[A modified Gritti-Stokes amputation for vascular indications in the elderly: futility or utility?]. / Amputation de genou dérivée de la technique de Gritti-Stokes pour artériopathie chronique chez le sujet âgé : est-ce faisable et raisonnable ?

AIM: Major lower limb amputation in elderly patients is a dreaded event with high mortality and morbidity. Peripheral arterial disease is the nearly exclusive etiology. The aim of this retrospective study was to assess the feasibility of through-knee amputation, and the morbidity and mortality risk in the elderly (>65 years). PATIENTS AND METHODS: From January 2000 to October 2010, 65 Gritti-Stokes through-knee amputations were performed in 58 patients (30 women, 28 men; mean age 79 years). Acute limb ischemia was the most common cause (40%). The others indications were: severe peripheral arterial disease with extensive necrotic lesions (19%), diabetic foot ulcers (15%), non-healing below-knee amputation (10%) and vascular graft infection after prosthetic lower extremity bypass surgery (6%). RESULTS: Overall 30-day mortality was 24% (n=14/58). Vascular morbidity was 9% (n=6/65). The mean hospital stay was 31 days (range 3 to 96). The overall healing rate was 78% (n=51/65). Conversion to above-knee amputation for failed Gritti-Stokes amputation was performed in one patient. CONCLUSION: Gritti-Stokes amputation is feasible in the elderly with an acceptable one-month mortality and a satisfactory overall healing rate. Most amputations are necessitated by complications of acute limb ischemia. For this subpopulation, Gritti-Stokes amputation should be the standard amputation level. The data collected in this study provide important information that can be useful before amputation for this population, their families and primary care physicians. Ambulation is an important postoperative goal and a multidisciplinary approach in specialized centers is required to achieve good wound healing rates.

[Aortic valve replacement in patients over 80 years of age. Short- and medium-term results in 140 patients]. / Remplacement valvulaire aortique chez les patients de plus de 80 ans. A propos de 140 patients, résultats à court et moyen termes.

One hundred and forty aortic valve replacements (AVR) performed between 1986 and 1995 at Rouen University Hospital in octogenarians (52 men and 88 women), including 9 emergency procedures, were analysed. One hundred and fifteen patients had pure aortic stenosis, 25 had mixed aortic valve disease with mainly aortic incompetence. The surgical decision was taken by the patient with the surgeon after an interview, in order to exclude too handicapped or undecided patients. Significant coronary artery disease was observed in 42% of cases. Isolated AVR was undertaken in 74% of cases and associated coronary bypass surgery in 23% of cases. Bioprostheses were used in 90% of cases. The valvular lesions were predominantly those of Monckeberg disease. The operative mortality was of 13 patients (9.3%). Functional recovery was satisfactory in 78% of cases; the average duration of the hospital stay was 12 days. All known risk factors for AVR: age, coronary lesions, cardiac failure, low ejection fraction, aortic regurgitation, were associated with insignificant increases in mortality. The secondary mortality was of 28 patients; 99 patients are still alive 4 to 91 months after surgery. The actuarial survival graph showed a 56.5% probability of 5 year survival. Eighty per cent of survivors live at home without loss of autonomy.

Aortic valvular replacement in octogenarians. Short-term and mid-term results in 140 patients.

Aortic valvular replacements were performed between 1986 and 1995 at Rouen University Hospital on 140 octogenarians (52 male and 88 female). Pure or predominant aortic stenosis was present in 115 patients, 25 had associated aortic stenosis and insufficiency or predominant aortic insufficiency. Significant coronary lesions were present in 42% of patients. An isolated aortic valvular replacement was performed in 74% of patients, associated with a bypass in 23% and a bioprosthesis was used in 90%. Valvular lesions were mainly caused by Mönckeberg disease. Thirteen operative deaths occurred (9.3%). Functional recovery was satisfactory in 78%, mean hospital stay was 12 days. All well-known risk factors for aortic valvular replacement: age, coronary lesions, cardiac insufficiency, impaired ejection fraction and aortic insufficiency, led to an increase in operative mortality but were not statistically significant. Late mortality occurred in 28 patients, 99 patients are still alive at 4-91 months after surgery. The actuarial survival curve shows a 56.5% probability of surviving 5 years. Eighty per cent of survivors are able to live independently at home.