The femoro-femoral cross-over bypass.

From 1984 to 1990 64 patients (56 men and 8 women) with a mean age of 67.1 years (36-88 yrs.) were treated with a femoro-femoral cross-over bypass (45 primary and 19 secondary procedures). All patients had an occlusion of one iliac artery. In 26 patients there were factors that made a central reconstruction unattractive. These disorders were congestive heart failure, COPD, CVA, an age over 80 years, etc. In 19 patients an occlusion of one leg of a former aortobifemoral bypass determined the choice for cross-over bypass. Three patients died (5 per cent), two patients of the so-called redo-group (septicaemia, one patient and arteriojejunal fistula one patient), the third patient died after a primary femoro-femoral bypass (myocardial infarction). The overall patency rate after three years was 78 per cent. Especially primary cross-over bypasses showed a good outcome with a primary patency of 80 per cent and a secondary patency of 85 per cent after three years. Considering that 23 of the 45 (51 per cent) primary procedures were for treatment of critical ischaemia (stage III and IV of Fontaine), a favourable limb-salvage of 21 out of 23 (91 per cent) was obtained. The cross-over bypass can be recommended as first choice therapy for patients with a unilateral iliac artery occlusion.

[Spontaneous pneumothorax; to operate or not?]. / De spontane pneumothorax; opereren of niet?

Disagreement remains on the best mode of therapy for spontaneous pneumothorax (SP). Treatment options vary from observation alone to thoracotomy depending on the stage of the disease and the preference of the physician. Between 1983 and 1988, 122 patients with SP were treated at the Elisabeth Hospital Tilburg according to a fixed protocol. Of these patients 86 (68%) were primarily treated with observation alone or with intercostal tubes. Seven of these patients (8%) had to be treated surgically after failure of the primary treatment. After thoracoscopical selection and in case of recurrent disease 39 patients underwent surgery: apical pleurectomy and bullectomy, in most cases by the transaxillary approach. In this group morbidity was minimal and there were no recurrences. We conclude that for most patients with spontaneous pneumothorax non-surgical therapy is the therapy of first choice.

Ascites after pleuroperitoneal shunting.

If conventional therapy fails in patients with intractable malignant pleural effusion, the pleuroperitoneal shunt is a valuable alternative. In a 59-year-old man with disabling malignant pleural effusion, massive ascites developed shortly after insertion of a pleuroperitoneal shunt. This shunt was replaced by a pleurovenous shunt. The ascites disappeared, and pleural effusion did not recur. The patient died 6 months later.

PTFE versus human umbilical vein in above knee femoro-popliteal bypass. Early results of a randomized clinical trial.

The results of a prospective randomized clinical trial comparing PTFE and HUV grafts in above knee femoro-popliteal reconstruction are presented. A total of 93 limbs were randomized, three patients died in the early postoperative period, leaving 90 (45 PTFE and 45 HUV bypasses) to be analysed. During 18 months of follow-up only 3 HUV grafts occluded in contrast to 15 occluded PTFE grafts. After one year patency rates for HUV were 90% versus 67% for PTFE grafts, after 18 months 86% and 63% respectively. From one year postoperatively onwards these results are statistically and significantly different. When an above knee femoro-popliteal reconstruction is performed and autologous vein is not available or purposely not used, HUV gives better results than PTFE and is the graft of choice.

Intramedullary fixation of fracture of the sternum.

A case of fracture of the sternum in a patient suffering from osteogenesis imperfecta is presented. Internal fixation was carried out using a plate which was placed within the medulla. The described technique is simple and useful for the rarely indicated operative treatment of fractures of the sternum.

Semi-closed thromboendarterectomy of the femoro-popliteal artery (results of 142 consecutive cases, 5 years after operation).

Semi-closed thromboendarterectomy with the aid of a ring stripper appears not yet to have been abandoned as a method of reconstruction in occlusions in the femoro-popliteal tract. In a series of 142 operations, 5 years postoperatively, 44% of the stripped vascular tracts were still patent and 41% were occluded. Eighteen patients, in whom 20 operations had been performed, had died less than 5 years after the operation. The surgical mortality rate was 0%. There is no significant difference between the results of the operations performed because of Fontaine stages II and III. The incidence of recurrent occlusion was not demonstrably influenced by diabetes mellitus, or by continuation versus cessation of smoking after the operation. A review is presented of the results of semi-closed thromboendarterectomy, open-thromboendarterectomy and venous bypass as reported in the literature.