[Treatment of asymptomatic carotid stenoses: evolution of ideas, medical treatment, surgical treatment, what about percutaneous transluminal angioplasty?]. / Traitement des sténoses carotidiennes asymptomatiques: progression des idées, traitement médical, traitement chirurgical, quid de l'angioplastie?

Asymptomatic carotid lesions treatment techniques have not greatly evolved over the last 15 years. Although there seems to be a consensus to apply only medical treatment for lesions less than 60-70%, there is still debate with regards to patient cohort suffering from high-grade stenosis (between 70% and 90%). Very high-grade lesions seem, however, to benefit from surgery. The most significant improvements come from Duplex scan and non-invasive radiology (TDM with injection and MRI) allowing a more accurate stenosis measurement and above all, detection of potential high-risk lesion (inhomogeneous plaque, haematoma under plaque). Medical treatment as well as risk factor balancing is always complementary to surgery. The most significant improvement is probably the anaesthesiology technique with the wide use of local analgesia allowing an ideal cerebral protection. The various surgical techniques: simple endarterectomy or with patch, eversion endarterectomy, venous or prosthetic by-pass show no significant difference either in the immediate results or in restenosis. These techniques enabled a mortality rate of less than 1% (due to a better cardiac check-up) and morbidity rate of less than 2%. The development of percutaneous transluminal angioplasty with stenting (secured by protection devices) has made indications slightly more difficult by adding a non-validated technique which has not proven its merits compared to surgery. One of the dangers from this technique is that it may lead to abusive indications. In summary, surgery is the most adequate treatment for high-grade asymptomatic carotid lesions after a precise locoregional check-up, especially a cardiac one. Medico legal implications in this asymptomatic situation call for precise and honest patient information.

[Study of atheromatous stenoses of carotid bifurcations by Doppler ultrasound, spiral angio-MRI, magnetic resonance angiography and comparison with arteriography]. / Etude des sténoses athéromateuses des bifurcations carotidiennes par écho-Doppler, angioscanner spiralé, angio-IRM et comparaison à l'artériographie.

PURPOSE: To evaluate Doppler ultrasound (US), Helical CT, Magnetic Resonance (MR) angiography in the detection of carotid bifurcation atherosclerotic disease and comparison with angiography. MATERIALS AND METHODS: After a Doppler US procedure, 56 carotid bifurcations were included (symptomatic stenosis greater than 60% or asymptomatic stenosis greater than 30%). Helical CT, MR angiography and selective arteriography were performed. Stenosis were measured with NASCET criteria. Sensitivity and specificity were calculated and compared to arteriographics findings for each procedure and each grade of stenosis. RESULTS: Helical CT and MR angiography had their best sensitivity in grade 3 (70-99%), 92%, 100% respectively, their specificity was identical (91%). All the occlusions were depicted by the three procedures. CONCLUSION: Association of Doppler US and MR angiography may replace in the future selective angiography in the evaluation of extracranial atherosclerotic disease. Arteriography would be performed only in case of discordance between these two procedures.

[Progressive complications associated with polyester arterial prostheses. Study of 61 specimens following surgical excision]. / Complications évolutives associées aux prothèses artérielles en polyester. Etude de 61 spécimens après exérèse chirurgicale.

Reports of individual surgical cases tend to be anecdotal because of the unique circumstances surrounding the patient, the surgeon, the intervention and, where applicable, the prosthetic device. To overcome this limitation the authors have taken a wider collaborative approach and report the analysis of 61 explanted polyester arterial prostheses associated with delayed complications on 53 patients reoperated upon in six different French hospitals. One advantage of such an independent and centralized retrieval programme is that the impact of centre specific factors, such as patient selection and surgical techniques, is minimized. Consequently, by following a standardized protocol for the evaluation of the morphologic, pathologic and mineralogic characteristics of the tissue surrounding the excised grafts, as well as the textile structure of the prostheses themselves, it has been possible to distinguish between iatrogenic and disease related complications and to demonstrate a number of general findings associated with the clinical performance of polyester arterial prostheses. Complications such as thromboses, infections and false aneurysms appear to occur randomly after different lengths of implantation, thicker fibrous tissue capsules are associated with velour grafts with highly textured yarns, the incidence of mineralized tissue and of endothelialized luminal surfaces is rare, weft knitted textile prostheses appear less mechanically stable and more sensitive to iatrogenic trauma than warp knitted, and the incidences of lipid and cholesterol adsorption, bacterial colonization and sterile fluid loss need further investigation. These observations lead to the recommendation that for patients with longer life expectancies surgeons should consider selecting low porosity, woven or warped knitted prostheses which contain yarns that have not been highly textured.

[Dobutamine in vascular surgery]. / La dobutamine en chirurgie vasculaire.

The hemodynamic parameters of 12 patients operated on not a coronary vascular disease have been controlled by means of not invasive technic. The aortic output was measured by means of an oesophageal probe that associates echography and Doppler effect. A double blinded study was done by dividing the patients into two groups. The group 1 was subjected to a perfusion of dobutamine and the group 2 to a perfusion of a placebo during the operation. The group 1 showed a mean aortic output similar-level than before anesthesia one (3.40 +/- 0.61 l/min; 3.35 +/- 0.5 l/min) and 37% greater than group 2 (p less than 0.01), during operation period. The average systolic volume of group 1 was nearly similar at the initial one (46.5 +/- 12.92 ml; 40.8 +/- 8.2 ml) and 35% higher than group 2 (p less than 0.01). The cardiac frequency was higher (average 14 beats per minute) in the group 1 (p less than 0.01). The total systemic vascular resistance of group 1 were maintained in equilibrium and did not show any significative change. In opposition, group 2 showed a 207% increase in their vascular resistance, in relation to the initial values (p less than 0.01). These values were significatively higher that those of the group 1 (p less than 0.00). Mean diuresis was of 144 +/- 41.5 ml/h for group 1 and 43.6 +/- 10.9 ml/h for group 2 (p less than 0.001). In group 2 the H+ concentration increased from 33 to 39 nmol/l (p less than 0.01) and it was higher (p less than 0.01) than group 1.(ABSTRACT TRUNCATED AT 250 WORDS)

Dopamina: acción hemodinamica durante la cirurgia vascular periférica / Dopamine: hemodynamic effect during peripheral vascular surgery

En un grupo de 10 pacientes operados sobre el territorio vascular periférico, se practicó una vigilancia hemodinámica no invasiva. El gasto aórtico fue medido en forma continua con una sonda esofágica asociando la ecografía al efecto Doppler. Bajo hipnoanalgesia el gasto aórtico mostró una caída de 27% (inicial = X 3,13 + ou - 0,51 1/min - X 2,29 + ou - 0,59 1/min, p <0.01). El gasto no mejoró significativamente con relleno vascular (X 2,49 + ou - 0,58 1/min, NS). Bajo perfusión de dopamina a la dosis de 3,50 mcg/Kg.min el gasto se elevó a 134% del valor inicial (X 3,91 + ou - 0,60 1/min p <0.01). El volumen de eyección sistólico progresó en 136% (inicial = X 38 + ou - 4 ml - X 52 + ou - 7 ml, p <0.01). La resistencias vasculares sistémicas totales fueron 19% más bajas que las iniciales. La frecuencia cardíaca dismimuyó de X 81 + ou - 11 a x 75 + ou - 9 p/min, mientras que la presión arterial media y la presión venosa central no sufrieron cambios significativos. No hubo variación en la concentración de H+. La dopamina a bajas dosis parece ser una terapéutica interesante en la prevención del bajo gasto preoperatorio, sobre todo en los pacientes que presentan ciertos riesgos cardiovasculares

[Contribution of epidural infiltration in the treatment of acute ischemia in the lower inoperable limbs (author's transl)]. / Ischémies aiguës des membres inférieurs non chirurgicales. Apport de l'infiltration péridurale dans leur traitement.

Epidural infiltration easily causes without surgical intervention, paralysis of the sympathetic nervous system and analgesia. In this way, spasm and vasoconstriction are inhibited and the use of collateral vessels which are still permeable is facilitated. The antalgesic position of the dropped foot, which is a cause of oedema and hemodynamic disconfort, is eliminated. Out of 17 patients showing an acute ischemia of the lower limbs treated by this method, seven were cured, 3 of whom already having trophic disorders, 7 underwent local amputations and 3 had leg and thigh level amputations. Six months later 10 of these patients were doing well. The best therapeutic conditions of this treatment are non-atheromatous arteritis: angiospasm, toxic or inflammatory acute ischemia and Buerger's disease. On the other hand, the results are mediocre with atheromatous arteritis.