[Surgery of the proximal vertebral artery. Indications and results]. / Indications et résultats de la chirurgie de l'artère vertébrale pré-transversaire.

OBJECTIVES: The purpose of this study was to: 1) detail the clinical presentations of diseases requiring revascularization of the vertebral artery and recall the guidelines of the 1975 Ad Hoc committee; 2) identify the explorations needed to detect vertebro-basilary insufficiency; 3) define operative indications since no consensus has been reached. PATIENTS AND METHODS: We reviewed retrospectively the files of 34 patients who underwent revascularization of the vertebral artery between January 1990 and December 2000. RESULTS: Surgery of the vertebral artery accounted for 4.6% of our vascular surgery cases involving the brain. Fifty percent of the cases of vertebro-basilary insufficiency were caused by hemodynamic disorders and 26.5% by embolism; 23.5% of the patients had no neurological sign. The most frequent neurological signs were vertigo (44%), balance disorders (41%), long pathway involvement (32%). Vertebro-basilary reimplantation was performed in 76% of the cases. There were no cases of stroke and no deaths during the early postoperative period. There was one case of asymptomatic thrombosis. Mean follow-up was 33.6 months with no patients lost to follow-up. Overall survival was 85.29% at 3 years with patent arteries in 97.06% of the cases at 3 years. CONCLUSION: Our series is in agreement with others reported in the literature, emphasizing the good outcome achieved after vertebral artery surgery. Surgery helps improve signs of vertebro-basilary insufficiency with little operative risk. This surgery is rarely indicated but must be recognized. One must also resist the temptation to "treat images".

Anatomic relations between the cephalic vein and the sensory branches of the radial nerve: How can nerve lesions during vein puncture be prevented?

UNLABELLED: The cephalic vein of the forearm is often used for IV catheters because of its ease of access for peripheral venous cannulation. But its close relation to the sensory branch of the radial nerve sometimes causes it to be damaged when the vein is cannulated. Our anatomic study conducted on 33 specimens confirmed the risk of nerve lesion. However, it is impossible to define a safe zone, because of the randomly located nerve and vein crossing zones, where the iatrogenic risk of damaging the radial nerve is maximum. We suggest that to avoid incidents, the cephalic vein should be punctured above the emergence of the sensory branch of the radial nerve, e.g., at least 12 cm above the level of the styloid process of the radius. IMPLICATIONS: We attempted to determine the relationship between the cephalic vein and the sensory branch of the radial nerve at the wrist to help prevent lesions of the radial nerve when the cephalic vein is cannulated. We examined the anatomy of 33 postmortem specimens and suggest that puncture of the cephalic vein 12 cm or more proximal to the styloid process can prevent radial nerve lesions.

Percutaneous transluminal angioplasty for management of critical ischemia in arteries below the knee.

Percutaneous transluminal angioplasty (PTA) can be performed safely in arteries below the knee by using current coaxial catheters. This study includes 37 consecutive patients treated between March 1992 and March 1999 by PTA for limb-threatening infrageniculate occlusive artery disease. The mean duration of follow-up was 28 months. Limb salvage was achieved in 32 patients. The actuarial limb salvage rate at 2 years was 87 +/- 6%. This study shows that PTA was a viable alternative to surgical treatment for management of critical lower extremity ischemia in carefully selected patients. Limb salvage rates after PTA and conventional surgical revascularization seem comparable. Based on these findings, we recommend that PTA be attempted, whenever possible, for initial treatment of patients presenting critical, limb-threatening ischemia due to isolated or multiple stenoses of below-knee arteries.

[Severe and distal ischemia of the upper limb. Results of a surgical follow-up of 11 years in 34 patients]. / Ischémie distale sévère du membre supérieur. Bilan d'un suivi chirurgical de 11 ans chez 34 patients.

The aim of this retrospective study was to evaluate etiology, frequency and prognosis of the distal and severe arterial diseases of the upper limb treated in a vascular surgical unit. Between Jan. 1986 and Jan.1997, 34 patients, 22 males and 12 females, mean age 56 years (range 30 to 87 years) were followed in the vascular and thoracic surgical unit in Angers. Follow-up was 100% complete. Each patient was explored by selective angiography of the upper limb due to the critical characteristic of ischemia.19 patients (56%) had tissue loss. Among multiple etiologies, arteriosclerosis was found in 32% of the cases. When medical treatment was unsuccessful, a thoracic sympathectomy was attempted in 50% of the cases, and 21% of the patients had direct arterial surgery. Nine deaths, due to initial pathology, occurred during follow-up. Eight digitalis amputations were carried out whose two directly because serious necrosis. Severe arterial diseases of the upper limb represented 6, 4% of critical limb ischemia treated during this same period. At time, this study showed arteriosclerosis preponderance over systemic diseases, and the seriousness of cases referred to a vascular surgical center after unsuccessful medical treatment (J Mal Vasc 1999; 24: 368-372).

High and low lateral approaches to the popliteal artery.

Using a series of 20 dissections and two anatomic transverse sections of a lower limb, the authors investigated the lateral approaches to the popliteal artery. The high lateral approach (above the knee) is not very aggressive and gives access to the retro-genicular part of the popliteal artery. After cutaneous and fascial incision, a simple gap between the vastus lateralis and biceps femoris mm. allows easy exposure of the popliteal vessels after backward retraction of the sciatic nerve. The low lateral approach to the artery (below the knee) is very aggressive for the vessels, nerves, and ligaments of the area. It involves the resection of the upper fourth of the fibula and the isolation and protection of the common peroneal nerve Nevertheless, these lateral approaches must be known and used when classic approaches (medial and posterior) are impossible.

Anatomic study of the deep plantar artery: potential by-pass receptor site.

The deep plantar artery is the main anastomosis between the dorsal and plantar arterial systems of the foot; with no change of calibre it unites the dorsalis pedis artery to the deep plantar arch, the second segment of the lateral plantar artery, passing into the first intermetatarsal space. Our anatomic study of 20 dissections of the deep plantar artery allowed us to verify the near-constancy of its descriptive anatomy and relationships. The deep plantar artery, when present, only found in 16 of our 20 cases, is totally linked to the dorsalis pedis artery. Its easy accessibility via the dorsal route, its medium calibre and the absence of collateral branches make this artery a possible anatomic site for the performance of a distal bypass, the last option before an amputation of the foot becomes necessary, although such a case remains exceptional.