Early and mid-term results of total laparoscopic bypass for aortoiliac occlusive lesions.

AIM: The aim of this study was to investigate the early and mid term results of total laparoscopic bypass for aortoiliac occlusive lesions. METHODS: From December 2001 to January 2007, we performed 32 laparoscopic bypasses for aortoiliac lesions. The mean age was 52.9 years. Clinical stages included: severe intermittent claudication (N.=24) ischemic rest pain (N.=5) and tissue loss or gangrene (N.=3). According to the TASC classification, the lesions were type B in three cases, C in nine cases and D in 20 cases. Graft patency was controlled by means of duplex scan before discharge and during the follow-up. The patency rates were calculated using Kaplan-Meier analysis. RESULTS: In 27 out of 32 patients the total laparoscopic bypass was successful (84%). Conversion was necessary in five patients. The mean operative time was 338 minutes (range, 200-620 minutes), the mean aortic clamping time was 73 minutes (range, 35-144 minutes). Mortality was 0%. The postoperative course was uneventful in 19 patients (70%). The mean follow-up was 32.1 months. In this period we had two deaths, one from breast cancer after 12 months. The second patient has committed suicide after 48 months. Two graft occlusions occurred at 3 and 21 months. No other late complications were observed. The primary and secondary graft patency rate was estimated by Kaplan-Meier analysis at 92% and 96% on the first year and 87% and 93% at three years, respectively. CONCLUSION: Early and mid-term results of total laparoscopic bypass are good in selected patients and comparable to these of conventional surgery.

[Late occlusion of the subclavian artery proximal to mammary bypass]. / Occlusion tardive de l'artère sous-clavière en amont d'un pontage mammaire. 2 observations.

We report the cases of two patients with an occlusion of the left subclavian artery several years after left internal mammary bypass of the anterior interventricular artery. The effect on the myocardium was only apparent after scintigraphy in one case, and was clinical in the second with angina pain on exertion of the upper limb. Re-implantation of the subclavian artery in the common carotid relieved the signs of myocardial ischaemia. While the internal mammary artery is the conduit of choice for coronary revascularisation because it is not affected by atheromatous lesions, this does apply to the proximal subclavian artery. Stenosis or occlusion here can entail ischaemia in the revascularised myocardial territory. Regular clinical and ultrasound surveillance can detect these lesions.

[Percutaneous angioplasty of the infra-renal aorta. Report of 9 cases]. / Angioplastie endoluminale de l'aorte abdominale sous-rénale. A propos de 9 cas.

Between June 1996 and September 2000, nine angioplasties of the infra-renal aorta were performed in two Surgical Vascular Centers (Hospital Saint-Joseph, Paris, Polyclinic La Baule), in 6 men and three women age ranged from 36 to 72 years (middle age 48 years and 2 months). Eight of these patients presented important stenoses of the middle infra-renal aorta, or in the aortic bifurcation, one of them presented an occlusion, leading to severe intermittent claudication, and rest pain. After endoluminal kissing balloon angioplasty, five aortic stents (five patients), and six iliac primitive arteries stents (in three patients), extended beyond the aorta, were placed. One isolated angioplasty was also performed. All the procedures were performed in the operative room, with good results, except for one patient requiring emergency aorto-bi-femoral by-pass, because of acute leg ischemia, immediately following the procedure. Follow-up was clinical, with Us-Doppler scan, and angiogram in all cases. After 36 months follow-up (4-52), all patients are asymptomatic, with permeable stents. This technique is well-known since 1980, without excessive morbidity. Aortic angioplasty represents the right technique, with good long-term results, for middle or terminal aorta atheromatous stenosis, according to classical aorto-bi-femoral by-passes. Final result depends on associated iliac arteries stenoses.

[Critical ischemia of the leg. A technique for distal anastomosis in a a small caliber artery]. / Ischémie critique des membres inférieurs. Un artifice pour anastomose distale sur artère de petit calibre.

CRITICAL ISCHEMIA OF THE LOWER LIMBS: This type of lesion, which spontaneously progresses to gangrene and amputation, is encountered more and more frequently. Emergency endoluminal revascularization or bypass surgery is required. When conventional endoluminal techniques cannot be used, a distal graft using the autologous saphenous vein is a promising alternative to achieve patent vascularization and salvage the limb. IF VENOUS MATERIAL IS NOT AVAILABLE: Usable venous material is not always available due to varicosities, thrombus formation, small size or previous surgery (stripping, coronary surgery, prior revascularization procedure); rates reported range from 20 to 40%. For such patients, other veins (external saphenous, arm veins, superficial femoral veins) may be useful but are not always appropriate for distal repair. Different prostheses might also be used but again do not always provide improved permeability. Most teams however use a polytetrafluoroethylene stent for revascularization of the distal leg. Different technical improvements favor success of prosthetic bypasses, but when used below the knee, flow remains less satisfactory than with venous bypasses. VEIN CUFFS: This procedure is a common adjuvant technique positioning a venous cuff between the recipient artery and the prosthesis. The cuff avoids the direct contact between the prosthesis and the fragile artery that is often difficult to suture. RESULTS: Several series have demonstrated that the rate of success of vein cuff procedures remains lower than venous bypass procedures, but also that flow is better than with simple femorotibial prostheses. PATHOGENIC HYPOTHESES: The reduction of the neo-intimal hyperplasia observed in experimental models is insufficient to explain entirely the observed in vivo benefit. The fact that the suture is easier to make is one possible reason. Indeed the rate of failure of simple prosthetic bypass surgery is high in the immediate postoperative period. These cases of thrombosis result from technical insufficiencies and are undoubtedly overcome by the use of the venous cuff.

Aneurysms of the internal iliac artery: management strategy.

With the widespread use of CT scans, detection and treatment of internal iliac artery aneurysms (IIA) have become more frequent. In the last few years, endovascular repair has been added to the therapeutic arsenal. We reviewed the records of 38 patients treated for 44 IIA between 1987 and 1997 to assess immediate and long-term outcome using various therapeutic methods. Aneurysms were divided into three groups according to the circumstances of treatment. Group I included 25 IIA treated at the same time as abdominal aortic aneurysm (AAA). The morbidity/mortality rate in this group was comparable to that in patients who underwent isolated AAA repair. Group II included 14 IIA treated during follow-up of AAA repair. Most complications in this group were intraoperative. Group III included five isolated IIA not associated with AAA repair. Complications were similar to those in group I. On the basis of this retrospective analysis, we propose a management strategy in which open surgery, endovascular repair, or both are used, depending on the circumstances of treatment.

[Behcet's disease and iatrogenic arterial complications: importance of pre-operative noninvasive explorations]. / Maladie de Behçet et complications artérielles iatrogènes: intérêt des explorations pré-opératoires non invasives.

We report a case of Behçet's disease complicated with a popliteal aneurysm, which appeared 8 years after first etiologic diagnosis. The points of interest of this observation are the pre-operative explorations and particularly the Magnetic Resonance Angiography (RMA). This last seems to be particularly safe for aortic and lower limbs aneurysms explorations, and can be performed without arterial functions. In fact the risk of arteriogram is effective in Behçet's disease with secondary false aneurysms. RMA and US-Doppler scan must be first proposed in Behçet's disease in case of aortic and peripheral aneurysms.

Prosthetic reinforcement of varicose saphenous vein grafts for infrainguinal bypass.

Use of varicose saphenous veins for infrainguinal bypass is often contraindicated because of the risk of immediate rupture or long-term aneurysm. In this report we describe four cases in which prosthetic reinforcement allowed successful femoropopliteal bypass grafting using highly varicose saphenous veins while preserving normal endothelium. No thrombosis or any other complication was observed after a mean follow-up of 41 months.

[Atherosclerotic lesions of the subclavian artery. Indications for subclavian carotid transposition]. / Lésions athéroscléreuses de l'artère sous-clavière. Place de la transposition sous-clavière carotide.

PURPOSE: To analyze the clinical and anatomical outcome after subclavian carotid transposition and to compare the results with other surgical procedures. METHODS: The hospital records of 51 patients undergoing subclavian carotid transposition were reviewed retrospectively for preoperative symptoms, Doppler and arteriography findings, preoperative details and postoperative complications. Long-term patency and symptoms were determined by physical and Doppler examination during the follow-up. RESULTS: The indications for subclavian transposition were: vertebrobasilar ischemia (24%), ischemia of the upper limb (45%), asymptomatic occlusion or non-specific symptoms (31%). Subclavian artery transposition was associated with vertebral revascularization (7 cases), and homolateral carotid surgery (11 cases). There were no deaths. Early occlusions occurred in two cases, one required reoperation. Minor complications were observed in 21% of the patients with no permanent morbidity. Overall patency after a mean 54 months follow-up was 96%. CONCLUSION: Subclavian carotid transposition is a good method for the treatment of proximal subclavian occlusive disease. Long-term patency can be achieved. Carotido-subclavian bypass should be limited to cases with extensive occlusive lesions as patency rate is lower.

Inadvertent arterial injury during saphenous vein stripping: three cases and therapeutic strategies.

We report 3 cases of iatrogenic arterial injuries in relation to saphenous vein stripping. In 2 cases the patients sustained acute severe ischemia and required prompt revascularization. The third patient was seen at a later stage with chronic ischemia and claudication. All 3 patients had their limbs salvaged without severe sequelae. The therapeutic strategies for different situations are discussed.

Femoropopliteal bypass: in situ or reversed vein grafts? Ten-year results of a randomized prospective study.

One hundred femoropopliteal bypass procedures performed in 91 patients between October 1980 and January 1985 were randomly divided into two statistically comparable groups including 50 in situ vein grafts and 50 reversed vein grafts. The indication for bypass was chronic critical ischemia in 97% of cases. The lower anastomosis was made on the distal popliteal artery in 75% of cases. Follow-up ranged from 10 years (for the last patient included) to 14 years. Three patients have been lost to follow-up. Median survival was 54 months in the in situ graft group and 76.5 months in the reversed graft group. Actuarial survival at 10 years was 30.8% in the in situ graft group and 29.5% in the reversed graft group. Actuarial limb salvage at 10 years was 73.5% in the in situ graft group and 74.4% in the reversed graft group. Graft occlusion was observed in 10 cases during the perioperative period (six in the in situ graft group and four in the reversed graft group) and in 19 cases during the late postoperative period (12 in the in situ graft group and seven in the reversed graft group). Reoperation during follow-up was required in 13 cases in the in situ graft group (11 patients) and in nine cases in the reversed graft group (five patients). Discounting residual arteriovenous fistulas (FAV) (five ligations in four patients), the incidence of lesions involving the bypass and anastomoses threatening graft patency was 6% in the in situ graft group and 8% in the reversed graft group. Actuarial primary patency at 10 years was 41.7% in the in situ graft group and 64.5% in the reversed graft group (p < 0.05). Actuarial secondary patency at 10 years was 64.8% in the in situ graft group and 70.2% in the reversed graft group (NS). As a function of vein diameter, actuarial secondary patency at 10 years in the in situ graft group was 37.5% for bypasses using veins with a diameter of 4 mm or less and 80.6% for bypasses using veins larger than 4 mm (p < 0.05). In the reversed graft group the patency rate was 71.2% for bypasses using veins with a diameter of 4 mm or less and 65.5% for bypasses using veins larger than 4 mm. In addition to requiring a training period the in situ technique raises the problem of valve removal especially for small diameter veins. The absence of these disadvantages makes the reversed technique the procedure of choice for femoropopliteal bypass.

[Lumbar sympathectomy by retroperitoneal endoscopy: feasibility study]. / Sympathectomie lombaire par rétropéritoneoscopie: étude de faisabilité.

Endoscopic surgery has been used as a new procedure to simplify different surgical processes. The goal of this study was to evaluate the benefits of endoscopic retroperitoneal surgery for lumbar sympathectomies. Between February 93 and November 95 we performed 35 lumbar sympathectomies using this technique. All patients were arteritic. The results were as follows: for 25% of the patients, conversion classical open technique was required; 6% complications (septic); 3% of the patients died. In comparing the various techniques of sympathectomy and sympatholysis, it would appear that the endoscopic technique produces fewer complications. However we believe that a learning period is necessary before this technique can be fully mastered.

[Surgery of carotid lesions after irradiation. Apropos of 15 cases]. / Chirurgie des lésions carotidiennes après irradiation. A propos de 15 cas.

Out of 15 patients operated on for a carotid stenosis 3 to 19 years after a cervical irradiation, 2 were treated by a subclavian-carotid by-pass, 3 by a common carotid-internal carotid by-pass, 10 by an endarterectomy (6 closed with a patch), 3 of these endarterectomy extended largely down on the common carotid. Although the surgical approach was often difficult through the sclerotic tissues and 8 times the scar of a lymphadenectomy, the removal of the atherosclerotic core was as easy as usual. We observed neither mishap in arterial and cutaneous healings nor post operative stenotic myointimal hyperplasia.

[Arterial lesions of the upper limbs in Horton disease. Surgical revascularization by bilateral carotid-humeral bypass]. / Lésions artérielles des membres supérieurs dans la maladie de Horton. Revascularisation chirurgicale par pontage carotido-huméral bilatéral.

BACKGROUND: While external carotid lesions predominate, giant cell arteritis (Horton's disease) involves the arteries of the upper limbs in 7.7 to 16% of the patients. CASE REPORT: We cared for one patient with clinically and biologically proven Horton's disease. The patient was given corticosteroid therapy, but although general health status improved and markers of the inflammatory reaction returned to normal levels, exertion-induced ischemia progressively worsened. Due to the length of the arterial lesions, we performed bilateral carotid-humeral bypass surgery. DISCUSSION: Clinical expression of Horton's disease is often quiescent even in cases with extensive anatomic lesions. When clinical signs do appear, they generally respond well to corticosteroid therapy. In certain cases, as reported here, improvement can only be obtained by surgical revascularization.

[Thrombo-aspiration in the surgical treatment of acute ischemia of the legs. Preliminary experience]. / La thrombo-aspiration dans le traitement chirurgical des ischémies aiguës des membres inférieurs. Expérience préliminaire.

Eleven thrombo aspirations were performed in ten patients with lower limb acute ischemia. Three were performed under local and 8 under general anesthesia. They were associated with 4 thrombectomies, 6 transluminal angioplasty procedures, 1 limb infusion, 1 treatment of a false aneurysm, 1 aponeurotomy, 1 angioscopy. Clinical and radiological success was achieved in 9 patients whereas there was one immediate failure requiring a popliteal distal bypass. Late partial rethrombosis requiring medical treatment occurred in one patient. Thrombo aspiration is a safe effective technique which can be combined with other endoluminal procedures in patients with acute lower limb ischemia.

[Coronary assessment and surgery for aortic aneurysm: a pragmatic attitude]. / Bilan coronarien et chirurgie pour anévrisme aortique: attitude pragmatique.

High prevalence of coronary artery disease in patients with AAA leads to a high rate of peri-operative cardiac complications. Coronary insufficiency is thus the cause of 40 to 60% of post-operative deaths after aortic surgery. Demonstration of coronary insufficiency depends on the clinical history, electrocardiographic evidence, non-invasive examinations and coronarography. Diagnosis is based on non-invasive tests, and of primary importance exercise tests, which have a high sensitivity. Specificity for predicting post-operative cardiac complications remains low but can be improved by combining with other tests (for example exercise test and Holter recording) or with other clinical parameters. Coronarography provides a precise map of the coronary status but gives little information on functional impairment of encountered lesions. Finally, besides the cost and a certain degree of morbidity, coronarography increases the number of indications for revascularizations with the inconvenience of its intrinsic mortality and also retards the operation increasing the risk of rupture. The evaluation of cardiac risk before surgery must be based on correct use of non-invasive tests, limiting coronarography to cases with frankly positive tests.

Resection of the aorta for leiomyosarcoma of the inferior vena cava.

Two cases of infra renal vena cava leiomyosarcoma are reported. Their locoregional extension resulted in a joint resection of the aorta and the vena cava. The follow-up of the two cases is of respectively 34 months and 32 months. We think that large resections are necessary, due to the microscopic characteristics of such tumors in order to try to improve the prognosis.

[Apropos of an inflammatory aneurysm of the abdominal aorta revealed by anuria]. / A propos d'un anévrysme inflammatoire de l'aorte abdominale révélé par une anurie.

Inflammatory aneurysms of the abdominal aorta raise particular problems, as they are often detected as a result of their complications. In the light of one case presenting with anuria, the authors discuss the various treatment options and the value of preoperative corticosteroids.