Assessment of cardiac risk before aortic reconstruction: noninvasive work-up using clinical examination, exercise testing, and dobutamine stress echocardiography versus routine coronary arteriography.

In this prospective study we evaluated the efficacy of a battery of noninvasive tests including clinical evaluation (CE), exercise testing (ET), and dobutamine stress echocardiography (DSE) for assessment of cardiac risk in 90 patients indicated for aortic reconstruction. As the gold-standard reference technique, coronary arteriography was performed in each patient after noninvasive evaluation. The sensitivity of CE was low (61%). ET proved to be more sensitive (71.4%) and highly specific (95.8%) but feasibility (77%) and diagnostic accuracy (42%) were low. DSE demonstrated acceptable sensitivity (78%) and specificity (75.5%) with high feasibility (94.5%) and diagnostic accuracy (100%). None of the four patients with false negative ET results and only one of seven with false-negative DSE required coronary bypass. On the basis of these findings we conclude that a combination of CE and ET with DES, if necessary, can reliably assess cardiac risk before aortic reconstruction. Noninvasive assessment is a reliable alternative to routine coronary arteriography.

[Angioplasty of renal artery stenoses before surgical treatment of subrenal abdominal aortic lesions]. / Angioplastie des sténoses de l'artère rénale avant traitement chirurgical de lésions aortiques abdominales sous-rénales.

PURPOSE: To evaluate the results of the association of a percutaneous transluminal renal angioplasty before a surgical revascularization of the infra-renal aorta. PATIENTS AND METHODS: Percutaneous transluminal angioplasty of one (n = 12) or two (n = 2) renal arteries have been performed in 14 patients (11 hypertensive and one with azotemia), 2 to 240 days (mean 54) before infra-renal aortic surgery (aneurysms: 8, occlusive disease: 6). RESULTS: 15 of the 16 dilatations were completely technically successful (residual stenosis less than 20%), with one groin hematoma treated medically. Mean duration of the surgical intervention were 137 minutes (occlusive disease) and 147 minutes (aneurysm). In the post-operative course were noted resolutive infections in two patients, and one death because of myocardial infarction. At the end of the follow-up (3 to 60 months, mean 32), all of the 13 patients alive had improved in terms of vascular disease. Hypertension was improved for 2 patients, stable for 10, worse for 1. Creatinine serum level was stable for 12 patients, and the renal insufficient was worsened. CONCLUSION: Combined percutaneous transluminal renal angioplasty and aortic revascularization seems to be reliable and safe; it can be an alternative to a simultaneous aortic and renal revascularization, notably for high-risk patients.

[Spontaneous remission of renal artery stenosis]. / Régression spontanée d'une sténose de l'artère rénale.

Retrogression of a renal artery stenosis after a six months follow-up is reported in a 43 years old woman who stopped smoking after the first angiography and was treated with antiplatelet, suggesting spontaneous atherosclerosis injury revision.

[Evaluation of the analgesic effect of naftidrofuryl in permanent ischemia in patients with arterial diseases. Double-blind versus placebo study]. / Evaluation de l'effet antalgique du naftidrofuryl dans l'ischémie permanente chez l'artériopathe. Etude double-aveugle contre placebo.

Ischemic rest pain, with or without trophic disorders and occurring very frequently at night, is responsible for insomnia and complications such as positional oedema. The pathophysiological mechanisms underlying the analgesic effect of naftidrofuryl led us to evaluate the efficacy of this treatment. 37 selected patients were given 2 daily infusions of 400 mg of naftidrofuryl for 8 days, under double-blind conditions. Evaluation criteria were pain assessment using a visual analogue scale, analgesic consumption considering both the power (WHO scale: level I paracetamol, level II dextropropoxyphene, level III morphine) and the dosage of the analgesic used (analgesic score), index of therapeutic success including the level of pain reduction and the absence of analgesic use. The results showed a significant difference in favour of naftidrofuryl for: reduction of pain, difference in the course of the analgesic score, the distribution of the population according to the index of therapeutic success. Three patients discontinued treatment due to inefficacy, but all 3 belonged to the placebo group. This study demonstrates the benefit of naftidrofuryl in pain reduction which was assessed, in particular, by the reduction of analgesic consumption.

Local fibrinolysis for superior mesenteric artery thromboembolism.

A 66-year-old man with atrial fibrillation was referred soon after developing left lower limb and abdominal pain with rectal bleeding. An immediate flush aortogram showed embolic occlusion of the left distal superficial femoral artery and superior mesenteric artery (SMA), 3 cm from its ostium. Recombinant tissue plasminogen activator (rtPA) 40 mg was selectively instilled in the SMA in two boluses. Abdominal symptoms resolved within 48 h, and complete recanalization of the SMA was shown on angiography. Exploratory laparotomy after 72 h showed a normal small bowel and right colon, and was completed by femoropopliteal embolectomy. Six months later, the patient remained asymptomatic.

[Percutaneous transluminal angioplasty of subclavian, axillary and brachiocephalic trunk arteries. Apropos of 18 patients]. / Angioplastie transluminale percutanée des artères sous-clavière, axillaire et du tronc artériel brachiocéphalique. A propos de 18 patients.

The authors report the immediate and mid term results of percutaneous transluminal angioplasty of stenosis of the subclavian (16 cases), brachiocephalic (1 case) and axillary arteries (1 case) in a series of 18 patients. These lesions were responsible for isolated ischaemia of the arm in 6 cases, vertebrobasilar insufficiency in 6 cases and an association of the two presentations in 2 cases; in 4 asymptomatic patients, the procedure was undertaken to maintain cerebral perfusion. A technical success was obtained in all cases, with one femoral haematoma and one episode of transient visual disturbance, which were spontaneously regressive, as the only complications. The good results were sustained clinically at the end of follow-up (4 to 40 months, average 17.7 months) in 13 of the 14 patients who were followed up. The symptoms recurred after 26 months in the final case which led to the diagnosis of restenosis which was successfully redilated.

[Study of the supra-aortic trunks using the humeral Seldinger technique and digitalized angiography of the aortic arch. Apropos of 175 cases]. / Exploration des troncs supra-aortiques par Seldinger huméral et crossographie numérisée. A propos de 175 cas.

Screening of cerebrovascular disease by transbranchial arch injection. One hundred and seventy five patients underwent non selective intra arterial digital subtraction angiography using a transbranchial approach. Unilateral failure occurred in eight patients, but contralateral approach was then possible. Transient cerebral ischaemia affected one patient. Seven locoregional complications occurred, five of them underwent among the seventy three first procedures. Experience of the examining radiologist, duration of procedure and diameter of the catheter (4 or 5 F) are essential safety factors. Three false-negative and one false-positive in carotid bifurcations appears with surgical results reviews. This safe and efficient technique is often sufficient for a therapeutic decision, especially for surgery, but, in a few cases, additional selective injections can be necessary. Possible in out patients, this approach is chosen when femoral artery catheterization is impossible, or before reconstructive aorto-ilio-femoral surgery, to decrease septic risk.

Type IV Ehlers-Danlos syndrome with isolated arterial involvement.

Ehlers-Danlos syndrome is a connective tissue disorder characterized by skin hyperelasticity and friability, hyperextensible small articulations, vascular fragility, and ocular and visceral symptoms. Ten types of Ehlers-Danlos syndrome have been described to date. Type IV is characterized by isolated arterial involvement with the risk of rupture, making diagnosis difficult. A 25-year-old man was operated on for a ruptured left and then right iliac artery and once again for a hepatic artery aneurysm within a nine month period. The diagnosis of Ehlers-Danlos syndrome was based on clinical and histopathologic findings. An asymptomatic iliac artery aneurysm was found in the patient's 23-year-old brother.

Aseptic periprosthetic fluid collection: a late complication of Dacron arterial bypass.

Fluid collection encompassing an arterial prosthesis often leads one to suspect graft infection. Four cases of aseptic seroma occurring three to five years after insertion of knitted Dacron implants for bypass are reported. The collection was serohematic in three cases, puriform in the other. Repeated bacteriological investigations did not reveal any growth and laboratory tests did not demonstrate any signs of infection. The following pathophysiologic hypotheses have been advanced: modification of the permeability of the prosthetic wall, immunoallergic reaction to the graft, and aging hematoma. The role played by anticoagulant is debatable. Management by needle aspiration or drainage failed. Multiple recurrences led to prosthetic replacement in three cases. Treatment consists of replacing the graft by one of a different fabric. These collections must be distinguished from postoperative lymphoceles, anastomotic false aneurysms, hematomas and infections.

[Aneurysms of the abdominal aorta. Fissures in the vena cava. Apropos of 4 cases]. / Anévrismes de l'aorte abdominale. Fissures dans la veine cave. A propos de 4 cas.

Four cases of aortico-caval fistulae of atheromatous origin have been treated over a period of 5 years, a frequency (4.8%) much higher than that reported in the international literature. Diagnosis in each of these 4 cases was suggested by clinical features associating signs of a complicated aneurysm with those of a high-output arteriovenous fistula, angiography showing the arteriovenous communication in one patient only. Treatment of choice is by graft to aneurysm sac and suturing of fistula by an endosaccular approach. Prognosis is much more favorable (mortality 25%) than that of rupture into the free peritoneum (mortality 77,4%).

[White thrombus syndrome. Apropos of 4 new cases]. / Le syndrome du caillot blanc. A propos de 4 nouveaux cas.

Four new cases of the white thrombus syndrome have been treated over the last 3 years. This is a rare but serious complication of heparin therapy, multifocal arterial thrombi developing in all three patients without signs of a hemorrhagic syndrome due to the thrombopenia. Physiopathologic mechanisms of this immunity phenomenon are discussed. The diagnosis should be evoked in all patients receiving heparin who on about the 10th day present vascular manifestations of the thrombosis type, rarely in association with a hemorrhage. Blood platelet levels are reduced to below 5000/mm3. Confirmation of diagnosis is by positive results of hematologic and immunologic tests. Treatment involves immediate cessation of heparin and administration of anti-platelet aggregation agents and anti-vitamins K or low molecular weight heparin, combined with arterial thrombectomy or prevention of pulmonary emboli.

[Bullet wounds of the carotid axis. Apropos of 4 cases]. / Plaies par balle de l'axe carotidien. A propos de 4 cas.

In three cases, there was an injury of primary carotid artery, and in one case a wound of bifurcation with a large destruction of vessels. In one, there was an A.V. fistula as shoot by the pre of angiogram. Only one patient was in light coma with right hemiplegia and aphasia. Repair was done with a simple suture in one, with a resection and a suture in an other. In two cases an inversed venous grafting was done. In all 4 cases results were satisfactory without any neurologic sequellae.

[Long-term result of the surgical treatment of funnel chest by Jung's method. Apropos of 32 cases]. / Résultat à distance du traitement chirurgical du thorax en entonnoir par la méthode de Jung. A propos de 32 cas.

A homogeneous series of 32 cases of pectus excavatum were treated by Jung's method of reversal of the breast-plate pedicle. Operation was usually performed at about puberty. The mortality is nill for this technique, which is simple and which, for a low morbidity, provides good functional and esthetic results in 87% of cases. Follow up examinations after 4 to 18 years in 26 patients showed maintenance of results and the absence of any case of recurrence. This confirms the pathogenic hypothesis suggested by the authors in 1972. By performing a true laparoplasty in addition to the sternum reversal, this operation corrects disorders of ventilatory mechanics at the origin of the deformity.

[Long-term results of reversed venous femoro-popliteal bypass. Apropos of 151 cases]. / Résultats a long terme des pontages veineux inversés fémoro-poplités. A propos de 151 cas.

Of 151 inversed autogenous vein grafting done in 137 patients for femoro-popliteal disease, 97 (65%) have been done for severe ischemia (rest pain or gangrene); others (35%) have been done for severe walking pain or popliteal and/or femoro-popliteal aneurysms. The follow-up is of 13 years. Hospital mortality was 5 (3,3%). Early failure is of 6%. Patency rate at 5 years is 60% and at 10 years 46%. The lower the anastomosis is done on the popliteal artery the better is the long-term patency rate. The worst results are in diabetic and younger patients. Technic of in situ vein grafting would have not allowed 26% of patients venous revascularization because of the poor condition of the saphenous vein, that the inversed technic permitted (on using internal + external saphenous, resection-suture, etc).

[Abdominal aortic aneurysm due to Salmonella. Apropos of a rupture case treated surgically with an in situ prosthesis]. / Anévrysme a salmonelle de l'aorte abdominale. A propos d'un cas rompu, guéri chirurgicalement par mise à plat-greffe in situ.

A patient with ruptured aneurysm of the infrarenal abdominal aorta was treated by reestablishing arterial continuity, by means of a prosthesis in situ, and has been followed up for 16 months. This type of lesion raises difficulties with respect to surgical strategy, conventional treatment consisting of total resection of sac with infrarenal ligature of abdominal aorta combined with revascularization by extra-anatomic bypass surgery. Results in the case reported were positive and demonstrate that the operation performed may be a valid alternative if, after effective long-term antibiotic therapy, findings on clinical, biologic and ultrasound follow-up reviews remain normal.

[2 cases of uretero-arterial fistula]. / Deux cas de fistules urétéro-artérielles.

Two cases of uretero-arterial fistulas are reported occurring in two patients after pelvic exenteration for cancer with cutaneous ureterostomy. In the first case a pelvic irradiation has been performed before surgery; in the other case a high degree of atherosclerosis was noted. Iliac artery-ureteral fistulas are uncommon and they are generally associated with several underlying pathogenic factors such as: arterial pathology, surgical complications, septis, prior x-ray therapy. It is not doubtfull that the use of a long term ureteral stenting contribute to the development of the fistula. The constant pulsation of the artery transmitted through the ureteral and the arterial wall to a stiff intraluminal stent produces a necrosis then a fistula between them. Retrograde uretero-pyelography seems the better diagnostic test. Treatment of these fistulas is always complex because operation should manage both vascular and ureteral injuries. Embolisation is a less invasive method of treatment but it needs a particular technics. Prognosis of such fistulas is poor and some precautions should be taken to prevent these accidents. When ureteral catheterization is needed for a long term one should assess the arterial conditions and during an operation catheterized ureter should be put far from the artery or an attempt for an epiplooplasty should be performed.

[Aneurysms of the subrenal abdominal aorta. Apropos of 115 cases]. / Anévrismes de l'aorte abdominale sous-rénale. A propos de 115 cas.

115 of infra renal abdominal aorta have been operated upon between 1969 and 1984. 107 male patients (93%) and 8 female (7%) were treated. Age was 65.5. Associated high blood pressure was found in 43%, smoking in 74% and coronary disease in 20.5%. Non ruptured aneurysms were 84 (73%) and diagnosis was made chiefly in ischemia of lower limbs, ruptured were 31 (27%). 4 fistulas between aorta and lower vena cava were found at surgery. Aortograms have not been done in every case, even for non ruptured aneurysms, as 19 patients have been operated without (22.6% of non ruptured aneurysms). Ultrasonography have been done in 37. Among 84 patients with non ruptured aneurysm, 6 were not operated, 2 got only palliative surgery for rest pain, and 76 (85.7%) underwent resection and grafting. 31 patients were operated when ruptured. Post operative mortality for non ruptured aneurysms was of 2 (2.63%) for resection and grafting. It was of 24 (77.4%) if ruptured. Follow-up study shows that at a five years range 62.7% of surviving operated patients are alive. Authors point out that lower limbs ischemia is still often a revealing symptom. Post operative colic ischemia is rare.

[Results of 68 revascularizations of the arteries of the leg]. / Résultat de 68 revascularisations des artères de jambe.

Results with 68 infra popliteal revascularization inversed autogenous grafts are subjected to life table analysis. The patency rate at 1, 3 and 5 years are 63.8%, 53.5% and 43.7%. This procedure allowed limb salvage in 78.5% (13 years follow up).