[Inframalleolar bypass in limb salvage. Late results]. / Les pontages périmalléolaires dans les sauvetages de membre. Résultats tardifs.

STUDY OBJECTIVE: The objective of this retrospective study was to report the long-term results of distal revascularization at the ankle in patients with critical ischemia. PATIENTS AND METHODS: From January 1989 to November 1999, 50 inframalleolar bypasses were performed in 49 patients (35 males and 14 females with a mean age of 75 years [range: 51 to 95 years]). Twenty-five patients (50%) were diabetics. All patients presented with critical ischemia of the lower limb. Distal anastomosis was performed at the retromalleolar posterior tibial artery in 28 cases (56%), pedal artery in 20 cases (40%) and distal fibular artery in two cases (4%). Bypasses were performed using a greater saphenous vein (n = 38), a cryopreserved arterial allograft (n = 9), or a PTFE graft (n = 2). A composite graft with greater saphenous vein and arterial allograft was performed in two cases. RESULTS: There were two early postoperative deaths. One patient presented a blow-out of the distal anastomosis that required bypass ligation and subsequent leg amputation. Early thrombosis of the graft occurred in four cases, leading to major amputation in three cases. No patients were lost to follow-up and mean follow-up was 26.7 months (range: 1 to 86 months). Graft thrombosis occurred in 15 patients and led to amputation in 6 cases. Bypass graft patency rate was 72% and 61% at 1 year and 3 years, respectively, yielding a 80% limb salvage rate at 3 years. The 3-year actuarial survival rate was 53%. CONCLUSION: Inframalleolar bypasses are a valuable tool in patients with critical ischemia. The lower limb salvage rate is satisfactory in this elderly population. Based on this experience, angiography with good run-off and, when necessary, a surgical approach to verify patency of the arteries at the ankle should always be performed before undertaking a major amputation.

[Venous aneurysm of unusual localization revealed by a pulmonary embolism. Report of two cases]. / Anévrysme veineux de siège inhabituel révélé par une embolie pulmonaire. A propos de deux cas.

We report two uncommon cases of venous aneurysm involving the soleus vein and the saphenofemoral junction. Both cases presented with pulmonary embolism. Diagnosis of the venous aneurysm was achieved by Doppler ultrasonography during the evaluation for deep vein thrombosis. Venography showed a large fusiform aneurysm. Both aneurysms were treated by resection and ligation. At follow-up, there was no evidence of recurrent pulmonary embolism. These cases clearly illustrate the risk of pulmonary embolism associated with uncommon localizations of venous aneurysms and the potential for thrombus formation due to the venous stasis. Surgical treatment, as in the case of popliteal aneurysms, is mandatory to avoid such embolic complications.

Below-knee bypass using fresh arterial allografts for limb salvage: early results.

The purpose of this study was to evaluate early results of below-knee bypass using fresh arterial allografts as arterial substitutes for limb salvage. From April 1991 to September 1993, we performed 28 below-knee bypass procedures using fresh arterial allografts in patients without a suitable autologous vein. Allografts were obtained by multiorgan harvesting from brain-dead subjects and preserved at 4 degrees C. Histologic examination of grafts was carried out. Secondary patency at 2 years calculated using the Kaplan-Meier method was 64% (confidence interval [CI] 45%-79%). No signs of graft deterioration or rejection were noted. These preliminary results are encouraging but long-term assessment is needed before expanding the range of application.

[Carotid revascularizations by venous grafting: long-term results]. / Revascularisations carotidiennes par greffes veineuses: résultats à long-terme.

Carotid artery reconstruction (CAR) may be achieved through a variety of techniques. The method of choice is based upon the patient's symptoms, the diffusion of the atheromatous lesion in the internal carotid artery and the experience of the surgical team that usually deals with these patients. Between January 1987 and May 1995, we performed 185 CAR using saphenous vein graft. The indication for surgery was atherosclerotic occlusive desease in all patients, sixty-two per cent of whom were asymptomatic. In the early postoperative period one patient died of aspiration, two patients suffered a stroke (one major and one minor) and five patients had a transcient ischemic attack due to carotid clamping intolerance. Two late restenosis and two graft occlusions occurred. The cumulative operative morbidity and mortality rate was 1.6%. This series demonstrates than venous grafting for carotid reconstruction yields satisfactory short- and long-term results and is a valuable alternative to endarteriectomy. Follow-up by Duplex-scan revealed no evidence of morphological degradation of the vein grafts.

[Prediction of respiratory complications after surgery of the abdominal aorta]. / Prédiction des complications respiratoires après chirurgie de l'aorte abdominale.

The most frequent type of complication in patients undergoing aortic surgery is respiratory. Preoperative lung function (PFT) and arterial blood gas measurement (ABG) are often carried out to assess the risk more precisely. The aim of the present retrospective study was to determine which value of lung function test could identify patients who developed such complications. "Receiver Operating Characteristic" (ROC) curves and the area beneath the curve for the diagnosis of respiratory complications were calculated for each variable of PFT and ABG. The greatest Youden index for each variable was chosen as indicative pulmonary function criterion of increased risk of pulmonary complications. One hundred and ninety-five patients (age: 65 +/- 10 years) were included. Respiratory complications occurred in 15% of patients. Respiratory complications increased from 12% if the vital capacity (VC) was > or = 77% of the predicted value to 35% if the VC was < 77% (P = 0.002), and from 10% if the FEV1 was > 76% to 34% if the FEV1 was > or = 76% (P = 0.0005). A decreased PaO2 or increased PaCO2 was not correlated with an increased incidence of respiratory complications. Length of stay in ICU or in hospital were increased when VC or FEV1 were low. Frequency of pulmonary complications was 9% in patients without PFT abnormalities, 16% in patients with either diminished VC or FEV1 and 35% in patients with both lowered VC and FEV1. However, all the areas under the ROC curves were < 0.7 and the sensitivity of the different variables was low. It is concluded that routine preoperative PFT and ABG cannot predict respiratory complications after abdominal aortic surgery.

[Popliteal aneurysm and leg ischemia: surgery first]. / Anévrisme poplité et ischémie de jambe: chirurgie première.

The treatment of symptomatic popliteal aneurysms is debated should local fibrinolysis or surgery first be used first? The authors report their experience in the treatment of 90 popliteal aneurysms in 66 patients. In this series were only examined those aneurysms with either acute ischaemia 12 (27%) or sub-acute ischaemia 21 (45%). The treatment of those cases with acute ischaemia was surgical for all, allowing salvage in all cases. Sub-acute ischaemia was treated with either: a surgical bypass with exclusion of the aneurysm in 7 cases, or lumbar sympathectomy in 7 cases, or medical treatment in 6 cases or local fibrinolysis for distal ischaemia in one case only. There was no peri-operative mortality, only one amputation was required (5%) (J Mal Vasc 1994; 19, Suppl. A: pages 150-153).

[Ostial stenosis of the renal arteries: results of surgery]. / Sténose ostiale des artères rénales: résultats de la chirurgie.

Surgery and percutaneous balloon are two contrasting methods for the treatment of renal artery stenosis. Surgical revascularizations offer excellent long term results with a 70% to 90% five year patency rate wherever the location of the lesion on the renal artery. Long term results of transluminal angioplasty are strongly correlated with the anatomo-radiological features of the lesions. From their own experience and after a literature review, the authors conclude that: For lesions located on the trunks of the renal artery, results of surgery and transluminal angioplasty are equivalent. For lesions involving the ostium of the renal artery, the failure rate is high and restenosis are frequent with angioplasty. In that case, surgery is a proper choice which offers better immediate and long term results.