Ambulatory Venous Pressure and Leg Volume Measurements before and after Surgery for Primary Varicose Veins

Objective:

To compare clinical disability, ambulatory venous pressure (AVP) and leg volume before and after venous surgery, and to relate the changes to those observed after one night preoperative in-hospital rest.

Design:

Prospective study.

Setting:

Department of Vascular Surgery, University Hospital, Paris, France.

Subjects:

Nineteen patients with primary varicose veins and mild chronic venous insufficiency (CVI), scheduled for venous surgery.

Main outcome measures:

Clinical disability recorded by the analogue scale method, and leg volume and AVP measurements. These evaluations were repeated three times: on the day before surgery, in the afternoon; in the early morning on the day of surgery; and 2 months after surgery, in the afternoon.

Results:

Varicose vein surgery improved disability ( p = 0.001) and two AVP parameters: recovery time (RT, p = 0.0049) and the calf muscle pump index (CMPI), which rose by 345% (95% confidence intervals: 29, 659). Preoperative supine rest for one night improved disability ( p = 0.0016) and reduced leg volume ( p = 0.0002). The improvements induced by surgery correlated with the changes induced by rest, for disability ( p = 0.016), RT ( p = 0.006) and CMPI ( p = 0.033).

Conclusion:

Surgery improves venous function in patients with primary varicose veins. AVP remains a standard method of evaluating CVI. Combined with volumetry, it allows sensitive comparisons between different treatments. Because venous function varies greatly with daily activity, it is imperative to standardize the times at which venous function is evaluated.

Vascular complications after surgical repair of aneurysms in Behçet's disease

The poor prognosis of vasculo Behcet's disease is often due to postoperative vascular complications (false aneurysm and graft occlusion). We report a case of an abdominal aortic aneurysm associated with an aneurysm of the left common femoral artery in a 23-year-old Portuguese man. The primary treatment was surgical (aneurysmectomy and prosthetic revascularization). The early occlusion of the left femoral revascularized artery was treated surgically with a new bypass. The occlusion of the right limb of the aortoiliac graft was asymptomatic and was not treated. Two months after admission to our hospital, the stenosis of the infrarenal aorta successfully treated by angioplasty via the occluded right limb of the graft. The patient was followed up for 18 months. He could only walk a short distance and had rest pain in the left foot. Magnetic resonance angiography showed a false aneurysm of the infrarenal aorta, and an occlusion of the remaining left limb of the aortoiliac graft. The endovascular treatment performed does not avoid the need for surgical treatment, because occlusion and false aneurysm may occur after dilatation. The endovascular approach can also be used during a sudden inflammatory surge, and makes it possible to wait for a quiescent period when surgery can be performed.

Long-term outcome in patients under 40 years after revascularization for chronic lower limb ischaemia

BACKGROUND

In order to find out if surgical or endoluminal treatment changes the long-term results of atherosclerotic occlusive disease in patients of under 40 years of age we reviewed 17 consecutive patients.

METHODS

Their mean age was 36.5. Patients with Buerger's disease or inflammatory arteriopathy were excluded. All patients were extremely heavy smokers. The indications for surgical procedures were disabling claudication (less than 100 meters) for 11 patients, rest pain for 4 patients and grangrene of a lower limb for 2 patients. The lesions were aorto-iliac in 12 cases and femoro-popliteal in 5. Ten surgical procedures were performed (5 aorto-femoral bypasses, 1 ilio-femoral bypass associated with an aorto-renal bypass, 2 femoropopliteal bypasses, 1 aorto-iliac endarteriectomy, 1 femoral endarteriectomy). On the other hand there were 7 endoluminal procedures (1 aortic, 4 iliac, 1 femoral and 1 popliteal).

RESULTS

The mean follow-up was 97.3+/-50 months (range, from 34 to 216 months). Two patients died by 57 and 132 months respectively. At 5 years the survival rate was 94%; the primary patency rate was 59%; the secondary patency rate was 81% and the limb salvage rate was 94%. At 10 years these rates were respectively 94%, 44%, 54% and 75%. A total of 21 reoperations were performed. During follow-up 11 patients were better, 2 were stable and 4 were worse with 2 limbs lost.

CONCLUSIONS

These bad results suggest keeping the surgical and endoluminal indications for patients younger than 40 years with threatened limbs.

[Effectiveness and safety of hydroxyethyl-rutosides in the local treatment of symptoms of venous insufficiency during air travel]

During air travel, the length of time spent in a sitting position and the absence of muscular activity in the calves severely slow the rate of blood flow in the lower limbs. The aim of this randomized, cross-over, double-blind study was to evaluate local application of Hydroxyethyl-rutosides (O-Beta-Hydroxyethylrutosides) in the treatment of symptoms of venous insufficiency including stasis-induced edema during extended air travel on flights exceeding 6 hours. Hydroxyethyl-rutosides or placebo was applied every 3 or 4 hours throughout the flight. In the 51 subjects evaluated (both males and females) the results show statistically significant differences favoring treatment with Hydroxyethyl-rutosides both with regard to objective signs of edema: change in minimum ankle circumference was less during trips in which Hydroxyethyl-rutosides was applied, whether compared with the maximum measurement (p = 0.04) or the last measurement made during the flights, and with regard to subjective signs: several symptoms occurred significantly less frequently when the subject applied Hydroxyethyl-rutosides during the flight [pain (p = 0.03), sensation of heavy and tired legs (p = 0.04) and sensation of swelling (p = 0.02)]. the patient's overall assessment of the treatment was also favorable after using Hydroxyethyl-rutosides Gel (p = 0.01). the number of subjects complaining of edema (pitting edema, marks of shoes, difficulties putting shoes back on) was significantly lower during periods of treatment with Hydroxyethyl-rutosides Gel (p = 0.001). Local application of Hydroxyethyl-rutosides, 3 to 4 times during 6 to 14 hours is thus effective in treating the main symptoms of venous insufficiency including stasis-induced edema caused by extended periods in the sitting position during long air flights.

[Abdominal aortic aneurysms and kidney transplantation]

Protection of the kidney is fundamental during the treatment of abdominal aortic aneurysms (AAA). This applies particularly in patients with a renal transplant, the artery of which has been implanted on an iliac artery. Reviewing 27 AAA in patients with a renal transplant, the authors discuss the various techniques used. The authors disagree with renal function preservation methods. To maintain perfusion during clamping, different types of bypasses have been described: axillo-femoral, the Gott aortofemoral shunt or a partial extracorporeal perfusion (Campbell). With local or total hypothermia, the clamping time can be lengthened and this is used particularly when an end-to-end anastomosis into the internal iliac artery has been carried out. Since the Lacombe 1986 publication, no renal protection has been carried out for the sake of the technical needs of an operation. To reduce relative ischemia time, either the blood flow in the aortic bifurcation is maintained during the aortic clamping and the fashioning of the proximal anastomosis, or the distal anastomoses are fashioned first (Mathey), thus ensuring sufficient flow into the kidney through the collateral anastomoses between the iliacs, or by combining the 2 techniques (Mellière). The risk of infection in these immuno-depressed patients is discussed and it is concluded that the simultaneous repair of an AAA and the performance of a renal transplantation (Cerilli) is not recommended because of the risk of sepsis.

Bilateral thrombosis of the internal carotid arteries after a closed trauma. Advantages of magnetic resonance imaging and review of the literature

Bilateral traumatic dissection of an internal carotid artery (BTDIC) after a closed injury is very rare. We report a case of bilateral thrombosis caused by internal carotid artery dissection due to a closed injury. The 22 cases documented in the literature are also reviewed. Six of the patients (26%) were asymptomatic at the initial examination, but all developed secondary symptoms, during the first 48 hours. Sixteen patients (69%) had associated traumatic lesions. Six patients died during the week after the accident, all of them had initial neurological symptoms. Magnetic resonance imaging (MRI) provided more items of information than angiography, showing a dissection on an occluded artery and a clearer picture of the length of the dissection, directly visualizing the wall hematoma and a residual signal that showed the persistence or arrest of blood flow. Treatment of BTDIC is based on early anticoagulation therapy.

Importance of cutaneous postural reflex vasoconstriction in patients with atherosclerotic occlusive disease of the lower extremities

OBJECTIVE

The present study was designed to measure the cutaneous postural vasoconstrictive reflex (PVR) in normal controls and patients with atherosclerotic occlusive disease of the lower extremities, and to determine its diagnostic and prognostic relevance.

EXPERIMENTAL DESIGN

The postural vasoconstrictive reflex was recorded in 34 patients with atherosclerotic occlusive disease of the lower limbs and 27 normal controls, using laser-Doppler flowmetry. Patients also had ankle and toe pressure measurements and transcutaneous oximetry (TcPO2).

SETTING

University hospital.

RESULTS

The PVR on the pulp of the big toe was 20+/-7 arbitrary perfusion units in normal controls, 9.4+/-12 in patients with claudication, and -19 +/- 5 in patients with rest pain and/or gangrene, who differed from the claudicant and control groups (p=0.001 and 0.0001 respectively). The sensitivity of negative PVR in the big toe was 89% for the diagnosis of rest pain and/or gangrene, and its specificity, 83%. The severity of foot ischaemia and PVR values exhibited a significant inverse correlation (r=-0.56, p<0.0001). All patients with a poor outcome, ie. death and/or major amputation within 100 days of follow-up, had a negative PVR, and all patients with a positive PVR had a good 100-day prognosis without even a minor amputation.

CONCLUSIONS

Laser-Doppler provides useful additional information in the assessment of foot ischaemia severity by showing that postural vasoconstriction is impaired in patients with severe atherosclerotic occlusive disease of the lower limbs, resulting in increased skin microcirculatory flow during leg dependency.

Pericardial effusion and AIDS: benefits of surgical drainage

OBJECTIVES

During the last few years, AIDS has been the main cause of large pericardial effusions in urban settings. We have therefore had to perform surgical pericardial drainage for diagnostic and/or therapeutic purposes in AIDS patients. This study was designed to establish the diagnostic and therapeutic yield of pericardial drainage for these patients.

METHODS

We retrospectively reviewed the data of the 13 AIDS patients with a pericardial effusion, referred to our surgical department between December 1989 and December 1996 for surgical drainage and pericardial biopsy.

RESULTS

Cytological studies and searches for bacteria, mycobacteria and parasites were all negative. The histology of the 13 pericardial biopsies disclosed three pericardial locations of a Kaposi's sarcoma (all three patients had a pre-existent extra-cardiac location of this sarcoma) and one pericardial location of an already known immature mediastinal teratoma. In the nine other cases, the lesions were aspecific. Four patients died of multivisceral failure within 30 days of surgery. For the survivors, surgical drainage afforded relief and there were no clinical signs of recurrent effusion.

CONCLUSIONS

The cause of pericardial effusion in AIDS is still often unknown, even after pericardial biopsy. Here, aspecific pericarditis was the most common diagnosis. Although the prognosis of such effusion in these patients is known to be poor, surgical drainage provided relief for those who survived the post-operative period.

Haemodynamics of patients with severe lower limb arterial disease: the critical aspects of critical ischaemia

OBJECTIVES

To compare the value of ankle and toe pressures as regards the diagnosis of critical ischaemia, its prognosis, and the need for vascular surgery.

DESIGN

University hospital-based retrospective study.

MATERIALS AND METHODS

Fifty-seven patients (23 women and 34 men) with gangrene or rest pain had a haemodynamic evaluation combining ankle systolic pressure, toe pressure and cutaneous oximetry (tcPO2) with long-term follow-up (until death, for 44%).

RESULTS

After 2 years of follow-up, actuarial rates were 49 and 79% for survival and limb salvage, respectively. Ankle and toe pressures gave rise to different subsets of patients, p < 0.001, mainly because of the existence of a group of patients with very distal foot arterial disease. Low ankle pressure was linked to the risk of major amputation. Low toe pressure was linked to a great need for vascular surgery. Diabetes increased the risk of minor amputation.

CONCLUSIONS

The concept of critical ischaemia remains clinically relevant. Haemodynamic quantitative data strengthen this concept, but ankle and toe pressures are not interchangeable parameters. For these reasons, toe pressures should be changed from a recommended to a mandatory haemodynamic parameter in the definition of critical ischaemia.

Nailfold capillary microscopy in patients with anticardiolipin antibodies: a case-control study

BACKGROUND AND DESIGN

This case-control study was undertaken to determine whether anticardiolipin antibodies (ACA) are responsible for particular abnormalities in nailfold capillary microscopy (NCM). Cases comprised 33 consecutive patients positive for ACA (24 women and 7 men). Controls comprised the same number of ACA-negative patients, with the same sex ratio, the same diagnosis and the most similar duration of disease possible. Clinical data, serum samples and NCM recordings were obtained from all patients and controls.

RESULTS

In each group, 22 patients had connective-tissue-related disorders and 11 various other diseases. In ACA-positive patients, the mean IgG ACA titre was 39 +/- 58 IgG phospholipid units. Cases and controls displayed various cutaneous manifestations. In ACA-positive patients, there were Raynaud's phenomenon (54%), cutaneous vasculitis (24%), scleroderma changes (18%), photosensitivity (9%), a history of digital gangrene (6%), malar rash (6%), acrocyanosis (6%), chilblains (3%), livedo reticularis (3%) and purpura (3%). Cases and controls exhibited numerous NCM abnormalities. In ACA-positive patients, they included haemorrhages (54%), oedema (24%), bushy capillaries (21%), disordered capillaries (18%), capillary bed disorganization (12%), capillary rarefaction (9%), giant capillaries (6%) and 'desert areas' (3%). There were no correlations between the ACA titres on the one hand and the number of cutaneous manifestations or NCM abnormalities on the other.

CONCLUSIONS

ACA-positive patients frequently exhibit clinical skin lesions and abnormal NCM. In this study, these lesions and NCM abnormalities resembled those of the matched ACA-negative controls.

Single-stage management of abdominal aortic aneurysm and colon carcinoma

We report two cases in which concurrent abdominal aortic aneurysm and colon carcinoma were treated in the same surgical procedure. In the first case both lesions were detected preoperatively but were uncomplicated. Single-stage treatment was undertaken electively. In the second case the colonic lesion was found during treatment of the aneurysm and both lesions were complicated. The decision to undertake single-stage treatment was made intraoperatively. Recovery was uneventful in both cases. Based on previous case reports and our experience in these two patients, we discuss the advantages and disadvantages of single-stage management. The principal risk is prosthetic infection. The advantages include avoidance of complications of the unoperated lesion and the ability to manage both lesions with only one operation. With a two-staged approach, complications following the first procedure and/or progression of the unoperated lesion may prohibit the second procedure. Despite the successful outcome in our patients, we recommend using single-stage management only in selected cases.

[Treatment of an exposed femorol-popliteal bypass: ex-situ replacement]

From December 1990 to July 1995 we performed 171 sub-inguinal revascularizations including 35 popliteal revascularizations and 146 revascularizations of an artery in the leg or foot. Five cases of infection were observed within a delay of 7 and 25 days after the operation. There were 3 men and 2 women (mean age 78 years). Four femoro-tibial bypasses were made for critical ischaemia (2 necroses of the toes, one eschar of the heal, one stage III). There was one femoro-popliteal bypass which was associated with a femoro-femoral for necrosis of the toes. Two bypasses were made with polytetrafluoroethylene, one with Dacron and two with the greater saphenous vein. Signs of sepsis were bleeding in 2 patients who had a venous bypass and septicaemia in 2 patients. Local skin necrosis and/or apparently infected discharge or patent pus were seen in all patients. Staphylococcus aureus was found in 4 patients and Enterobacter cloacae in one. Revascularization was done with an extra-anatomic bypass in 4 patients and with a cryopreserved in situ allograft in 1. Mortality was 20% and amputation rate was 40%. All exposed bypasses were infected but the severity of the infection varied depending on the causal germ, general signs and ischaemia of the limb. Conservative treatment has its limits: 1) intact anastomoses, 2) absence of bleeding, 3) patent bypass, 4) absence of generalized sepsis. Results of in situ revascularization depend on the virulence of the causal germ. Radical treatment (explanation + extra-anatomic revascularization) still has indications in infected infra-inguinal bypass surgery.

Incorporation of fibronectin-impregnated vascular prostheses in the pig. Microscope study

An interface near the endothelial extracellular matrix is necessary to augment and maintain endothelial cell attachment. The use of plasma lectins constitutes one of the present lines of research designed to improve this interface. We studied the incorporation of 2 series of arterial prostheses with a diameter of 4 mm and a mean length of 9 cm. They were implanted in the carotid arteries of adult Europig minipigs. Prostheses were of two types: polytetrafluoro-ethylene (PTFE) and knitted Dacron. Two series of 12 pigs each were used. One was explanted at 3 months and the other at six. Each pig was grafted with one prosthesis impregnated with the plasma components of diluted Fibrogel and one non-impregnated prosthesis which served as control. The explanted prostheses and adjacent parts of the carotid were prepared for light or scanning electron microscopy. Proximal, median and distal segments were cut and embedded in resin. Collagen distribution was revealed by Milligan's trichrome stain, and fibrin distribution by Picro-Mallory staining. Macroscopic examination showed discrete periprosthetic adhesion for impregnated prostheses and complete adhesion for non-impregnated prostheses. Scanning electron microscopy revealed a median endothelial cell coating on impregnated grafts whereas the only endothelial cells on non-impregnated grafts, were perianastomotic. On impregnated grafts, Milligan's trichrome staining revealed an even collagen distribution. The walls of non-impregnated grafts exhibited capillary cell infiltrations with breaches in the outer structures. In impregnated prostheses, the absence of such breaches enabled us to postulate that their incorporation was better than that of the non-impregnated grafts. The minipig model was hard to handle because of the aggressiveness engendered by restricted feeding designed to limit weight increases. In general, however, we may justifiably conclude that in this model, the use of plasma lectins improved prosthetic incorporation.

Distal bypass for limb salvage: comparative study in patients below and above 80 years of age

Revascularization for chronic lower extremity ischemia in patients of 80 years and older is controversial. To better define operative risk and outcome after peripheral vascular procedures in the elderly, our experience from January 1990 to December 1992 was reviewed. We compared two groups of patients: group I with 26 patients (28 revascularizations) 80 years of age and older (84 +/- 3 years) and group II with 29 patients (32 revascularizations) younger than 80 years (70 +/- 8 year). The two groups were similar with regard to risk factors, surgical indication (rest pain and/or gangrene) and type of graft (in situ vein: 35, reversed vein: 12, PTFE: 13). Fourteen femoro-popliteal bypasses, 17 femoro-tibial bypasses (8 to the anterior tibial artery and 9 to the posterior tibial artery) and 29 femoro-peroneal bypasses were performed. The operative mortality rate was 11.5% in group I and 6.9% in group II. The cumulative life-table survival rate at 24 months was 39.5% in group I and 55% in group II. Primary patency rate at 24 months was 64% in group I and 67% in group II. Secondary patency rate at 24 months was 74.5% in group I and 73% in group II. Limb salvage at 24 months was 80% in group I and 83% in group II. Comparison of the older and younger groups showed no statistically significant difference in mortality rate, graft patency and limb salvage. Operative mortality and graft patency were not different with regard to age of patients.

Aneurysm of the gastroduodenal artery associated with stenosis of the superior mesenteric artery

A 68-year-old patient was hospitalized after the incidental discovery of an aneurysm of the gastroduodenal artery associated with stenosis of the superior mesenteric artery. This patient had severe heart failure, which led to acute pulmonary edema and inoperable triple-vessel coronary disease. In the first of two procedures the superior mesenteric artery was dilated; 48 hours later the gastroduodenal artery aneurysm was embolized with minicoils and acryl glue. Immediate and follow-up arteriograms at 10 months showed that results were satisfactory. Transluminal treatment of both lesions is an alternative to surgical treatment, especially in high-risk patients.

Diagnosis and management of 17 consecutive patients with inflammatory abdominal aortic aneurysm

This report reviews the authors' experience in diagnosing and managing 17 consecutive patients with inflammatory abdominal aortic aneurysm (AAA). Among 491 patients undergoing repair for AAA during a 10-year period, 17 (3%) had evidence of associated periaortic fibrosis, which was confirmed histologically. No patient had acute rupture, and two patients (12%) had chronic contained rupture. Ureteral obstruction was evident in seven patients. In 41% of the patients, available surgical correlation demonstrated that computed tomographic (CT) scan accurately delineated the extent of the disease. Sixteen patients underwent aneurysm resection. Ureteral obstruction was relieved by ureterolysis in three patients treated early in this series. In the last period of the study, well-documented hydronephrosis spontaneously subsided in two patients without special treatment. Of these 17 patients, 15 (88%) were early (30-day) survivors. There were two late deaths at 2 months and 5 years; 12 (71%) patients are still alive and free of symptoms up to 10 years after operation. On the basis of our study, we conclude the following: (1) precise preoperative diagnosis and detailed anatomic information are widely available with CT; (2) aneurysm resection is the treatment of choice because the risk of rupture still exists, and this procedure seems to reverse the inflammatory process; (3) good early and late results can be expected with proper surgical technique; and (4) routine follow-up with CT is recommended to document resolution or progression of the fibrotic process after aneurysm resection.

Human immunodeficiency virus and infected aneurysm of the abdominal aorta: report of three cases

Three patients who were seropositive for human immunodeficiency virus underwent surgery for infected aneurysm of the abdominal aorta. Fever and abdominal pain were the principal presenting clinical features. None of the patients had any opportunistic infections or endocarditis. In two cases, a ruptured aneurysm was demonstrated radiographically. In the remaining case, sonograms were diagnostic. The organisms responsible were salmonella, Hemophilus influenzae, and Mycobacterium tuberculosis. In two cases, the infectious origin was evidenced by bacteriologic examination of the aortic wall, which revealed the presence of Salmonella enteritidis and Koch's bacillus. Although Hemophilus influenzae was not found in the aortic wall of the remaining case, the infectious origin of the aneurysm was established because preoperative blood cultures were positive for this pathogen, and pathohistologic examination of the specimen showed destruction associated with leukocyte infiltration of the aneurysmal wall. An in situ prosthetic graft replacement protected by omentum was performed in all three cases. Antibiotic therapy was continued for several weeks. All patients are well with follow-up ranging from 10 to 21 months. Infectious aneurysm associated with human immunodeficiency virus seropositivity results in bacterial infestation of an atheromatous aorta. Infected phenomena are promoted by cellular immunodeficiency. Surgery was justified in these cases because of the immediate threat of rupture.

[Early prognostic factors of the surgery of aneurysms of the abdominal aorta with renal artery clamping]

The aneurysms of the abdominal aorta requiring suprarenal clamping are rare. Suprarenal clamping was required for only 43 of 544 aneurysms operated electively from 1981 to 1989. Twenty-five patients had a juxtarenal aneurysm, without any normal aortic segment under the renal arteries, and suprarenal clamping was therefore necessary while the upper anastomosis was being established (group I). Eighteen patients had an aneurysm enclosing the root of at least one renal artery (group II). Several prognostic factors have been assessed: patient's age, presence of preoperative renal insufficiency, of arterial hypertension or of coronary insufficiency, and revascularization method. Five patients died. Four of them belonged to group II and were over 75 years old. All presented with a preoperative renal insufficiency. Two of these deaths were caused by mesenteric infarction. Four cases of regressive postoperative renal insufficiency were observed in patients for whom renal clamping had lasted longer than 45 minutes. This study allowed outlining three prognostic factors: the patient's age, preoperative renal insufficiency, a period of renal ischemia exceeding 40 minutes. On the other hand, the severity of hypertension had no predictive value. Coronary insufficiency requires a strict hemodynamic surveillance, but is not a contraindication for revascularization.

Aortoiliac surgery and kidney transplantation

Between January 1980 and December 1989, we performed 407 renal transplantations. Twelve of these patients (3%) underwent aortoiliac reconstruction before (Group I, two patients), concomitant to (Group II, five patients) or after (Group III, five patients) renal transplantation. The aortoiliac lesions treated included four aneurysms and seven occlusions of the abdominal aorta and one postarteriography dissection of the iliac artery. A prosthetic graft was inserted in nine cases (75%). Endarterectomy was performed in the three other cases (25%). Four of five patients in Group III were operated on without any particular protection for the transplant. There were no postoperative deaths in Groups I and III. In Group II, one patient died of infection secondary to a urinary tract fistula. Early and late vascular morbidity (renal artery stenosis, occlusion of aortoiliac reconstruction, anastomotic false aneurysm) occurred with equal frequency in the three groups. Renal transplantation in patients having already undergone aortoiliac surgery and, conversely, aortoiliac reconstruction in the renal transplant patient, are possible without any particular technical precautions with minimal mortality and kidney morbidity. Simultaneous renal transplantation and aortoiliac reconstruction carries a significant risk of infection and a two-stage procedure should be considered in this situation.

False aneurysm infected by Aspergillus fumigatus: an unusual complication of aortofemoral bypass graft

Two cases of Aspergillus fumigatus infection of aortobifemoral prosthetic grafts are reported. Both patients were treated successfully by excision of the infected prosthetic material, axillofemoral extra-anatomic bypass, and prolonged medical treatment. The patients received amphotericin B, 5-flucytosine and itraconazole until negative aspergillus serology was obtained (at 9 and 18 months, respectively). Later, repeat disobliteration procedures for thrombosis of the axillofemoral bypass were required. No recurrent aspergillus infection was found.

Mesenteric infarction in Takayasu's disease

Obstructive lesions of the visceral arteries in Takayasu's disease are common but rarely symptomatic. This report concerns two patients with Takayasu's disease who died of mesenteric infarction due to superior mesenteric artery thrombosis. Prophylactic revascularization of the visceral arteries in Takayasu's disease remains controversial, and lesions can be more severe than classically recognized.

Combined lung and heart extraction in clinical transplantation

The anatomical conditions for single lung and double lung transplantation allow a heart transplant and one or two lung transplants to be performed in two or three different recipients from a single donor with healthy lungs. The extraction of the heart and lung block for the purposes of these separate transplantations is described on the basis of our experience of 6 single lung transplants with 6 extractions for cardiac transplantation in different recipients, of a total of 8 lung transplants. We report these 12 successful operations and the particular technical modalities of cardiopulmonary extraction for separate transplantation. After cannulation for cooling of the abdominal viscera (kidneys, liver, pancreas), thoracic and mediastinal dissection, cardioplegia and surface pulmonary cooling by iced saline on the collapsed lungs, the heart and lungs were extracted as a single block and were separated ex situ. After periods of cold ischaemia of 1 h to 3 h 30 min for the hearts and 1 h 30 min to 5 h for the lungs, the immediate and medium term functions were satisfactory. Logistical difficulties involved in matching the population of recipients have prevented the grafting of three different recipients up until now. These successes make it essential to preserve the lungs from donors with healthy lungs. A rigorous coordination between the various transplantation teams helps to avoid competition between the three types of transplantation: heart-lung, double lung and single lung.

Renal artery emboli: the role of surgical treatment

Twelve cases of emboli to the renal artery (one of which was recurrent) were reviewed. In seven patients, emboli were unilateral and the opposite kidney was functional. In five patients, emboli were bilateral or occurred in a solitary kidney, leading to anuria. Cardiac rhythm disorders were encountered in eight patients and were responsible for emboli in other areas in three. Arteriography in ten patients demonstrated seven complete truncal occlusions (one bilateral), two incomplete truncal occlusions, and one distal embolus. One patient with a distal embolus was treated by heparin alone with satisfactory results. One patient in poor general condition was treated with intraarterial streptokinase, resulting in incomplete lysis of the clot. The five patients with anuria were operated on: four regained satisfactory renal function whereas the other patient died. In five patients without anuria who were operated upon, renal function returned to normal in four, and one patient required nephrectomy. Surgical treatment is imperative with anuria and is indicated in unilateral emboli with a functional contralateral kidney, especially when there is complete occlusion of the renal trunk. If the embolus is recent, intraarterial fibrinolytic treatment or percutaneous embolectomy can be attempted, but these techniques are not of proven efficacy. Patients with distal emboli or contraindications to operation should be treated by anticoagulant therapy, alone or with local fibrinolytic treatment.

[Standard thoracic radiography in recent pneumonectomized patients. Its contribution to the diagnosis of empyema and bronchopleural fistula]

Case reports of 110 patients undergoing pneumonectomy were reviewed to assess value of standard postoperative chest radiography for detection of early complications, consisting mainly of empyema and/or bronchopleural fistula. Most radiologic modifications observed do not represent abnormal findings, although two signs can contribute to the radiologic diagnosis of empyema: the central superimposed air/fluid levels and the secondary mediastinal displacement, but even these signs are inconstant and of late onset. Five signs may be of significance for the diagnosis of bronchopleural fistula: in addition to the two described above there are the rapid fall in principal air/water level, the increase in subcutaneous emphysema and the late onset contralateral alveolar syndrome. The diagnosis of a bronchopleural fistula prior to the development of clinical symptoms was possible in one of two cases.

[Fatal hematemesis due to erosion of a retro-esophageal right subclavian artery by an esophagogastric tube]

A case of fatal haematemesis due to erosion of a retro-oesophageal right subclavian artery by a nasogastric tube is reported. In view of this exceptional but extremely serious complication, no oesophageal tube should be used in patients known to have this abnormal anatomical arrangement. Systematic treatment of aberrant subclavian arteries should perhaps be considered when it can be performed during thoracic surgery.

[Recent tracheobronchial ruptures caused by closed injuries of the thorax. Diagnosis and complications in 18 cases]

Tracheo-bronchial ruptures are serious complications of thoracic trauma. The authors report their experience of 18 cases: 3 tracheal ruptures, 3 tears in the tracheal or bronchial membrane, 11 unilateral bronchial ruptures and 1 bilateral bronchial rupture. Diagnostic endoscopy was performed immediately in 9 cases, with a delay of 2 to 3 days in 6 cases and with a longer delay (15th, 23rd and 25th days) in 3 cases. The treatment was non-operative in the 3 cases with membranous tears. The other patients were operated by resection of the contused area and end-to-end anastomosis of the ruptured extremities: within 24 hours following the diagnosis in 10 cases, and after a delay in the 5 other cases. The post-operative course was uncomplicated in 13 cases; 1 patient developed a bronchial stenosis requiring pneumonectomy and 4 patients died, including 2 from infective lesions due to delay in the diagnosis.

[Stenosis of hemodialysis grafts. Treatment with a short graft]

In elective or emergency operations 363 short venous or polytetrafluoroethylene grafts were inserted to correct stenosis of haemodialysis grafts. Such stenoses are located in the upper part of the graft or in the receiving vein in 80% of the cases. After 2 years, 74% of the short grafts were still permeable. This original technique has several advantages: the initial venous approach is respected, the graft can be used immediately for dialysis, and the patient's venous "capital" is spared.

[Treatment of an aneurysm of the abdominal aorta above a transplanted kidney. Renal protection by inert subclavian-femoral bypass]

Opening and grafting of an aneurysm of the abdominal aorta located between and below the renal arteries were carried out in a 44-year old patient with a transplanted kidney in right hypogastric position. Renal ischaemia during clamping of the aorta was prevented by means of an inert bypass between the right subclavian and femoral arteries. The patient's renal function remained normal. The different techniques available to protect renal transplants are compared.

[Ureterovesical reimplantation. A technic derived from Lich and Gregoir's procedure]

Fifty-five uretero-neocystostomies were carried out using a technique derived from the Lich-Gregoir technique. Tightness is ensured anastomosis and burying over the vesical dome, with minimal vesical opening; the anti-reflux system is effective. Urinary complication of this ureter transplantation method are now rare, in our series, only two complications due to necrosis of the ureteral segment were observed. This technique could be used in all obliterations of the ureter, whether accidental or by necessity, located near the bladder.

[Thymic seminomas (author's transl)]

The authors report on three cases of thymic seminoma treated between 1971 and 1981. These tumours, first described by Friedman in 1981. These tumours, first described by Friedman in 1951, belong to the group of extra-gonadal germinal tumours. They constitute about 2.5% of all thymic masses. The most probable pathogenic theory is abnormal migration of germinal cells from the vitelline sac to the embryonic thymus. Thymic seminomas are usually found in young men and are asymptomatic in 30% of the cases. Macroscopically, they present as solid tumours capable of invading the surrounding structures. Histologically, they resemble gonadal seminomas but are sometimes difficult to identify, which is unfortunate since treatment is dependent upon an accurate histological diagnosis. The authors suggest that the tumour should be biopsied under mediastinal fluoroscopy, so that an accurate histological diagnosis can be made. Treatment consists of surgical excision, which should be restricted and on no account should destroy important structures, completed by mediastinal radiotherapy. The mean survival time is 6.3 years; the 5-year survival rate is 75%.