Value of bone scintiscan for diagnosis of arterial prosthesis infection: preliminary results.

Diagnosis of arterial prosthetic infection is often difficult to confirm. Several cases of lower extremity hypertrophic osteoarthropathy (HOA) have been associated with arterial prosthetic infection. The presence of bone and joint abnormalities could constitute an early sign of HOA. The purpose of this prospective study was to determine the diagnostic value of routine bone scintiscan in patients hospitalized for suspected arterial prosthesis infection. Between December 1995 and May 1997, 17 patients with suspected infection were admitted to our institution. All underwent bone scintiscan before surgical treatment. Presence or absence of infection was defined according to the criteria proposed by Yeager. During the same period, bone scintiscan was performed in a control group of 8 patients with arterial prostheses but no clinical or laboratory signs of infection. Scintiscans were studied to detect bone and joint abnormalities distal to the arterial prosthesis. The results of this preliminary study indicate that routine bone scintiscan can assist definitive diagnosis in patients with suspected arterial prosthesis infection. Demonstration of bone and joint abnormalities distal to a prosthesis appears to be a fairly sensitive and highly specific sign of infection.

[Complications of vascular surgery]. / Complications de la chirurgie vasculaire.

Vascular surgery, which in certain life-threatening situations is the only possible therapeutic option, has progressed considerably since its beginning in the 1950s. Because of the constant progression of vascular diseases, this surgery will present, in the forthcoming years, a major public health problem. Because of advances in medico-surgical management, evermore elderly and frail patients can be treated. Perioperative mortality is constantly decreasing, but much progress remains to be accomplished to prevent, avoid or treat, postoperative complications. They are common and serious in these typical patients with cardiovascular diseases (men over 50 years of age, heavy smokers, atheromatous ...). The AA divide these complications into 3 main groups depending on the surgical procedure: abdominal aortic surgery, carotid surgery and arterial and venous surgery of the lower limbs. There is much data on abdominal aortic surgery because these long and complex procedures produce repercussions often involving many systems. The postoperative complications are treated according to the system they involve: cardiovascular, the most serious, respiratory, the commonest, alimentary, neurological, renal, others, as well as combined systems. The AA do not deal with the specific problems associated with cardiac and cardio-thoracic surgery. The AA discuss the different epidemiological findings of the large surgical series published in the 1970s and 1980s. The more recent literature analyses the relationship between preoperative risk factors (atheroma, COAD, hypertension ...), peroperative problems (surgical difficulties, emergencies, massive transfusions, others) and the corresponding postoperative morbidity. Thus a few general outlines of the physiopathology of these different complications emerge. In the light of these notions the few proposed methods will be evaluated in order to improve the preoperative condition of the vascular patient. The AA also review the relevance of the preoperative investigation in patients for vascular surgery. All these measures aim at reducing the incidence and severity of perioperative morbidity.

Early rupture and degeneration of cryopreserved arterial allografts.

Arterial allografts are used in vascular surgery to solve a major problem: vascular reconstruction in the infected area. To palliate the unavailability and to reduce the risk of viral disease transmission, vascular allografts are currently cryopreserved and stored in tissue banks. In our recent clinical experience, we observed several cases of rupture and degeneration of cryopreserved arterial allografts. All indications are that current cryopreservation protocols are probably the cause for these degenerations.

[Exposed infra-inguinal bypass: conservative treatment or in situ replacement]. / Pontages sous-inguinaux exposés: traitement conservateur ou remplacement in situ.

Infection or exposure of a infra-inguinal bypass is a severe complication which can lead to death or amputation. With conservative treatments, the bypass is left in situ or replaced with an autologous vein or an allograft. Results in a series of 393 consecutive conservative treatments for infra-inguinal revascularizations were analyzed retrospectively. Sixteen patients were studied and divided into 2 groups: Group 1 included 8 patients who had no bleeding or signs of infection and who were treated locally. Group II included 8 patients with bleeding or signs of infection in whom the bypass was replaced by an in situ autologous vein (n = 4) or an arterial allograft (n = 4). Mortality was 12.5% and the rate of amputation was 12.5%. These percentages are in agreement with reports from other authors who also propose this therapeutic option. Local treatment should be reserved for infection free of complications due to thrombosis, hemorrhage or signs of a septic syndrome. Other cases should benefit from in situ replacement with a vein or an arterial allograft. In some unsuccessful cases there are a few indications for extra-anatomic prosthetic bypasses.

[Is surgery of a carotid lesion possible without arteriography?]. / Peut-on opérer une lésion carotidienne sans artériographie?

Cerebro-vascular angiography has been for a long time the standard for operative decision. It has been ten years since the development of duplex scanning has allowed a non invasive approach of the diagnosis. Several authors have reported series of endarterectomy, some of them without preoperative arteriography. The authors remind us of the different arteriography procedures, their advantages and their risks and compare them to the results of duplex scanning: they admit that it is possible to do a carotid endarterectomy without preoperative arteriography. They define their indications but they are persuaded that arteriography is an excellent procedure and the rate of neurologic complications due to the technique is lower than 0.5%.

Aneurysms of the extracranial internal carotid artery due to fibromuscular dysplasia: results of surgical management.

Between January 1977 and December 1990, eight patients underwent surgical correction of aneurysms of the extracranial internal carotid artery due to fibromuscular dysplasia. Mean age of patients was 50 years (range 31 to 70 years). Five patients presented with neurologic hemispheric symptoms. Most aneurysms were saccular and occurred preferentially at the level of C2 or C3. All of these patients underwent operation through conventional cervicotomy. Resection-anastomosis was performed in three cases whereas resection-graft was performed in five. Histopathological examination of the eight specimens was consistent with fibromuscular dysplasia of the media. There was no central nervous system-related mortality and morbidity. Seven patients were alive and free of new neurological manifestations at mean follow-up of 156 months (18 to 180 months). One patient died of myocardial infarction at 96 months. All patients had postoperative duplex scanning or arteriograms. These revealed that carotid restorations were patent in seven whereas one patient had asymptomatic occlusion at 18 months.

[In situ bypasses in limb salvage. Late results and patency factors]. / Pontages in situ dans les sauvetages de membre. Résultats tardifs et facteurs de perméabilité.

One hundred limbs with critical ischemia (stages III and IV) were saved from 1983 to 1987 by in situ venous bypass at the lower femoropopliteal or femorotibial level. The average age of the patients was 66 (40-89) years. The surgical indication involved 51 cases of stage III ischemia and 49 of stage IV. The etiology of the ischemia was occlusive chronic arteritis (n = 67), diabetic arteritis (n = 20), embolic disease (n = 10) and aneurysmal disease (n = 3). The systolic pressure index in the ankle recovered an average value of 0.42 preoperatively. In 48 cases, the distal implantation of the graft was on the lower popliteal artery, and on the arteries of the leg in 52 cases. During the immediate postoperative period, 8 patients died and 13 underwent amputation. At 5 years, the limb salvage rate was 72%. The primary patency at 5 years, calculated with the actuarial method, was 51% and the secondary patency at 5 years was 62%. Among the factors likely to significantly influence patency, only the site of the lower anastomosis and the quality of the III and IV segments of the popliteal artery were selected (p less than 0.05), while the number of patent vessels in the leg and the clinical stage did not influence patency.

Long-term results of thrombectomy for late occlusions of aortofemoral bypass.

Sixty-two first episodes of aortofemoral (eight patients) or aortobifemoral (42 patients) bypass thrombosis were operated upon in 50 patients between 1980 and 1985. There were 47 men and three women whose mean age was 58 years. Retrograde thrombectomy through the distal anastomosis was achieved in all cases by using either a balloon catheter or Vollmar rings. If thrombectomy was impossible, revascularization was ensured by an extraanatomic bypass or complete replacement of the graft. Angioplasty, repeat distal anastomosis or femoropopliteal bypass of the native runoff artery were done in 55 (89%) operations. The cause of thrombosis was elucidated in 45 cases. Suture line stenosis and atheromatous stenosis of the native runoff artery were the two most common causes. Three patients died and two required above-knee amputation in the immediate postoperative period. Contralateral embolism occurred in two patients undergoing retrograde thrombectomy. Mean follow-up was 47 months. Thrombectomy was possible in 51 or 62 prosthetic thromboses (Group I). Thirty-nine of these grafts have remained patent. Twelve instances of repeat thrombosis occurred, requiring either repeat thrombectomy or a new bypass. Primary patency in group I was 97.8%, 81.2%, and 71.3% at one, three, and five years, respectively. Thrombectomy was impossible in 11 graft thromboses (Group II). A new bypass was performed in all 11 cases. Primary patency in Group II was 100%, 75% and 50% at one, three, and five years, respectively. Retrograde thrombectomy combined with treatment of native runoff artery anomalies can restore long-term patency when thrombosis occurs late after aortofemoral bypass and is associated with low mortality and morbidity.

[Popliteal vascular trauma: therapeutic management]. / Les traumatismes vasculaires poplités: attitude thérapeutique.

The functional severity of popliteal artery injury is intimately related to the direct consequences of tissue ischaemia increased by the associated traumatic attrition. The conservation of a functional limb requires: limitation of the duration and repercussions of ischaemia, by the use of a rigorous therapeutic protocol; "functional" surgical or even microsurgical reconstruction whose limits are still confused with the degree of traumatic myolysis and the potential of nervous recovery. Therefore, it seems obvious that the major difficulty lies in the definition of the limits for limb preservation.

Persistent proatlantal artery associated with carotid artery stenosis treatment by percutaneous transluminal balloon angioplasty.

A 58-year-old man had an asymptomatic tight stenosis of the internal carotid artery associated with a persistent proatlantal artery. This as well as other compositional arterial anomalies of the basilar artery were discovered on arteriograms. The stenosis was successfully treated by percutaneous transluminal balloon angioplasty. Therapeutic choices are discussed in this setting because of the risk of carotid clamping in the presence of persistent carotid-basilar anastomoses.

Aortoappendicular fistula after aortoiliac prosthetic replacement.

A 48-year-old patient who had had an aortofemoral reconstruction with a Dacron graft nine years earlier presented with intestinal bleeding. At laparotomy the cause was found to be a fistula between a proximal false aneurysm and the vermiform appendix. The patient recovered after removal of the graft and extraanatomic revascularization associated with appendectomy. Four other similar case reports have been found in the literature.

[Thrombectomy or thrombolysis in the treatment of proximal phlebitis. Functional long term results]. / Thrombectomie ou thrombolyse dans le traitement des phlébites proximales. Résultats fonctionnels à long terme.

MATERIALS AND METHODS Between 1981 and 1985, 78 iliocaval thrombi were treated by aggressive therapy: 52 surgical thrombectomies were performed by a femoral approach associated, depending on the case, with a caval approach; and 26 iliofemoral thrombi were lysed according to a protocol in which urokinase and plasminogen were used over a 48-h period. Subsequent functional evaluation was based on clinical scoring (0 to 9 points) taking into account functional impairment, edema and trophic disorders. Patency of trunks and the deep valvular state were assessed by Doppler examination and plethysmography. RESULTS In the surgical group, 3 early deaths occurred, only one of which could be attributed to an embolic course. Six weeks after surgery the rate of recurrence of iliac thrombosis was 50% (25% postoperative + 25% secondary). Beyond this period, there were no recurrences of thrombosis. There was a direct, statistically significant relation between the degree of iliac patency and the realization of an ideal thrombectomy on a nonadherent fresh clot. The functional results, assessed after four and a half years of follow-up, are satisfactory (score less than 3) in 80% of patients. The poor results with venous claudication or varicose ulcer all occurred in the case of massive persistent thrombi of the femoral confluence. Valve lesions were signaled in 46% of patients by a massive backflow in orthostatism. In the medical group, a major hemorrhagic complication occurred under urokinase therapy in 11% of patients, including one for whom it was fatal. Sixty percent of patients showed immediate radiological improvement allowing partial or total freeing of a venous confluence. The functional results after 4 years of follow-up were nondisabling in 85% of patients. No leg ulcers were detected. Late iliac patency was low (26%), whereas at the femoral level almost all of the thrombi which remained after lysis became patent again spontaneously. Valve failure was found in 37% of patients. Both groups had very similar late functional results despite rather different anatomical conditions. The iliac patency rate was higher in the surgical group (50% vs 26%), but plethysmographic study showed that in case of therapeutic failure devalvulation was greater after surgery (46% vs 37%).

[Value and strategy of paraclinical studies in the diagnosis of aneurysm of the abdominal aorta]. / Valeur et stratégie des examens paracliniques pour le diagnostic des anévrysmes de l'aorte abdominale.

With the development of abdominal echotomography and computed tomography, the abdominal aortic aneurysm is no longer explored by arteriography alone. After a retrospective review of 167 patients with aneurysms, the authors propose a schematic diagnostic procedure in 4 arms: positive diagnosis, extension evaluation, emergency statement and follow-up of the aneurysm. The expenditure with these tools has to be considered because of the large deviations in cost price between them. Arteriography is still selectively used for exploration of renal segment but it can often be replaced by computed tomography which is cheaper, external, simply and repeatedly used.

Per-operative uncontrollable bleeding at polyester (Dacron) arterial prosthesis implantation.

An aortobifemoral knitted polyester graft was placed in a 58-year-old woman with aorto-iliac occlusive disease. Although the prosthesis was preclotted in the usual manner, it never became impervious to blood under normal intra-arterial pressure. Examination of the graft showed lipid infiltration not ordinarily seen. We recommend that when a knitted prosthesis fails to preclot a woven graft should be used instead.

Intervertebral disk space infection following translumbar aortography.

After 1,748 translumbar aortograms three cases of intervertebral disk space infection were observed over a five-year period, for an incidence of 0.15%. Cultures suggested that the intervertebral disk had been inoculated with digestive tract organisms by the needle used to puncture the aorta. Diagnosis of this complication can be made early by retrieval of the responsible organisms from the intervertebral disk under CT control. Treatment consists of prolonged immobilization associated with appropriate antibiotic therapy for at least three months.

[Intentional normovolemic hemodilution in the medical treatment of lower limb arteritis]. / Hémodilution normovolémique intentionnelle dans le traitement médical de l'artérite des membres inférieurs.

Thirty patients suffering from arterial occlusive disease (stages II, III or IV of Fontaine's classification) were treated by isovolaemic haemodilution (IDH). Most of these patients received conventional medical treatment without success (negative selection). Angiography was performed on all patients prior to treatment. 500 ml of whole blood was withdrawn from each patient. 250 ml of dextran 40 mixed with 250 ml of 5% albumin solution was injected intravenously to avoid hypovolaemia. This procedure, carried out three or four times, was repeated until a haematocrit of 0.30 was reached. This haematocrit level of 0.30-0.35 was maintained for 60 days. The measurement of ankle systolic pressure, systolic index at rest, treadmill performance and lower limb thallium-201 muscular scintigraphy were used to assess laboratory efficiency. On the sixtieth day, 14 patients (46%) showed clinical improvement, nine were stable and arterial occlusive disease worsened in seven patients. Clinical improvement persisted for several months (15 months in one case). Clinically, it seemed that patients treated by IHD showed improvement of their arterial occlusive disease. However, the prediction of the chances of success of IHD, as well as the quantification of results by common laboratory examination, were difficult. Muscular scintigraphy with thallium-201 gave a good assessment as well as a quantifiable analysis of results.

[Vascular injuries associated with osteoarticular lesions of the lower extremities]. / Les traumatismes vasculaires associés à des lésions ostéo-articulaires des membres inférieurs.

The authors report 38 observations of vascular traumatisms associated to osteo-articular lesions of lower members cured by restorative treatment. The authors define a diagnostic and therapeutic line of conduct. They insisted upon the necessity of early diagnosis of vascular lesion, based on ultrasonic exploration of vessels as soon as the patient was admitted to hospital. Restoration must be considered from a global point of view in taking into account the state of integuments , the type of selected osseous restoration, the vascular approach and the possible necessity of aponeurotomy . The importance of vascular lesion and the slowness of circulation restoration induced the results of the treatment, the major risks of which were infection and metabolic lesion of the kidney. In 18% of the cases amputation was necessary.

[Bone and skin vascularization of the lower 4th of the leg]. / Vascularisation osseuse et cutanée du quart inférieur de jambe.

The authors have studied the vascular network of bone and skin in the lower third of the leg by injection of methyl methacrylate in 31 cadavers. The vascular supply of the bone is given by metaphyseal and epiphyseal arteries branching from the main trunks. Different types of vascular network are described. The vascular supply of the skin is given by a subaponeurotic plexus with branches crossing in areas which can be considered as radiating vascular hili. These hili should be preserved during surgical operations. Conclusions are given concerning the security of the surgical approaches at the lower third of the leg.