Limb salvage and popliteal aneurysms: advantages of preventive surgery.

OBJECTIVES: to assess the prognosis of atherosclerotic popliteal aneurysms (APAs), according to whether they were occluded or patent at the time of diagnosis. DESIGN: retrospective study. PATIENTS AND METHODS: fifty-two APAs were investigated in 35 patients. Nineteen were occluded (group I) and 33 patent (group II). In group I, 11 lower limbs had critical ischaemia, and eight had severe claudication. In group II, 27 were asymptomatic, 3 were painful, and 3 presented with symptomatic distal occlusion. In group I, treatment consisted of six bypasses, five thrombectomies, four thrombolyses, but for five APAs, no revascularisation was possible due to lack of runoff. In group II, 30/33 APAs were treated by graft replacement; the other three were not operated on due to the patients>> poor general condition. RESULTS: the 4-year survival rate was 72% in group I vs. 77% in group II, and the limb salvage rate was 72% in group I vs. 100% in group II, p<0.01. CONCLUSION: prophylactic treatment of asymptomatic popliteal aneurysms may avoid amputation caused by thrombosis and embolisation of runoff.

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.

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.

[Forefoot gangrene and infra-crural bypass: sequential amputation]. / Gangrène de l'avant-pied et pontage sous-crural: amputation séquentielle.

When revascularizing for gangrene, deciding on amputation depends on the risk of infection due to trophic injury both for the foot and for the bypass and on the requirement to attempt amputation at the correct level at the first operation. In our experience, the importance of infection has led us to propose the following sequence: if the lesions are infected--immediate amputation, differed revascularization after the infection has been controlled; if the lesions are dry early vascularization followed by amputation either during the same operation with strict separation of the two operative fields or a few days later, particularly if the level of the amputation has been determined.

[Treatment of an exposed femorol-popliteal bypass: ex-situ replacement]. / Traitement d'un pontage fémoro-poplité exposé: remplacement ex-situ.

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.

[Surgical strategy in the association: aneurysm of the abdominal aorta and colonic lesion]. / Stratégie chirurgicale devant l'association: anévrisme de l'aorte abdominale et lésion colique.

An association of an aneurysm of the abdominal aorta and a lesion of the colon raises an important question as to the correct sequence to follow. A simultaneous operation raises the major risk of infection and most authors prefer a sequential approach, treating either the aneurysm or the lesion of the colon first depending on the initial clinical situation or complications. In our first patient, both pathologies were known before surgery and simultaneous procedures were deliberately programmed. In the second case, both lesions were complicated and required simultaneous cure. In the third case, both were recognized before surgery and a sequential approach was followed--colon then abdominal aorta. In the fourth case, the colon disease was complicated and responded to medical treatment; three months later surgery was performed on the aneurysm followed by a colectomy two months later. A review of the literature and an analysis of our four cases offer a means of developing a management strategy for patients with an aneurysm of the abdominal aorta associated with a lesion of the colon.

[Bilateral stenosis of the renal arteries: multiple bypasses]. / Sténoses bilatérales des artères rénales: pontages multiples.

Bilateral ostial renal arterial stenoses are in fact atheromatous lesions of the aortic wall. These anatomic features must be considered for the treatment of such lesions. It can be achieved by bilateral renal bypass grafting with the concomitant replacement of the aorta when necessary. This combined surgery carries a certain operative risk, which has been notably lowered with the recent advances in anaesthesiology and intensive care. We consider this combined renal and aortic surgery is easier and safer than transaortic endarterectomy.

[Renal artery occlusion: surgical revascularization]. / Occlusion de l'artère rénale: revascularisation chirurgicale.

Five patients were treated for renal artery occlusion, as a result of embolism (2 patients), thrombosis of a stenosed vessel (1 patient) or acute occlusion during percutaneous transluminal angioplasty (2 patients). Three patients had poorly controlled hypertension. One patient was anuric. Patients were treated operatively in 4 cases and non operatively in 1 case. There were no death and no renal failure that necessitated chronic hemodialysis. All bypasses except one remained patent. Blood pressure increased in the patient with the bypass occlusion and was reduced in all four other patients. Renal artery occlusion does not necessarily cause renal infarction. Evaluation of renal viability is necessary before decision of revascularization. Surgical exploration seems the best predictive factor.