion, two in the middle cerebral artery) were disclosed. Sensitivity and specificity of transcranial Doppler as correlated with arteriographic findings were 70 and 90%. Preoperative transcranial Doppler can measure the velocities of the principal cerebral arteries and the collateral capacity of the circle of Willis, and can forecast tolerance to carotid cross-clamping. Intraoperatively, the velocity of flow in the middle carotid artery was correlated with stump pressure, which allowed for surveillance of the shunt.

Secondary aortoduodenal fistulas: value of initial axillofemoral bypass

Between January 1970 and April 1989, 20 patients underwent operation for secondary aortoduodenal fistulas. When the preoperative diagnosis was certain and emergency control of bleeding not required, initial axillofemoral bypass was performed before ablation of the infected aortic prosthetic graft during the same operation. When diagnosis was uncertain or severity of bleeding required emergency laparotomy, the therapeutic plan varied over time. Until 1980, we performed either a direct repair (three cases) or the ablation of the aortic graft followed by secondary axillofemoral bypass (four cases). After 1980, the order of procedures was 1) control of bleeding whenever necessary, 2) axillofemoral bypass, and 3) ablation of the aortic graft. Postoperative mortality was two of 13 in patients undergoing initial axillofemoral bypass, compared with six of seven patients undergoing direct surgery or initial ablation of the aortic graft. Of the 12 patients surviving the postoperative period, three died of aortic stump hemorrhage, four, 12, and 14 months after operation. Two patients had a new aortic graft inserted. Repeat replacement of the abdominal aorta graft was performed in one case and ascending thoracic aortobifemoral bypass in the other because of secondary thrombosis of the axillofemoral bypass. We conclude that initial axillofemoral bypass before dealing with the aortic graft improves the immediate prognosis in operations for secondary aortoduodenal fistulas. This procedure does not, however, preclude the possibility of aortic stump infection which can lead to recurrent aortoduodenal fistula. The risk of infection or secondary occlusion of axillofemoral bypass is minimal. Secondary prosthetic replacement is not systematically necessary.

[Revascularization of the distal portion of the deep femoral artery. Indications and results]

Most of the times, the distal part of the deep femoral artery is not affected by atheromatous disease. It constitutes an acceptable alternative, whenever the femoral bifurcation is not usable for bypass. This artery is readily approached directly, at a point removed from Scarpa's fascia. We used this technique on 60 patients. Indications included: multiple reoperations (45 cases, 75%), infection of Scarpa's fascia (2 cases, 3%), calcified or thrombosed femoral bifurcation (13 cases, 22%). Lim salvage for decubital pain, grade-IV or acute ischemic disease involved 49 cases (82%). After a mean 28.5 month follow-up period, arterial permeability was 74% and 53% after one year and 5 years, respectively. These results are compared with literature data. Long-term permeability is related to two factors: proximal bypass implantation site and the state of the popliteal reentry and arterial network of the leg. Utilization of the distal segment of the deep femoral artery via an elective approach is interesting of the deep femoral artery via an elective approach is interesting and sensible, whenever the femoral bifurcation is unusable owing to progressive atheromatous disease, repeated surgery or infection.

[Digestive arterial bypass. Long-term clinical results]

In the period between September 1966 and December 1988, 69 patients were operated, including 92 cases of restorative surgery on celiac, hepatic or superior mesenteric arteries. This is a presentation, of the detailed retrospective analysis of 12 years' experience with more homogeneously matched indications and technics. Only indirect, venous or prosthetic bypasses and reimplants are discussed; excluded are all other digestive revascularization procedures, as well as acute ischemic surgery cases. 31 patients (28 men, 3 women) of mean age 59.8 years (47-80) have undergone consecutive surgery: 11 presented with symptoms of predominantly digestive origin; 18 had a combined aortoiliac bypass operation; radiological signs of disease occurred in 46 cases. (celiac artery): 22 including 14 stenoses, 5 thrombotic cases and 3 aneurysms; superior mesenteric artery: 21 including 13 stenoses and 8 thrombotic cases; inferior mesenteric: 3 thrombotic cases). A restorative operation was carried out on 45 patients, 6 of whom had had previous surgery. 21 patients had a single artery restored: celiac (3), hepatic (9), superior mesenteric (9). Double artery surgery was performed in 12 cases. The procedures most commonly used on the hepatic and superior mesenteric arteries were indirect reimplantation and bypass surgery, respectively. Evolution showed increased numbers of anterograde constructions. No deaths were recorded in the perioperative period. Two patients had early recurrences of thrombosis at D10, which required new bypassing. During the mean retrospective period of 6.1 years, we recorded 6 cases of blindness, 8 secondary deaths, 1 single case of mesenteric infarction 18 months after a repeated restorative operation on the superior mesenteric artery; 17 patients remained symptom-free.

[Practical reflections on Linton's operation. Apropos of 110 operations]

Appropriate surgery on venous ulcers (Linton's operation) is an efficient therapeutic method. In 110 of these operations, rapid healing of the ulcer was achieved in 90% of cases, with 10% affected by necrosis and infection of the cutaneous incision. The result held without relapse for three years for 85% of the 52 patients who were able to be reviewed after this length of time. The operative technique has to adhere to two imperatives: a long incision up to the ulcer, and very exact skin closure. Ulcerous relapse, and ulcers failing to respond to routine treatment are the prime indications of surgery; indications can be extended to certain pre-ulcerous conditions.

Aneurysms of the renal artery and its branches

During the last ten years, 29 aneurysms of the renal artery, observed in 20 patients were operated on. These cases represent 10% of the total number of renal vascularization procedures performed during the same period. Diagnosis was made most often during the workup for arterial hypertension (16 patients). There were 20 cases of sacciform aneurysms, eight cases of fusiform aneurysms, usually associated with stenotic lesions, and one case of dissecting aneurysm. Fibromuscular dysplasia was the principal etiological factor. A total of 22 kidneys were involved. Restoration was performed "in situ" in 15 cases (21 aneurysms), using aortorenal bypass in fusiform aneurysms and usually aneurysmorrhaphy for sacciform aneurysms. Six cases (seven aneurysms) were treated with "ex situ" surgery. Primary nephrectomy was performed in one patient. There was no operative mortality. Early occlusion occurred in two cases, resulting in secondary nephrectomy. During a mean follow-up period of 51 months, there were no secondary occlusions. Blood pressure control was obtained in 14 patients (87%). Surgical management is recommended for most renal artery aneurysms. Repair using "in situ" techniques is usually feasible and provides satisfactory long-lasting results in most cases.

Simultaneous revascularization of the internal carotid and vertebral arteries in their distal cervical segments

Fibrodysplasic lesions or tortuosity, involving both ipsilateral carotid and distal vertebral arteries may be treated by a one stage combined procedure of external and internal carotid artery transposition and possibly dilatation of the internal carotid artery. Indications for this technique are uncommon. Only 4 of 969 cerebrovascular reconstructions performed between January 1980 and June 1986 utilized this method. Good results were obtained in all cases. This technique is a satisfactory and simple solution for certain situations requiring vascular reconstruction.

Routine intraoperative carotid angiography: its impact on operative morbidity and carotid restenosis

The impact of routine intraoperative carotid angiography was evaluated by comparing 206 procedures without such angiograms with our last consecutive 100 endarterectomies with completion angiography. No significant age or sex differences were observed between the two groups. Exploratory surgery was repeated in five cases for a stenosis greater than 40% or for an intimal flap. This protocol reduced operative mortality (2.9% to 1%), the permanent stroke rate (1.9% to 1%), and the temporary stroke rate (6.3% to 1%). Furthermore, a second angiogram was performed in these 100 cases (at a mean interval of 19.2 months later) and the incidence and evolution of both residual and recurrent carotid lesions were analyzed. Five internal carotid artery lesions that had been immediately repaired because of intraoperative angiographic defects remained normal. Of 58 normal internal carotid arteries at the completion of surgery, two became stenotic during the next year. In addition, three spastic internal carotid arteries became normal. Of 20 internal carotid arteries with modest irregularities, 16 became normal and four were stenosed. Of three internal carotid arteries with intimal flaps, two became normal and one was stenosed. Among 13 internal carotid arteries with modest stenosis (40%), eight became normal, two became severely stenotic, and three became thrombosed. Among 21 instances of a proximal common carotid artery "shelf," 17 resolved and four progressed to less than 50% stenosis. Of 67 normal external carotid arteries, late stenosis was seen in one case. Of 33 external carotid arteries with residual stenosis, 17 became normal, 14 remained unchanged, and two were thrombosed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Suture of a carotid arteriotomy over a dilator]

Using a conical dilator as support during closure of arteriotomy improves the caliber of the vessel and makes its wall much more regular. This improvement has been confirmed by routine per-operative arteriography.

Carotid stenosis. Surgery after 75 years

Is it reasonable and useful to perform surgery on carotid lesions after 75 years? ("old man" according to the W.H.O. classification). To answer this question, we re-examined 66 patients aged 75 to 87 years, who underwent 76 carotid thromboendarteriectomies with one post-operative death. The results study showed that morbidity and general complications were not more important than in younger patients. Late results from 2 to 94 months showed a very low percentage of secondary neurologic complications even if patients had a vascular or general surgical intervention in a second period: 13 cases. There were only 2 re-stenoses. Indications were defined, but it was above all the asymptomatic patients or patients who had a TIA who could benefit from them.

A gliding space between the femoral artery and inguinal ligament: mechanism of formation of false aneurysm

False aneurysms preferentially arise in the inguinal region subsequent to aorto-femoral bypass. This finding suggests that the position of the inguinal ligament against the anterior surface of the prosthesis may be an etiological factor. Description of the inguinal region, forming a borderline between the trunk and thigh and specific to the erect posture, has been the subject of many anatomical studies. These papers describe mainly the relations between the vascular sheath of the femoral artery, the fascia transversalis and inguinal ligament. Based on a series of anatomical dissections we have found a gliding space between the femoral artery and inguinal ligament. This finding has led us to propose section of the fibrous portion of the inguinal ligament and the insertion of free omentum between the arch of the ligament and prosthesis in order to prevent false aneurysm. Preliminary results obtained with this technique are satisfactory.

Surgical treatment of bilateral carotid artery lesions

Sixty-eight patients (7.1% of all cases) underwent bilateral carotid thrombo-endarterectomy, with one peroperative death due to permanent vascular cerebral ischemia. Two patients were re-operated (saphenous vein) for a thrombosis which had given rise to a totally regressive transient ischemia. The usual surgical technique was not modified for bilateral lesions, and the follow-up was similar. The evolutive risk of bilateral lesions was higher than that for isolated lesions as the risk of an accident after unilateral surgery in bilateral cases remained higher. As regards the surgical technique, we did not observe significant differences between the stump pressures according to the side operated. A one-week interval between the two surgical stages seems necessary and sufficient. Operative indications are studied except in cases of bilateral lesions which are asymptomatic or with former TIA, where surgery is considered mandatory.