In situ arterial allografting for aortoiliac graft infection: a 6-year experience.

Between October 1988 and May 1994, all aortoiliac graft infections seen in the authors' service were treated by in situ arterial allografting after resection of any infected graft or tissue. Some 83 consecutive cases were treated; there were 68 isolated primary prosthetic infections (82%) and 15 aortoenteric fistulae (18%). Emergency arterial allografting was performed in five cases (6%), elective allografting in 64 cases (77%) and elective allografting after emergency palliative revascularization using a temporary prosthetic graft in 14 cases (17%). Arterial allografts were harvested from cadavers as part of a programme to retrieve multiorgan transplant tissue. Fifteen patients (18%) died either intra- or postoperatively. Three died during the operation, one from septic shock and two from uncontrollable coagulopathy. Twelve patients died in the early postoperative period, from from septic shock, two from myocardial infarction, two from pneumonia, one from a pulmonary embolism, one from an intestinal infarction, one from recurrence of a duodenal fistula and one from disruption of the native aorta at the suture line. Three patients presented with an early complication directly related to the use of the allograft. Eleven early survivors of the series died during follow-up. Among these late deaths, only one could likely be allograft-related. In four patients, the aortic segment of the allograft was mildly dilated on late computed tomography scan; three were reoperated on for disruption of the extra-abdominal segment of their allograft. All four cases were managed with simple suture of the allograft or with the use of a new allograft. Fifteen patients exhibited 19 late occlusive lesions of their allograft; 17 of these lesions had to be treated either with transluminal angioplasty or with surgery using autogenous or allograft material. In all but one case, secondary patency could be achieved through these additional procedures. Late occlusive disease was more prevalent in the femoral segment of the allograft than in the iliac or, moreover, the aortic segment. There were no late amputations in this series.

Direct transposition of the distal cervical vertebral artery into the internal carotid artery.

From January 1979 to December 1991, 92 revascularizations of the V3 segment of the vertebral artery were performed in 91 patients through a direct transposition of this artery into the internal carotid artery (ICA). These cases represented 15.1% of 610 vertebral revascularizations and 38.8% of 280 distal vertebral revascularizations performed during this period at our institution. The sex ratio of this population was 0.59, and the mean age was 59.4 +/- 13.2 years (range 14 to 82 years). Preoperative ischemic symptoms were vertebrobasilar in 87 (94.6%) cases, exclusively hemispheric in one (1.1%), and absent in the remaining four (4.3%). One of these four patients had asymptomatic severe multivessel occlusive disease and three others underwent resection of a spinal tumor involving the vertebral foraminal canal. In 31 (33.7%) cases significant carotid occlusive disease was also present. The distal V3 segment of the artery was directly transposed into the ICA in all cases in this series. In 24 (26.1%) cases the ICA was endarterectomized during the same operation. There were no deaths or strokes in this series but there were two (2.2%) transient ischemic attacks-one vertebrobasilar and the other hemispheric. However, eight (8.7%) transposed vertebral arteries were totally occluded at early follow-up. At 1 month, among the 87 patients with vertebrobasilar insufficiency, 44 (50.6%) were cured, 31 (35.6%) were improved, and 12 (13.8%) remained unchanged. Among the 12 who were unchanged, eight (66.7%) had occlusion or stenosis of the distal transposition at the time of discharge. At 5 years, the primary patency rate in the series was 89.1% +/- 7.2%. At the time of the last follow-up, among the 87 patients with vertebrobasilar insufficiency, 50 (57.5%) were cured, 25 (28.7%) were improved, two (2.3%) had remained unchanged since the operation, two (2.3%) suffered a relapse, and eight (9.2%) exhibited vertebrobasilar symptoms of varying severity and therefore could not be considered improved. Direct transposition of the V3 segment of the vertebral artery into the ICA is a simple, safe, and reliable technique for revascularization of the distal cervical vertebral artery.

Interdigital neuroma. Local cutaneous changes after corticosteroid injection.

Interdigital neuroma was diagnosed in a patient who was treated subsequently with a local corticosteroid injection. Two to 3 weeks after injection, a 2.5 x 1.5-cm area of hyperpigmentation, thinning of the skin, and subcutaneous fat atrophy developed at the site of the injection. Occurrence of these side effects depends on the solubility of the steroid preparation, the dosage, and the anatomic site and depth of the injection. When using local corticosteroid injections to treat interdigital neuromas, the physician should be familiar with the properties and recommended dosage of the given steroid. The injection should be deep enough so that the cortisone solution does not leak into the subcutaneous area. The possibility of skin atrophy and altered pigmentation should be discussed with all patients.

Carotid eversion endarterectomy: short- and long-term results.

From January 1979 to December 1993, of 2723 carotid revascularizations performed on our service, 168 (6.2%) were isolated carotid eversion endarterectomies (CEEs) for atherosclerotic occlusive disease. Since 10 of these procedures were bilateral, there were 158 patients total (88 men and 70 women). Twenty-six (16.5%) had diabetes, 54 (34.2%) had coronary disease, and 107 (67.7%) had hypertension. The mean age was 68.9 +/- 8.9 years (range 38 and 85 years). Preoperative ischemic symptoms were hemispheric in 93 (55.4%) patients, retinal in 31 (18.4%), and vertebrobasilar in 37 (22%). They consisted of one or more strokes in 44 (26.2%) patients and one or more transient ischemic attacks in 99 (58.9%); 25 (14.9%) patients were asymptomatic. The operated lesion contained atherosclerotic stenotic plaque in all cases. The lesion was tightly stenotic (> 75%) and hemodynamically significant in 93 (55.4%) cases and irregular or ulcerated in all others. In 86 (51.2%) patients a coil or kink of the distal internal carotid artery was also present. The contralateral carotid artery was totally occluded in eight (4.7%) patients and tightly stenotic in seven (4.2%). All patients were operated on under deep general anesthesia; they were given systemic heparin and normal blood pressure was maintained. After freeing and cross-clamping of the carotid bifurcation, the end of the common carotid artery or the ostium of the internal carotid artery was sectioned. The section allowed a deep-plane endarterectomy through eversion and excellent control over the endarterectomized surface and its extremities. Since January 1989 completion arteriography has been routinely performed after CEE.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of dihydroergocryptine on serum prolactin levels and milk secretion in puerperal women.

The aim of the present study was to evaluate the efficacy and tolerability of the dopamine agonist drug dihydroergocryptine in the suppression of puerperal lactation. A single blind and placebo-controlled study was performed. A total of 90 postpartum women was acutely or repeatedly treated with dihydroergocryptine at different doses in order to investigate the efficacy of this drug in the suppression of puerperal lactation and to find the optimum dose for therapy. Prolactin levels, mammary symptomatology and rebound effects were monitored during the repeated treatment and also 1 and 8 days after drug discontinuation. With acute administration, dihydroergocryptine significantly reduced prolactin levels only at the dose of 10 mg and not at 5 mg. With repeated administration, a daily dose of 15 mg was more effective than 10 mg in reducing prolactin levels and in suppressing puerperal lactation. No side-effects occurred during the treatment. These results suggest that dihydroergocryptine might be considered an effective drug in the suppression of puerperal lactation.

In situ allograft replacement of infected infrarenal aortic prosthetic grafts: results in forty-three patients.

PURPOSE: Dissatisfaction with conventional methods of treatment of infected infrarenal aortic prosthetic grafts and excellent long-term results reported by heart surgeons after allograft replacement for management of infections involving the ascending aorta have prompted us to investigate allograft replacement in the management of arterial infections. METHODS: From October 1988 to April 1992, 43 consecutive patients with infected infrarenal aortic prosthetic grafts underwent in situ replacement with preserved allografts obtained from cadavers as part of a program to retrieve multiorgan transplant tissue. Thirty-four patients had isolated prosthetic infections, whereas nine had aortoenteric fistulas. One patient had a concomitant below-knee amputation for septic arthritis of the ankle as a result of septic emboli. Nineteen patients had nonvascular-associated procedures, including 17 intestinal procedures. RESULTS: Five patients (12%) died after operation: four of general causes and one of rupture of the native aorta as a result of persistent infection. Three patients successfully underwent repeat operation for allograft-related complications (one case each of occlusion, septic rupture, and graft-enteric fistula). All surviving patients were discharged after control angiography showed patent allografts. Two patients were unavailable for follow-up. The other 36 patients have been monitored with serial duplex and computed tomography scanning for a mean follow-up of 13.8 months (range 1 to 42 months). There were four late deaths: three were unrelated to the vascular operation, and one may have been caused by late persistent or recurrent infection. Nine patients (26%) have had pathologic changes in the allograft, with three (9%) requiring repeat operation. There were no early or late postoperative amputations in the entire series. CONCLUSIONS: Although complete protection against persistent or recurrent infection has not been achieved and late deterioration may be expected, in situ allograft replacement seems to be a major advance in the management of infected infrarenal aortic prosthetic grafts.

[The treatment of postoperative pain in obstetrical-gynecologic surgery. A comparative study between ST-679 and paracetamol]. / Trattamento del dolore postoperatorio nella chirurgia ostetrico-ginecologica. Studio comparativo tra ST-679 e paracetamolo.

In double-blind conditions, ST-679 (a single oral 1200 mg dose in 20 patients), or paracetamol (a single oral dose of 1000 mg in 20 patients) was administered to forty patients who presented pain as a result of obstetrical-gynecological surgery. The study proposed to evaluate the analgesic efficacy and tolerability of ST-679, a new non-steroid antiphlogistic drug, as compared to a reference drug amply utilized in clinical practice such as paracetamol. The average estimation of tolerability, with regard to paracetamol, was significantly in favor of ST-679.

In situ fresh allograft replacement of an infected aortic prosthetic graft: eighteen months' follow-up.

We report a case in which an allogenic aortic graft was used to treat the last one of a series of infectious graft complications. The original operation was a Dacron aortobifemoral bypass for aortoiliac occlusive disease in an institution other than ours. The patient was referred for the treatment of the infection of the prosthetic implant. We inserted a prosthetic bypass from the left axillary to the left deep femoral artery, as well as a crossover autogenous saphenous vein graft from the prosthesis to the right deep femoral artery; in the same operation the infected intraabdominal prosthesis was removed with closure of the proximal aortic stump. Subsequent stenosis of the vein graft made it necessary to insert a prosthetic bypass between the descending thoracic aorta and the two deep femoral arteries. Infection of the last named prosthesis made it necessary to remove it and replace it with a tailored allogenic arterial allograft between the infrarenal abdominal aorta and both deep femoral arteries. The patient had an uneventful recovery as the infection was controlled and both lower limbs were salvaged. Eighteen months later the allograft was patent without any signs of degeneration. Further clinical experience under appropriate conditions may prove the use of allografts effective in the treatment of selected cases of aortic prosthetic infection.

[Long term results of surgery of aortic aneurysms]. / Résultats tardifs de la chirurgie des anévrysmes de l'aorte.

During 10 years, between 01.01.80 and 01.12.89, 838 patients have been operated on consequently for a A.A.A. in the vascular surgery department of the Hospital Pitié-Salpêtrière (Paris). Post-operative death was 7.3% (51 patients) among 692 operated on without emergency and 41.7% (60 patients) among 146 patients operated on emergency. The study was undertaken with the 727 surviving patients (86.8%) for the long term follow-up. Only 25 patients (3.4%) were lost out, so 702 patients (96.6%) had complete recalls even to their late death until the fourth trimester 1990. Total deaths, were 172 patients, (24.5%) out of the 702 patients in the follow-up. 60 patients (34.9%) died from cancer, 52 patients (30.2%) from heart disease, 21 patients (12.2%) from C.V.A. (cerebro-vascular-accident), 8 (4.6%) from rupture of aneurysm, 6 (3.6%) from renal insufficiency, 5 (2.9%) from prosthesis infection, 10 (5.8%) died from known reasons, 10 (5.8%) from unknown reasons. All these results were studied according to the "actuarial method" and the conclusions were as follow. The actual survival rate at 5 years was 72.1% +/- 5.6% and the average annual death rate was 5.8%. The factors which have influenced the late death are: a) Patients age: survival rate at 5 years and average annual death rate were significantly different whether the patients were less or more than 70 at the time of surgery. b) Surgical circonstances: late survival was significatively less with patients operated on emergency. c) Cerebro-vascular insufficiency. The average annual rates from cardio-vascular and cerebro-vascular accident were significatively more important in patients which previously had cerebro-vascular insufficiency. This work shows out that cardiac death are slightly overcame by cancer, but these two factors represent almost 2/3 (65.1%) of late death. So it should be important for prevention of late death to screen for lung and E.N.T. cancers. Some authors have proposed for prevention of coronarian accidents extensive use of coronarography and myocardial revascularisation. We prefer more acute screening than aggressive methods for patients with coronary problem who had surgery for A.A.A. and specially when they are less than 70 at surgical time.

[Clinical aspects of continuous ambulatory peritoneal dialysis in diabetics]. / Les aspects cliniques de la dialyse péritonéale continue ambulatoire chez les diabétiques.

The treatment of end stage renal diabetic nephropathy remains a challenge. A large experience allows us to clearly outline the advantages and the drawbacks of continuous ambulatory peritoneal dialysis (CAPD). 81 patients, mean age 51.3 years, were treated over the past nine years by CAPD-CCPD. Extrarenal complications, mainly vascular lesions, account for qualifying these patients as a high risk population. The technique was modified in order to inject insulin intraperitoneally, four times per day, to control blood glucose level. Peripheral vascular disease was prospectively studied in 19 patients. Actuarial survival was 92% at one year, 50% at four years mainly influenced by age: 85% survival at two years in 35 patients aged less than 50 years and 62% at two years in 46 patients aged more than 50 years. The main causes of death were of cardiovascular origin: arteritis, myocardial infarction, stroke. The main causes for transfer to an alternative method of treatment were technical complications. Peritonitis rate was one episode ever 14 months. Satisfactory control of blood pressure, blood glucose levels, main biological parameters, visual status were the clear advantages of the method. Peripheral vascular disease is not influenced by the technique. CAPD can be the technique of first choice in young diabetics awaiting a kidney transplant and the reference technique for home dialysis.

Exclusion-bypass for aneurysms of the descending thoracic and thoracoabdominal aorta.

From October 1973 to April 1985, 81 patients with aneurysms of the descending thoracic or thoracoabdominal aorta underwent surgery. Eight (10%) of these patients were treated by exclusion-bypass. The aneurysm was located in the descending aorta alone in five cases, and in the descending thoracic and thoracoabdominal aorta in three cases. In all cases, the proximal anastomosis of the bypass was performed on the ascending aorta. The site of the distal anastomosis was the supraceliac aorta in two cases, the infrarenal aorta in three cases and the iliac arteries in three other cases. Exclusion was bipolar, at each end of the aneurysm, in six cases, and unipolar, ie. proximal interruption only, in two cases. Two patients died during the first postoperative month, one of rupture of the distal portion of the aortic arch, the second, after onset of secondary paraplegia. There were no other spinal, cardiac or cerebral complications. One patient died three months postoperatively of intercurrent pulmonary infection. The five other surviving patients whose mean follow-up period is 48.1 +/- 25 months, are alive and enjoying good health. Resection and grafting as advocated by Crawford, is the usual treatment proposed for aneurysms of the descending thoracic and thoracoabdominal aorta. Exclusion-bypass may however be preferred in the following cases: elderly patients with compromised respiratory status, aneurysms of the descending thoracic aorta, either voluminous, of infectious origin or associated with aneurysm of the infrarenal abdominal aorta.

Post-operative angiographic control. A. Cerebrovascular disease. Main surgical techniques.

Carotid endarterectomy is the procedure most commonly used for the treatment of lesions in the internal carotid artery. It is occasionally also necessary to insert an internal shunt. After surgery, the patient should be kept in intensive care for 24 h. The most serious complication that can occur is a neurological deficit. Endarterectomy of the origin of the vertebral artery is also the most common procedure used at this location. The techniques for treatment of lesions in the supra-aortic trunks are also discussed, as are the procedures used in cerebral revascularization by extra-intracranial anastomosis.

Surgical repair of vertebral artery stenoses.

During an eight year period (1973-1980) 290 patients were submitted to surgery for correction of obstructive lesions at the origin of the vertebral arteries. The pathologic process was atherosclerotic stenosis in 283, kinks in 25 and extrinsic compression in 17 cases. The operative procedures, mostly supraclavicular, on 325 arteries were: ostial endarterectomy (111), subclavian-vertebral endarterectomy (153) with patch (17), reimplantation in subclavian artery (14), subclavian-vertebral anastomosis (6), subclavian resection-anastomosis (5). Associated procedures included supra-aortic trunk reconstruction (9) and carotid endarterectomy (36 simultaneous, 51 pre and 21 post). Postoperative arteriograms were obtained in 33% of the patients with 5% occlusion and 81% excellent results. Hospital mortality was 0.6%. Long-term results with a follow-up from 2 to 9 years (mean 5 years) was the following: mortality 12%, asymptomatic 68%. Obstructive lesions of the vertebral artery are responsible for symptoms of vertebrobasilar insufficiency and are often neglected. Their frequency is suggested by the observation that during a 20-year period, 1,382 carotid, 789 supra-aortic trunk and 683 vertebral operations were performed. This series indicates that trans-subclavian vertebral ostial endarterectomy is a simple and safe procedure, providing durable results.

Interference of MHV3 virus on ascites tumor growth.

In this experimental study the Authors have evaluated the interference of MHV3 hepatitis virus on Ascites Tumor's growth, using 4 groups of mice, the first one considered as control, the others inoculated with the virus 48 hours before, at the same time and 48 hours after tumor's inoculation. In each group labeling index, mitotic index and ascites volume were assessed a week after tumor's inoculation. The results seem to reveal an inhibition of tumor's growth in the second group. For this reason on the base of these encouraging observation, the Authors will continue researches to further confirm these preliminary results.