[Management of perianastomotic stenoses complicating vascular accesses for haemodialysis]. / Prise en charge des sténoses périanastomotiques compliquant les abords vasculaires pour hémodialyse.

OBJECTIVE: Perianastomotic stenoses (PAS) complicating native arteriovenous fistulas (AVF) of the forearm can be treated by angioplasty or surgery. The objective of this study was to report primary patency (PP) and primary assisted patency (PAP) rates of surgery and angioplasty of these stenoses. The secondary objective was to identify factors influencing the patency rates of these reoperations. MATERIAL AND METHODS: Seventy-three patients with a mean age, 65 years were treated for PAS between January 1999 and December 2005 in two centres (Tours and Le Mans), which were retrospectively included. PAS were treated by surgery (n=21) or angioplasty (n=52). The two groups were comparable. The mean follow-up was 39 months for the angioplasty group and 49 months for the surgery group (p=0.088). RESULTS: The PP rate was 71+/-10% for surgery and 41+/-6% for angioplasty (p<0.0175). The PAP rate was not significantly different (p=0.462) between angioplasty (92+/-4%) and surgery (95+/-4%). In the endovascular group, the site of stenosis on the anastomosis was a risk factor for early recurrence (95% CI between 0.006 and 0.392; p=0.047). CONCLUSION: These results suggest that anastomotic stenoses should be treated surgically rather than by angioplasty. Angioplasty and surgery give identical patency rates in other types of perianastomotic stenoses at the cost of a higher reoperation rate for angioplasty.

Infection-related exposure of the lower anastomosis of femorodistal bypass: salvage through use of pedicle muscle flaps.

Wound dehiscence with exposure of the lower anastomosis is a limb- and life-threatening complication of femorodistal bypass. Plastic surgeons consider pedicle flaps to be unreliable in patients with arterial disease. Despite this opinion, we attempted to treat exposure complications using pedicle muscle flaps after careful study of vascularization on control angiography. The purpose of this report is to describe our results. From 1994 to 1997, infection-related exposure of the distal anastomosis was observed in three men and two women with a mean age of 76 years (range, 66 to 89 years). The exposed anastomosis was located on the dorsalis pedis artery in three cases, the anterior tibial artery in the upper third of the leg in one, and the anterior tibial artery in the lower third of the leg in one. The bypass material was a vein graft in three cases and a cuffed PTFE prosthesis in two cases. Bacteriological examination identified Staphylococcus aureus in three cases, Pseudomonas aeruginosa in one case, and both in one case. Two patients were diabetics and one was undergoing corticosteroid treatment. The anastomosis was covered with a pedicle muscle flap fashioned from the extensor digitorum in four cases and the lateral head of the gastrocnemius in one case. Our results showed that anastomoses on the anterior tibial artery and dorsalis pedis artery are at higher risk for infection-related exposure but this complication can be treated using pedicle muscle flaps. This alternative should be considered before bypass removal or amputation.

[Intravascular lipoma of the superior vena cava]. / Lipome intravasculaire de la veine cave supérieure.

Lipomas of the major central veins are very rare tumors that have mostly been described in the inferior vena cava. They are often incidentally revealed by computed tomography or magnetic resonance imaging. Histological examination is unusual. We report the case of a lipoma of the superior vena cava discovered on computed tomography performed after a thoracic trauma in a 55-year-old man. The tumor was surgically removed and the fatty nature of the mass was established.

[Femoro-distal revascularization for "critical" chronic atheromatous ischemia. 695 cases]. / Revascularisations fémoro-distales pour ischémie chronique "critique" d'origine athéromateuse. 695 observations.

The results of the revascularizations carried out over a 10-year period for "critical" chronic ischaemia, using the femoropopliteal bypass technique, have been retrospectively analyzed. In all, 600 patients underwent femoro-distal revascularization in 644 limbs, and 695 bypasses were performed. The hospital mortality rate was 4.3 percent. Among these 695 bypasses, postoperative occlusion occurred in 16.5 percent of the cases, and major amputations were necessary in 9.8 percent. The probability of 5-year survival was 47 percent. The probabilities of bypass patency and limb salvage were 50 and 76 percent respectively. The failure of revascularization ending in amputation did not significantly increase the postoperative mortality rate (4.1 percent versus 4.6 percent), but the life expectancy of patients who were amputated was significantly lower than that of patients who were not (55 +/- 5 percent versus 63 +/- 3 percent at 3 years; P = 0.03). The factors predictive of successful bypass were examined; they included age, clinical stage, diabetes, bypass material, site of distal implantation, revascularization procedure and reoperation. Femoro-distal revascularization makes it possible to cope with the challenge of limb salvage, even when the receiving vessel is an artery of the foot.

Dissecting aneurysms of the main trunk of the superior mesenteric artery.

We treated four symptomatic patients who were admitted with a spontaneous and isolated dissecting aneurysm of the superior mesenteric artery. All four patients underwent operation. The superior mesenteric artery was repaired by means of either a bypass graft in two cases or an endoaneurysmorraphy in the latter two cases. Complete symptomatic relief with no postoperative complications was achieved in every case. The arterial repairs remained patent, and the patients remained free of symptoms, with follow-up ranging from 6 to 47 months. The available literature on this unusual lesion is reviewed.

Renal artery revascularization with polytetrafluoroethylene bypass graft.

Between January 1979 and December 1986, a total of 74 renal revascularizations were performed in 68 patients using the reinforced expanded polytetrafluoroethylene prosthetic graft. These 74 revascularizations represent 29% of 251 surgical renal revascularizations performed during the same period of time. Eight patients had a total of nine revascularizations in the emergency setting (group I) for ruptured suprarenal aneurysm or acute thrombosis of the renal arteries. Only one patient survived and six years later, his anatomic and functional results are satisfactory. Sixty-five revascularizations were performed electively in 60 patients (group II). This group consisted of 19 renal revascularizations alone, and 46 combined aortic and renal revascularizations. One patient died of respiratory complications two months after operation after his thoracoabdominal aneurysm was cured. Early repeat postoperative arteriography showed that six reconstructions had occluded (three major renal arteries, three polar arteries). One patient was lost to follow-up. The remaining patients were followed for a mean of 41 months. Follow-up arteriograms obtained during 1987 showed that there were two late occlusions and two distal anastomotic stenoses. Actuarial patency was 85 +/- 10% at 72 months. Polytetrafluoroethylene prosthetic grafts constitute a reliable material for renal revascularization and combined aortic and renal reconstruction in certain anatomic conditions.

[Lesions of the aortic arch in Recklinghausen's disease]. / Lésions de l'arche aortique dans la maladie de Recklinghausen.

Two young patients with Von Recklinghausen's disease developed an obstructive aortic arch syndrome. Follow-up over several years showed progressive changes in the clinical signs with no development of symptoms. Angiography demonstrated great changes in the anatomical relationship of the supraaortic trunks which lead to surgical repair. In one case, the histology of operative biopsies established a relation between the neurofibromatous and the arterial lesions. Modern investigative procedures and therapeutic possibilities are reviewed in the light of these two cases. These two patients seem to be the first reported cases of neurofibromatosis causing the aortic arch syndrome.

[Double isthmic coarctation of the aorta: "tandem" coarctation]. / La double coarctation isthmique de l'aorte: coarctation "en tandem".

A second case of double coarctation of the thoracic aorta is reported, the first having been observed at the Marie-Lannelongue Surgical Center in an older child. This case was a 3 months infant in which the missed pre- and postoperative diagnosis led to reoperation after control catheter and angiographic studies. These investigations were carried out one month after the first operation because of persistent severe cardiac failure. Surgical cure in two stages consisted in a Waldhausen plastic enlargement procedure and a Crafoord-type resection anastomosis, ensuring the best chances for a good result.