'Pole test' measurements in critical leg ischaemia.

BACKGROUND: For the quantification of critical limb ischaemia (CLI) most vascular surgery units use sphygmo-manometric and transcutaneous oxygen pressure (TcPO2) measurements. However, measurements obtained by cuff-manometry can be overestimated especially in diabetic patients because of medial calcification that makes leg arteries less compressible. TcPO2 measurements present a considerable overlap in the values obtained for patients with different degrees of ischaemia and its reproducibility has been questioned. Arterial wall stiffness has less influence on the pole test, based on hydrostatic pressure derived by leg elevation, and this test seems to provide a reliable index of CLI. OBJECTIVE: The objective of this study was to evaluate the pole pressure test for detection of critical lower limb ischaemia, correlating results with cuff-manometry and transcutaneous oxygen pressure. DESIGN: University hospital-prospective study. MATERIALS AND METHODS: Seventy-four patients (83 legs) with rest pain or gangrene were evaluated by four methods: pole test, cuff-manometry, TcPO2 and arteriography. CLI was present if the following criteria were met: (a) important arteriographic lesions+rest pain with an ankle systolic pressure (ASP) < or = 40 mmHg and/or a TcPO2 < or = 30 mmHg, or (b) important arteriographic lesions+tissue loss with an ASP < or = 60 mmHg and/or a TcPO2 < or = 40 mmHg. Fifty-seven lower limbs met the criteria for CLI. RESULTS: Measurements obtained by cuff-manometry were significantly higher to those obtained by pole test (mean pressure difference: 40 mmHg, p<0.001). The difference between the two methods remained statistically significant for both diabetics (50.73, p<0.001) and non-diabetics (31.46, p<0.001). Mean TcPO2 value was 15.51 mmHg and there was no important difference between patients with and without diabetes. Overall, there was a correlation between sphygmomanometry and pole test (r = 0.481). The correlation persisted for patients without diabetes (r = 0.581), but was not evident in patients with diabetes. Correlation between pole test and TcPO2 was observed only for patients with diabetes (r = 0.444). There was no correlation between cuff-manometry and TcPO2. The pole test offered an accuracy of 88% for the detection of CLI. The sensitivity of this test was 95% and the specificity 73%.

Juxtarenal aneurysm. Comparative study with infrarenal abdominal aortic aneurysm and proposition of a new classification.

OBJECTIVE: to propose an anatomical classification of juxtarenal aortic aneurysm (JRA) that relates to their epidemiology and the result of surgical repair. MATERIAL AND METHODS: retrospective study of 53 JRA and 376 infrarenal aortic aneurysm (AAA) operated between January 1989 and August 1999. RESULTS: perioperative mortality after JRA repair was 19% for type A (interrenal), 13% for type B (aneurysm of one or two renal origins) and 4% for type C (no infrarenal neck). These differences were not significant. The overall perioperative mortality after JRA repair (11%) was significantly higher than mortality of AAA (3%p<0.01). Postoperative morbidity after JRA repair was 62% for type A, 75% for type B and 33% for type C. Postoperative morbidity after type B repair was significantly more frequent than after type C (p<0.001). The overall postoperative morbidity (51%) was significantly more frequent than after AAA repair (26%p<0.01). Preoperative ischaemic heart disease, aortic clamping above the coeliac axis and aortic proximal clamping longer than 30 min were significant risk factors for death after JRA repair. Survival by life-table analysis at five years after JRA repair and AAA repair were respectively 73%+/-7% and 76%+/-3%. CONCLUSION: there is a less favourable outcome after JRA repair as compared to AAA repair. The complexity of the surgical procedure requires accurate preoperative morphological assessment. The proposed classification of juxtarenal aneurysms may be helpful in guiding surgical access.

Late complications after prosthetic replacement of the ascending aorta: what did we learn from routine magnetic resonance imaging follow-up?

OBJECTIVE: Advances in surgical technique have improved early survival after surgery of the ascending aorta. However, follow-up data document serious late complications, mainly evolutive peri-prosthetic false aneurysms. Magnetic resonance imaging (MRI) has proved to be highly effective for monitoring these complications. This study evaluates 10 years of experience with routine MRI for follow-up. METHODS: Since January 1988, 114 patients with replacement of the ascending aorta either for type A acute dissection (group I, 45 patients) or aneurysms (group II, 69 patients) were followed up with annual MRI. Prosthetic replacement was either limited to supra-coronary ascending aorta (45%, 51/114) or extended to the aortic root and/or the aortic arch (55%). Biological glue was always utilized. MRI focused on peri-prosthetic haematoma, analyzing signal intensity changes and volume augmentation for early detection of false aneurysms, and on persistent residual dissection with or without evolutive aortic aneurysm distant to the prosthesis. RESULTS: Peri-prosthetic hematomas were almost equally found in both groups (26 (58%) in group I and 42 (61%) in group II) and were detected within the first year. Peri-prosthetic false aneurysms developed in 15 patients (group I, seven; group II, eight) as a complication of pre-existing hematomas and were indicated for elective reoperation. Forty-three (96%) of patients in group I had persistent residual dissection. Five patients in group I and two in group II needed reoperation for evolutive aortic aneurysm. In total, 22 of 114 (19%) patients were reoperated on during follow-up (12 (27%) in group I and ten (15%) in group II). Operative mortality was 13% (3/22). Freedom from reoperation at 1 year/5 years was: group I, 93%/84%; group II, 98%/88%. CONCLUSION: Peri-prosthetic haematoma occurs equally after aneurysm or dissection repairs and is a pre-existing condition for peri-prosthetic false aneurysm; biological glue or extended repair do not prevent late complications. Long-term MRI follow-up allows successful elective reoperation for life-threatened but asymptomatic patients.

[Role of laparoscopy in surgery of the adrenal glands]. / Place de la coelioscopie dans la chirurgie des surrénales.

It has been recently demonstrated that resection of the adrenal glands can be performed laparoscopically, providing certain advantages over conventional open surgery. The aim of this work was to determine the role of laparoscopy in the surgical approach to the adrenal glands. From June 1994 to December 1995, transperitoneal laparoscopic procedures were proposed in patients with a unilateral 8 cm or less non-malignant tumors of the adrenal gland. For tumors under 4 cm in diameter, only secreting tumors were removed. One patient had Cushing's disease and underwent bilateral resection. Among 58 patients requiring ablation of the adrenal gland; 37 (64%) underwent a laparoscopic procedure: 20 Conn adenomas, 8 Cushing adenomas, 1 Cushing's disease, 5 pheochromocytomas, 3 incidentalomas. Mean tumor size was 26 mm (7-75 mm). Two tumors were found to be malignant: one cortisone-secreting tumor and one leiomyosarcoma. Conversion was required in 4 cases (11%) due to difficulties in exposing the dissection in 3 cases and due to malignancy in 1. Mean operative time for unilateral operations was 159 minutes (75-300 minutes). There were no deaths. Morbidity included one hemorrhage via the trocar orifice requiring reoperation, one infarction of the spleen which regressed spontaneously, one parietal hematoma, and one case of phlebitis of the lower limb. The endocrinopathy was successfully cured in all patients with secreting tumors. The 21 other patients underwent open surgery. Laparoscopic access was contraindicated due to suspected malignancy in 10 cases, past surgical history in 7 and bilateral or extra-adrenal lesions in 4. Laparoscopic resection of the adrenal glands is the preferred technique in patients with Conn adenomas, Cushing adenomas and in most cases of pheochromocytoma. It is not indicated for malignant and/or very large tumor (> 8 cm). In our experience, the laparoscopic approach has replaced open posterior approach which is now only used exceptionally. Currently two-thirds of our patients with an indication for resection of the adrenal glands are operated laparoscopically.