Embolization of hypogastric artery aneurysm: 17 cases.

Surgical management of hypogastric artery aneurysm is associated with high morbidity due to hemorrhage and ischemia. Occlusion by embolization is an attractive alternative treatment. Between 1991 and 1995, we used Gianturco coils to embolize 17 hypogastric aneurysms in 14 patients. All patients were men with a mean age of 77 years. Ten patients had previously undergone aortic repair. Complete occlusion of the aneurysm was achieved in 16 cases but placement of an iliac stent was required in 1 case. Embolization failed in one case involving rupture of a large aneurysm. No complications were observed. Moderate buttock claudication was noted after bilateral embolization in three cases. Embolization of hypogastric artery aneurysm using coils resolves the long-term problems associated with surgical ligation. Extensive aneurysm of the origin to the bifurcation is the main indication for nonresective treatment but embolization can also be a useful alternative to open surgery for high-risk patients. Availability of stent grafts may extend the indication for endovascular treatment.

Endovascular treatment of iliac aneurysms with covered stents.

The purpose of this retrospective, single-institution study was to analyze the results of endovascular treatment of iliac aneurysm using covered stents. Since January 1, 1996, a total of 34 iliac aneurysms have been treated with covered endovascular stents. The series included 9 isolated aneurysms, 29 aneurysms following repair of aortic aneurysm, and 3 false anastomotic aneurysms. The mean diameter of aneurysm was 42 mm (range, 21 to 120 mm). The aneurysm was either symptomatic or complicated in 11 cases. Three procedures were carried out under emergency conditions after acute rupture. Stent deployment was successful in 33 cases (technical success rate, 97.6%). Exclusion of the aneurysm was obtained in all cases with one (n = 26) or two overlapping (n = 7) covered stents. Mean procedure duration was 45 min (range, 25 to 75 min). The internal iliac artery was patent in 28 cases, but patency was preserved in only 4 cases. In the remaining 24 cases the internal iliac artery was excluded either preoperatively by embolization using Gianturco coils (n = 15) or intraoperatively by placement of the stent (n = 9). Endovascular treatment of iliac aneurysm with covered stents achieves good short- and middle-term results but usually requires exclusion of the internal iliac artery.

The Erasme study: a multicenter study on the safety and technical results of the Palmaz stent used for the treatment of atherosclerotic ostial renal artery stenosis.

PURPOSE: To assess, in a multicenter setting, safety, technical results, and restenosis rate of the Palmaz stent for treatment of atherosclerotic ostial renal artery stenosis. METHODS: Ten centers enrolled 106 patients (120 treated renal artery stenoses) in the study. Patient selection was based on unsuccessful percutaneous transluminal renal angioplasty (residual stenosis >/= 20%) performed for treatment of ostial stenosis >/= 50%, in patients with hypertension and/or impaired renal function. Safety was assessed by means of the complication rate, and technical results by the number of successful stent placements and occurrence of restenosis (>50%) at intraarterial angiographic follow-up. RESULTS: Stent placement was successful (n = 112) or partially successful (n = 5) in 117 (98%) arteries. Complications occurred in 19 procedures; seven were of serious clinical significance. Angiographic follow-up was performed in 89 of 117 (76%) cases, at a mean of 8 months (range 2. 5-18 months). Fifteen stents (16.9%) showed restenosis (at a mean of 8.5 months), of which 10 were successfully redilated. CONCLUSION: Renal artery stenting has a high technical success rate, a complication rate comparable to percutaneous transluminal renal angioplasty, and a low rate of restenosis at 8 months angiographic follow-up.

[Forensic medical implications of vascular punctures and catheterization and radiologic procedures with diagnostic or therapeutic purpose]. / Implications médico-légales des ponctions et cathétérismes vasculaires et des procédés radiologiques à visées diagnostique ou thérapeutique.

Whatever the aim of the procedure, puncture of a vessel can lead to local complications. Access to the artery carries a risk of hemorrhage, occlusion, stenosis, arteriovenous fistulization or pseudo-aneurysm. The same types of complications can occur in veins. Other complications include skin necrosis due to extravasation of the contrast medium, perforation of the superior vena cava after insertion of an infusion catheter and the risk of pericardial effusion. General complications occur immediately, usually caused by contrast media, or late. There are different examples of secondary legal procedures following punctures involving, with the exception of radiology cases, intraarterial injection at the elbow, perforation of the right atrium by a jugular catheter and acute ischemia of the foot after catheterization of the pedial artery. Legal procedures after radiological procedures were discussed in more detail. The personal experience of the authors and others concerns accidents occurring after arteriography, angioplasty or embolization. Finally, two legal cases after treatment for impotency are analyzed. We focus on a certain number of rules on patient information, preangiography consultation, participation of an anesthetist, careful post-operative follow-up and operation report. Finally, the possibility of radiation-induced arteriopathy is demonstrated by one case reported here.

[Emboligenic aortopathies. Cholesterol embolisms: surgical treatment]. / Aortopathies emboligènes. embolies de cholesterol: traitement chirurgical.

Emboligenic aortopathies are defined as lesions of the aortic wall leading to the production of thromboatheromatous material which can migrate in fragments or entirely. Emboligenic aortopathy can occur in all parts of the aorta. Localized lesions are rare and usually involve the subrenal abdominal aorta or the isthma. Diffuse lesions involving several segments of the aorta are encountered more often. There are three anatomic types of lesions: ulcerated plaques, atheromatous ulcerations, an evrysmal disease of the aorta. Therapeutic indications depend on: 1) clinical presentation: fibrinocruoric emboli, distal microemboli, disseminated cholesterol emboli; 2) the unique or multiple nature of the emboli; 3) the anatomic lesion; 4) localization.

[Prevalence of anatomic renal artery stenosis in hypertensive patients with arteritis]. / Prévalence des sténoses anatomiques des artères rénales chez les hypertendus artéritiques.

Atherosclerosis is a diffuse disease that can affect renal arteries. An important point for the management of hypertensive patients is the prevalence of anatomical renal stenosis when lower-limb peripheral vascular disease coexists with hypertension. From Sept 1, 1987, to Aug 31, 1990, 252 consecutive hypertensive adults with peripheral vascular disease were referred to our clinic. For each patient a standardised collection of information was checked and registered with a computerised system. The evaluation included the search for a curable cause of hypertension, the investigation of cardiovascular risk factors, and a complete clinical review. Peripheral vascular disease was confirmed at least by clinical observation, including and ankle/brachial systolic blood pressure ratio of less than 0.90 at rest. In 117 patients (73 males, 44 females, mean age 66), renal arteriography was performed because clinical history, initial diagnostic work-up, or duplex Doppler examination suggested renal artery stenosis. Finally, 89 anatomical renal artery stenoses were detected in 64 patients (54.7%). Stenosis was judged mild (25 to 50%) in 12 patients and severe (> 50%) in 52 patients including 5 occlusions of the renal arteries. Artery stenosis was found bilateral in 23 patients. Even if none patient without renal arteriography would have an anatomical renal artery stenosis, the prevalence of anatomical renal stenosis in this study would reach 25.4% (64/252). These results confirm that lower-limb peripheral vascular disease is an excellent marker for the presence of anatomical artery renal stenosis in hypertensive patients.

[The diabetic foot: prognosis in a series of 75 patients]. / Le pied diabétique: pronostic dans une série de 75 patients.

Prognosis for 75 diabetic patients with foot ulcers. The aim of the study was to evaluate the prognosis regarding amputation and mortality in 75 consecutively presenting diabetic patients admitted because of foot ulcers. Median follow-up was 16 months. The amputation rate was 69% but only 4 major amputations were done. The mortality rate was 10.6%. Peripheral vascular disease was present in 69 patients. These finding stress the poor short-term prognosis of diabetic patients with foot ulcers and peripheral vascular disease.

[Treatment of diabetic arteriopathy. Importance of transluminal angioplasty]. / Le traitement des artériopathies diabétiques. Intérêt de l'angioplastie transluminale.

Results are reported of a retrospective analysis of transluminal angioplasty (TLA) interventions in 20 diabetic patients, 16 men and 4 women, mean age 56 years (range 32 to 82 years), with 24 dilated lesions, 16 patients having insulin-dependent diabetes. In 12 cases the lesions were at the intermittent claudication stage, trophic lesions being present in 8 cases. Stenotic lesions were iliac (12 cases), superficial femoral (2 cases), popliteal (6 cases) and tibial (4 cases). One patient developed an acute occlusion following popliteal-anterior tibial recanalization, the only direct complication of the angioplasty. Angiography showed immediate satisfactory results in 22 of the 24 dilated lesions. Functional and hemodynamic improvement was a constant finding in patients with intermittent claudication, trophic lesions being healed in 4 cases (50%) the other patient showing either no change or requiring an unavoidable amputation (2 cases). These overall findings suggest that at the intermittent claudication stage no differences exist in the results of TLA when compared with a non diabetic population; inversely, in the presence of trophic disorders, the local conditions (distal bed, infection, gangrene) interfere considerably in the course of the dilatation. Transluminal angioplasty should therefore be carried out as early as possible in diabetics; arteriography should be performed as soon as even minimal claudication appears and, a fortiori, even at the onset of a trophic lesion.

[Takayasu's disease. Exploration by intra-arterial digital angiography. 50 cases]. / Maladie de Takayasu. Exploration par angiographie numérisée intra-artérielle. 50 observations.

The long-term prognosis of Takayasu's disease depends on an elective surgical treatment which requires full and accurate assessment of the lesions. We present here a retrospective study of 50 patients explored before surgery by intra-arterial digital angiography. In 92 percent of the patients the thoraco-abdominal aorta and its branches were well documented on 2 orthogonal projections performed in one single session. The high-quality intra-arterial opacification made it possible to detect incipient parietal lesions and to evaluate the lesions of the small caliber branches and the downstream bed in case of occlusion. These advantages, and the absence of morbidity in our experience, make digital panarteriography a method of choice to evaluate Takayasu's disease.

[Thrombosis of renal veins]. / Thromboses des veines rénales.

According to whether they are acute or progressive, complete or partial, uni- or bilateral, renal venous thromboses have quite various clinical expressions and biological consequences. The diagnosis is readily suggested by acute pain in the side with an increase in the size of one or both kidneys, associated with hematuria, proteinuria, or in case of renal failure, which is characteristic of acute bilateral thrombosis. On the other hand, chronic thrombosis of a renal vein is sometimes suggested only when complications such as pulmonary embolism occur. This explain why it is often discovered on autopsy. The diagnosis is confirmed on the basis of radiology, with ultrasound combined with vascular Doppler becoming increasingly important. Renal venous thrombosis may have various causes: disorders in renal blood flow, especially in the acute forms in newborns; hypercoagulability, in particular in nephrotic syndromes and above all in extramembranous glomerulonephritis; extension of vena cava thrombosis; retroperitoneal diseases involving the renal pedicle or extension of a renal tumor. The treatment of renal vein thrombosis is mainly medical and based on anticoagulants. The role of fibrinolytic treatment is controversial. Surgery is exceptional.

Congenital anomalies of the external iliac artery: case report and review of the literature.

Routine arteriograms obtained during work-up for occlusive arterial disease of the lower limbs disclosed a rare congenital anomaly in a 47-year-old man. The common femoral artery arose directly from a pelvic artery which followed the normal course of the internal iliac artery. Congenital anomalies involving the external iliac artery can be classified into three groups: (1) anomalies of origin or course which are in fact anatomic curiosities; (2) hypoplasia or atresia coexisting with persistent sciatic artery; and, (3) isolated hypoplasia or atresia which can occasionally cause chronic ischemia of the lower limbs. The anomaly reported herein can be classified either as agenesia or abnormal course of the external iliac artery.

Pelvic arteriovenous fistulas: therapeutic strategy in five cases.

Pelvic arteriovenous fistulas are rare. They may be defined as arteriovenous communications developing in the pelvis from the internal iliac artery, the origin of its posterior trunk or branches of its anterior trunk. Congenital arteriovenous malformations, more common in women, and posttraumatic arteriovenous fistulas are the two main etiological forms. Diagnostic problems include appreciation of visceral extension in arteriovenous malformations and precise localization of fistulas especially when they affect the internal iliac artery itself. Therapy is aimed at complete closure of arteriovenous communications using interventional radiologic methods or surgery. Although indications are difficult to assess, complete, one-stage therapy is preferable due to surgical difficulties following failed or incomplete radiological or surgical attempts.

[Study of the circle of Willis with digital angiography. Contribution to the detection of high-risk carotid clamping]. / Exploration du polygone de Willis par angiographie numérisée. Apport au dépistage des clampages carotidiens à risque.

Radiological studies of Willis' circle morphology are mainly performed in search of intracerebral aneurysms, and for this purpose digital imaging has not superseded conventional radiology. In contrast, conventional imaging does not seem to have given satisfactory results in the functional study of this substitute vascular network, and it is in this field that digital angiography is of particular value. Between January, 1985 and June, 1986, we performed 300 digital angiographies of the supra-aortic vessels in patients with carotid artery stenosis. Each exploration included a stage of investigation for intracranial substitute vessels by compression of the carotid artery on the side of the lesion. Substitute vessels were found to be adequate in 93 p. 100 of the cases. The test showed that there was no alternative blood flow in 3.7 p. 100 of the cases, which made it imperative to use brain protection measures during clamping of the carotid artery. The substitute network was found to be insufficient in 1 p. 100 of the cases, and the method failed in 2.4 p. 100.

Long term follow-up of 43 pure dural arteriovenous fistulae (AVF) of the lateral sinus.

Forty-three patients with arterio-venous fistulae of the dura of the transverse sinus with a complaint of tinnitus are reviewed, with a follow-up of 12 months to 11 years. 34 patients were embolized, 2 treated surgically, and 7 were untreated. Embolization appears to have been beneficial. The frequently benign nature of this abnormality must be emphasized, and serious psychological study of the patient must be made before deciding on therapy.

[Hemorrhagic vascular complications of pelvic fractures . The role of embolization. 9 cases]. / Complications vasculaires hémorragiques des fractures du bassin. Place de l'embolisation. Neuf observations.

Emergency haemostatic embolization of the branches of the hypogastric artery was performed within 24 hours in 9 patients with fracture of the pelvis and major progressive retroperitoneal haematoma. Eight to 48 units of blood had been transfused. The patient in the worst condition (48 units of blood) died of respiratory failure and myocardial incompetence 2 hours after embolization. In the remaining 8 patients, embolization was effective without any immediate or delayed complication of the angiographic procedure. The usefulness of emergency angiographic exploration and the possible applications of endovascular haemostasis are discussed.