Beware of suboptimal medical management of patients with atherosclerosis requiring revascularization.

AIM: The aim of this paper was to assess a daily-life evaluation of vascular risk factor control, pharmacological treatment and prognosis in patients with atherosclerosis referred for revascularization. METHODS: Prospective observational study conducted in a French University Hospital with collection of atherosclerosis referral site information, reported patient history, documented atherosclerosis sites seen on examination, biological data, and clinical outcomes. RESULTS: 956 patients (82.6% men, 64.5±10.1 years) were enrolled for supra-aortic vessel disease (SVD, 24.6%), coronary heart disease (CHD, 40.4%), peripheral artery occlusive disease (PAOD, 34.2%), and visceral artery disease (1.7%). Involvement of >2 vascular territories was documented in 85%. Vascular risk factor frequency results were: previous (65.7%) or current (10.6%) tobacco use, hypertension (64.3%), hyperlipidaemia (75.4%), diabetes (25.8%), overweight (43.8%), and obesity (25.2%). LDL-cholesterol was >100 mg/dL for 38.1%, most frequently seen in patients with PAOD referral (P<0.001) or history (P=0.002), and for 29.2% of the patients taking a statin. HbA1c levels were >6.5% for 53.8% of patients with diabetes. The triple combination of an antiplatelet agent, a statin, and a renin-angiotensin-system inhibitor was not prescribed often enough, especially for PAOD referrals (PAOD referrals, 45.1%; SVD referrals, 48.1%; CHD referrals, 65.9%). Independent risk factors for all-cause mortality were: a previous CHD or PAOD clinical event, body mass index <25 kg/m2, HbA1c >6.5%, and no aspirin treatment. CONCLUSION: Even at the time of revascularization, medical management of atherosclerosis was not optimal. The need for continuing education of physicians and patients remains essential.

Thoracoscopic plication of the diaphragm for postoperative phrenic paralysis: a report of two cases.

Unilateral phrenic nerve paralysis after cardiothoracic surgery is not uncommon. When symptomatic, it can require surgical treatment. Plication of the diaphragm through a thoracotomy is known to provide excellent long-term results. Plication is now being performed via video-assisted thoracoscopic surgery (VATS). We report the cases of two patients with postoperative left phrenic nerve paralysis who underwent plication of the diaphragm using VATS and achieved total relief of all symptoms.

Surgical treatment of recurrent carotid artery stenosis and carotid artery stenosis after neck irradiation: evaluation of operative risk.

Surgical treatment of recurrent carotid artery stenosis after endarterectomy and carotid artery stenosis after neck irradiation purportedly has a higher complication rate than primary carotid endarterectomy (CEA). Accordingly, carotid angioplasty has been proposed as a safer alternative. The purpose of this study was to evaluate operative risks on the basis of our experience with these lesions. A series of 679 carotid revascularizations (CRV) performed over a period of 9 years was retrospectively reviewed. Immediate outcome and operative technique was analyzed in three groups: group 1 included 549 "routine" CRV, group 2 included 8 CRV for recurrent stenosis after CEA, and group 3 consisted of 11 CRV for stenosis after neck irradiation. No difference in revascularization techniques was found between groups 1 and 2. In contrast there were fewer CEA and resection-anastomosis procedures in group 2 than in group 1 (62.5% vs. 98.2%; p < 0.0006) and more bypass procedures (37.5% vs. 1.8%; p = 0.0015). The cumulative neurological morbidity/mortality rate (CMMR) was 0% in groups 2 and 3 as compared to 4.4% in group 1. In comparison with group 1, early and permanent neurological morbidity rates were significantly higher in both group 2 (2.2% vs. 25.0%; p = 0.015 and 0.2% vs. 12.5%; p = 0.028, respectively) and group 3 (2.2% vs. 18.2%; p = 0.028 and 0.2% vs. 9.1%; p = 0.039, respectively). Surgical treatment of recurrent stenosis after CEA and stenosis after neck irradiation is not associated with a higher CMMR. The only potentially valid justification for using percutaneous transluminal angioplasty in these patients would be a higher risk of cervical neurological morbidity.

[Rotational vertebro-basilar insufficiency secondary to a fibrous band of the longus colli muscle: value of CT spiral angiography diagnosis]. / Insuffisance vertébro-basilaire rotationelle par une bande fibreuse du muscle longus colli: apport de l'angioscanner spiralé

A CASE REPORT: The authors report a case of rotational vertebro-basilar insufficiency causing "drop-attacks". To our knowledge, it is the first case of extraluminal vertebral artery compression caused by a fibrous band of the longus colli muscle, demonstrated by spiral computed tomographic angiography with volume rendering reformation.

Long-term outcome of 121 iliofemoral endarterectomy procedures.

Iliofemoral endarterectomy (EA) is now considered by most vascular surgeons to be an obsolete technique that is difficult and unreliable. The purpose of this retrospective study was to reassess the place of iliofemoral EA on the basis of long-term outcome in our experience. From 1982 to 1995, we performed a total of 121 iliofemoral EA procedures on 98 patients with a mean age of 57 years. The anatomical presentation involved iliac occlusion in 55 cases and complex iliac stenosis in 63. The indication for treatment was critical ischemia in 28 cases. Operative mortality was nil. Major amputation was required in only one patient because of contralateral thrombosis during the procedure. Postoperative thrombosis requiring early thrombectomy occurred in five cases. At 5 and 10 years, actuarial rates were 77.6% and 61.3%, respectively, for survival, 98.3% and 90.1%, respectively, for limb salvage, 78.9% and 65.1%, respectively, for primary patency, and 88.2% and 73.8%, respectively, for secondary patency. On the basis of these findings, we consider iliofemoral EA to be a viable alternative to iliac bypass in patients ineligible for transluminal angioplasty.

Suprahepatic inferior vena cava cannulation.

Inadequate venous drainage may represent a major problem in operations on the descending thoracic aorta performed with the aid of cardiopulmonary bypass. We herein describe an alternative technique of venous cannulation, which allows steady performances and high pump flows.

Results of surgical management of internal carotid artery aneurysm by the cervical approach.

From 1981 to 1995 a total of 14 patients with a mean age of 52 years (range: 23-71) underwent surgery for 15 aneurysms of the extracranial internal carotid artery. Fusiform aneurysms of the carotid bifurcation were not included in this study. Aneurysm led to brain ischemia in 10 cases and rupture in one case. In the remaining four cases, aneurysm was asymptomatic including three that were detected following hemispheric stroke related to a contralateral aneurysm. The etiology was spontaneous dissection in four cases, blunt trauma in three cases, fibromuscular disease in five cases, and atheroma in three cases. The upper limit of the aneurysm was located at C1-C2 in six cases, at C1 in three cases, and above C1 (at the base of the skull) in six cases. The cervical approach was used to successfully perform 12 revascularizations and three ligations (including one after extra-intracranial bypass). There were no postoperative deaths. One transient ischemic attack (TIA) occurred after ligation. Peripheral facial paralysis (PFP) occurred in four of the nine cases in which an extended cervical approach was used. No patients were lost to follow-up. Mean duration of follow-up was 4 years (range: 2 months-10 years). Two patients died at 2 and 4 years of causes unrelated to the procedure. All carotid reconstructions are currently patent and no neurologic manifestations have occurred. PFP persisted in one case. The results of this series confirm that surgical therapy of aneurysms of the extracranial internal carotid artery achieves satisfactory short- and medium-term results and that the extended cervical approach allows treatment of lesions near the base of the skull.

Pulsed transthrombotic fibrinolysis: technique and results in the management of occluded lower limb bypass grafts.

Between March 1987 and March 1993 we used pulsed transthrombotic fibrinolysis to treat 58 symptomatic thrombotic occlusions of lower limb bypass grafts in 45 patients. There were 17 suprainguinal grafts and 28 infrainguinal grafts. Treatment consisted of pulsed infusion of fibrinolytic agents into the thrombus followed by continuous infusion using an electric pump. Minor percutaneous or surgical procedures were often associated. The mean delay to treatment was 7 days. The mean duration of treatment was 150 +/- 66 minutes. Immediate patency was achieved in 88% of cases with no significant difference between suprainguinal and infrainguinal grafts. The clinical success rate was 55%. Actuarial patency at 1 year was 54% +/- 11% for suprainguinal grafts and 26% +/- 7% for infrainguinal grafts. The probability of patency was much lower in patients whose grafts had been implanted within 3 months before occlusion and in patients in whom an adjuvant procedure had not been performed. This study demonstrates that, in cases not requiring immediate surgery, pulsed transthrombotic fibrinolysis can achieve durable patency by treating both the bypass and distal arterial network. This technique allows identification of lesions causing thrombosis and adaptation of treatment specifically to these lesions.

Transpericardial inferior vena caval cannulation in thoracic aorta operations.

Surgical treatment of thoracic aneurysms is frequently performed with the aid of partial cardiopulmonary bypass. When profound hypothermia and circulatory arrest are employed, inadequate venous drainage may represent a major problem. We herein describe a technique of inferior vena caval cannulation that allows steady performance when high pump flows are imposed.

[Acute carotid occlusion: thrombolytic treatment]. / Occlusion carotidienne aiguë: traitement par thrombolyse.

The occurrence of a neurologic deficit at the time of an acute obstruction of the internal carotid does not equate with neurons death. The size of the residual infarct depend on the duration and the depth of ischemia. The goal of fibrinolytic therapy is to obtain a fast reperfusin of the ischemic areas to limit the size of the residual infarct. The risk of reperfusion depend on the depth of the blood-brain barrier ischemia. The indications of reperfusion in emergency settings are based on pretherapeutic CTscan and angiographic assessment with cerebral digitalized parenchymography. Between 1984 and 1994, 100 ischemic strokes have been treated on emergency by local intra-arterial thrombolysis. The results depend on the condition of lenticulostriate arteries: --when the lenticulostriate arteries are not involved in the occlusion, arterial thrombolysis is very efficient (75% good results; 0% bad results) and has been performed up to the 12th hour. --when the lenticulostriate arteries are involved, the results are not as good (58% good results; 23% bad results); the hemorrhagic risk has dramatically dropped in this group when the decision was taken to do not treat the patients after the 5th hour (16.7% to 2.3%). There has been 7 deaths, 6 were due to non efficient revascularization of the parenchyma with vasogenic oedema. In conclusion, we think that ischemic stroke is an emergency; the cerebral digitalized parenchymography appears to be a major diagnostic and prognostic tool; intra-arterial thrombolysis is a very efficient technique when used at the right site and time.

[Carotid and aortic lesions: two-stage surgery]. / Lésions carotidiennes et aortiques: chirurgie en deux temps.

The problem of chronology between different surgical acts is at stake when a patient suffering from carotid and aorto-iliac or femoropopliteal diseases requires surgery. The joint operation increases surgical risk and its practice penalizes the surgeon. Sequential surgery is safer. It does not increase the risk of a adverse evolution of the diseases areas which has not been operated on at time of the first operation.

[Massive hemoptysis ten days after bronchial extraction of an accidentally inhaled tablet of ferrous sulfate]. / Hémoptysie massive dix jours après extraction bronchique d'un comprimé de sulfate ferreux inhalé accidentellement.

Fatale haemoptysis occurred as a result of circumferential caustic erosion to the right intermediate bronchus caused by a tablet of ferrous sulphate which remained in contact for 4 days. The necrotic process continued, after removal of the foreign body, in the bronchial wall and its vessels. We suggest local bronchial lavage with 1% bicarbonate saline during extraction of the tablet and subsequent follow-up fibroscopies. The discovery of a necrotic ulceration of the bronchus requires strict medico-surgical surveillance in order to rapidly intervene under cover of selective intubation when necessary.

Calcified obstructive disease of the aortic isthmus.

A 52-year-old man presented with a calcified thrombus measuring 5 cm in length, which was responsible for obstruction of two-thirds of the aortic isthmus lumen. At operation the thrombus was seen to stem from an ulcerated plaque in the aortic wall, 4 mm in diameter. Six years later, his aortograms were normal. We believe the thrombus had an atheromatous origin.