Venous allografts preserved at 4 degrees C for infrainguinal bypass: long-term results from 170 procedures.

From April 21, 1982 to December 31, 1997, we performed 170 infrainguinal bypass procedures using isolated (n = 35) or composite (n = 135) venous allografts preserved at 4 degrees C as a substitute for saphenous autografts in 146 patients. The mean age of the patient population was 74 years. The indication was critical lower limb ischemia in 71% of cases. Seventy-five percent of procedures were below the knee and 26% were infrapopliteal. Mean length and diameter were 19.5 +/- 0.5 cm and 4.8 +/- 0.5 mm, respectively. After December 8, 1993, a reinforcement net was placed over the graft to prevent expansion in 71% of cases. Primary and secondary 5-year patency, calculated according to the Kaplan-Meier method, were 33 +/- 6% and 43 +/- 6%, respectively. Factors correlated with secondary patency were studied using the log-rank test. Previous ipsilateral infrainguinal revascularization was associated with a 40% decrease in secondary patency at 2 years (71% vs. 31%). Patency at 5 years was correlated with the level of anastomosis (47% for low popliteal anastomosis vs. 30% for infrapopliteal anastomosis). The likelihood of stenosis or dilatation of the allograft was 8% and 29.5%, respectively, at 5 years. The 5-year limb salvage and survival rates were 84% and 57%, respectively. The encouraging results of this series suggest that venous allografts provide a useful alternative for infrainguinal bypass when autologous grafts or other more reliable conduits are unavailable.

-Emergency surgical treatment of acute carotid occlusion-. / Traitement chirurgical d'urgence des occlusions carotidiennes aiguës.

Conservative medical treatment of acute occlusion of the extracranial internal carotid artery usually gives mediocre results. When a major neurological deficit is involved, mortality can reach 16 to 55%, morbidity due to definitive deficit 40 to 69% and cure only 2 to 12%. It is thus logical to attempt revascularization as an emergency procedure. In situ intraarterial fibrinolysis is appropriate for acute occlusion in the intracranial territory of the internal carotid involving severe neurological deficits but surgery is more adapted and safer for acute occlusion of the extra-cranial internal carotid. In a personal series of 8 patients, we had 1 death, 1 aggravation, 1 improvement and 5 "cures" (62.5%). Based on data in the literature and our experience, we assessed the advantages of emergency surgery (immediate and definitive re-establishment of the carotid flow and vascularization of the hemisphere before installation of irreversible brain damage) and conditions suggesting chances of success: 1) diagnosis by noninvasive echo-Doppler of the cervical vessels and transcranial Dopler, without preoperative arteriography or CT-scan. 2) operation before 6 hours, 3) quality of the desobstruction, 4) no post-operative anti-coagulant treatment, 5) control of post-operative episodes of hypertension.

The role of intraoperative transcranial Doppler monitoring in carotid artery surgery.

Of 135 carotid artery reconstructions performed under general anesthesia in 127 patients (mean age 68 years), 119 were performed with continuous intraoperative Doppler recording of the middle cerebral artery. This investigation was impossible in nine (6.7%) cases because of the absence of a visible temporal window, and results were deemed uninterpretable in six (4.5%) additional cases. The goals of this study were to test the feasibility and reliability of transcranial Doppler monitoring in the evaluation of intracranial perfusion and to determine the risk of cerebral ischemia during carotid artery clamping. The two outcome parameters measured were mean velocity and percentage of decreased flow in the middle cerebral artery during clamping. Patients were divided into four groups based on variations in these parameters. Groups I and IIA (low risk) represented 69.7% of cases, group IIB (significant risk) represented 21.9%, and group III (major risk) represented 8.4%. Transcranial Doppler monitoring appears to be a reliable means of observing middle cerebral artery flow during carotid surgery and in our opinion provides objective criteria for determining the need for an indwelling shunt. Accordingly, in this study no neurologic complications imputable to clamping were observed. Transcranial Doppler monitoring can also be used to ensure correct functioning of the shunt and to detect intraoperative embolic complications.

[Aneurysmal iliac lymphangiomyoma. Report of a case]. / Lymphangiomyome iliaque à forme anévrysmale. A propos d'un cas.

Single lymphangiomyoma, rarely encountered, is a form of lymphangiomyomatosis with characteristic proliferation of smooth muscle cells in lymph nodes and vessels. We observed a case in a 47-year-old woman with no past medical history. An echography performed for menorrhage revealed a single iliac localization in the right pelvis. The precise pre-operative diagnosis was difficult, but the pathology report formally identified the tumor as an isolated form without thoracic involvement. Unlike lymphangiomatosis itself which involves pulmonary lesions and which may require complementary treatment, total exeresis of a single tumour is the only treatment necessary, as was confirmed in this case.