[Aortofemoral bypass: gold-standard or outdated?]. / Le pontage aorto-bifémoral: traitement de référence ou intervention du passé?

Although aorto-bifemoral bypass procedures have proven efficacy for the treatment of aortoiliac occlusion, complications have led to a preference for less invasive interventions. A precise knowledge of this morbidity is thus necessary to evaluate and compare outcome with alternative techniques. The purpose of this study was to analyze the course of complications observed in a large group of patients who recently underwent aorto-bifemoral bypass performed by the same team. Between 1975 and 1996, 720 patients underwent aorto-bifemoral bypass procedures for occlusion. Indication for surgery was invalidating claudication in 68%, pain at rest in 28% and trophic disorders in 4%. Mean follow-up was 9.6 years. Twenty-three patients were lost to follow-up. One hundred sixty cases of prosthesis complications were recorded (21.3% of patients): ten infections (1.3%), 14 false aortic aneurysms (2%), 40 false femoral aneurysms (5.5%), 82 prosthetic thrombotic events (11.2%), and 14 femoral anastomotic strictures (1.9%). These complications led to death in nine patients (1.2%) and amputation in 23 (3.2%). Analysis of the results show that late mortality attributable to the prosthesis was minimal compare with other causes of death. Numerous complications occur late after prosthetic repair but their impact on mortality and amputations is limited. Aorto-bifemoral bypass is a safe technique that remains the gold standard for evaluation of other revascularization methods.

[Long-term results of aorto-bifemoral prostheses in the surgery for atheromatous stenosis of the aortic bifurcation]. / Résultats à long terme des prothèses aorto-bifémorales dans la chirurgie des sténoses athéromateuses du carrefour aortique. 700 malades suivis pendant 20 ans.

Seven hundred patients operated consecutively by the same surgical team for atheromatous stenosis of the aortic bifurcation were followed up for 20 years with only 5 patients lost to follow-up. There were 94.5% of men with a mean age of 58 years. The operative mortality was 2.7% with few deaths due to true cardiovascular causes (0.7% of patients). The secondary mortality was very high with two main causes: cancer (39% of patients) and cardiovascular diseases (37%). Other causes were responsible for only 24% of deaths. The principal complications of the prostheses were: infection (0.6% of operated patients), thrombosis (6.7%), pseudo-aneurysm of the aorta (1.57%) and pseudo-aneurysm of Scarpa's triangle (4%). The benefits of surgery are unquestionable both on terms of survival, as amputation, bed confinement and invalidity are avoided, and in terms of function, as amputation was avoided in 84% of the 32% of patients in Stages III or IV before surgery. Only 5% of patients were amputed during the observation period. Moreover, 79% of survivors had a good functional result at 15 years. Improvement of results depends on better hygienic measures, systematic screening for high risk cancers and a better management of the arterial disease with early treatment of other arterial diseases (coronary, carotid) in order to reduce postoperative and mostly medium- and long-term cardiovascular mortality.

The human saphenous vein in pharmacology: effect of a new micronized flavonoidic fraction (Daflon 500 mg) on norepinephrine induced contraction.

Local acidosis (pH 6.4) depresses reactivity of vascular smooth muscle and especially the response of human isolated saphenous veins to exogenous norepinephrine. Experiments were performed to study, under acidosis conditions, the interaction between Daflon 500 mg, a micronized fraction of 90% diosmin and 10% hesperidin, and norepinephrine on human rings of veins. Varicose veins were obtained by conservative varicose veins surgery and normal veins from patients undergoing coronary artery bypass graft surgery. Isometric tension was recorded from venous rings in organ chambers filled with Krebs-Henseleit solution (pH 7.4; 37 degrees C). Metabolic acidosis (from pH 7.4 to 6.4) was obtained by lowering the HCO3- concentration of the Krebs-Henseleit solution. Cumulative concentration-response curves for norepinephrine (10(-7) to 10(-5)M) were obtained at pH 6.4 in the presence or in the absence of Daflon 500 mg (10(-5)M) added 20 min previously to the organ bath. Under acidotic conditions, Daflon 500 mg induced a shift to the left of the concentration-response curves for norepinephrine. This potentiation was significant in both normal and varicose veins and was increased in proportion with the pathological status of the venous rings. These results support the therapeutic benefits of Daflon 500 mg in chronic venous insufficiency.

Long-term of patients receiving an aorto-bi-femoral prosthesis for atherosclerotic occlusive disease of the aortic bifurcation.

Over a 14-year period (1975-1989), 547 patients with a mean age of 57 years received an aorto-bi-femoral prosthesis for atherosclerotic occlusive disease (AOD) and underwent regular follow-up over a 13-year period. Immediate post-operative mortality was 2.5% with few deaths due to cardiovascular causes (0.5%). The long-term mortality was significantly elevated at 5 years (10% higher than controls) and at 10 years (16%). These deaths were due to the AOD and its surgical treatment (10%), other cardiovascular disease (30%) and cancer (41%). Approximately 5% of patients required an immediate post-operative, or delayed amputation, compared to 33% which had a threatened limb before the operation. Thrombosis of the prosthesis was relatively rare. At 5 years, 81% of the survivors remained largely improved; at 10 years, 67% and at 13 years, 62%. The benefit of this intervention is therefore unquestionable with regards to the functional state and survival. Also, in avoiding immobility due to the disabling intermittent claudication or amputation, it considerably improves the quality of life which largely compensates for the low mortality rates and subsequent complications of the prosthesis.

[Bilateral aorto-iliac prosthesis. Long-term results]. / Prothèses aorto-bi-fémorales. Résultats à long terme.

Over a 12-year period (1975-1987), 565 patients (male: 94.5 percent; female: 5.5 percent) underwent aorto-iliac bilateral reconstruction. The operations were performed by the same surgical team and all patients were followed up for 13 years. The patients' mean age was 59.4 years; 16.6 percent were over 70; 16 percent had a non-fissured aneurysm. The postoperative mortality rate was 2.8 percent, with relatively few deaths of cardiovascular origin (0.5 percent). The late mortality rate was significantly higher than that of an age-matched control population. Arteritis and its surgical treatment accounted for a low proportion of late deaths: 10.7 percent as opposed to other cardiovascular diseases (33 percent) and chiefly to cancer (39 percent)--a figure not found in other reports. Five percent of the patients had to be amputated soon after the operation or later; this is a low figure compared with the 33 percent of patients who had one limb threatened before reconstructive surgery. After the aorto-iliac reconstruction 81 percent of the patients remained considerably improved at 5 years and 67 percent at 10 years. Long-term arterial patency was satisfactory (95 percent at 5 years, 90 percent at 10 years). This type of surgery, therefore, benefits the patients' functions and their life: it avoids rupture of aneurysms and sedentarity due to a disabling intermittent claudication, and it considerably increases the duration of life.

[Survival and causes of secondary mortality in patients undergoing coronary bypass. Comparison with a same age control population]. / Survie et causes de mortalité secondaire des malades opérés de pontages coronaires. Comparaison avec une population témoin de même âge.

During 10 years, 867 patients in whom the same surgical team had performed coronary bypass were followed up regularly without any of them being lost sight of. Moreover, the cause of all deaths in this group could be determined fairly accurately. A comparison of mortality between these patients and an age-matched control population studied longitudinally, year after year, showed that the mortality rate in the surgical group was slightly higher than in the control group (84 vs 77). Conversely, when the operative mortality was discounted, it appeared that the patients who survived coronary bypass had a much better survival than the control population (47 vs 77). Without any doubt, the prognosis for life is improved by surgery. In particular, patients with three-vessel disease (58 per cent), tight stenosis of the common coronary artery (10-25 per cent) or altered ventricular ejection fraction (about 30 per cent) would probably have died without myocardial revascularization. However, this study produced a rather astonishing result: compared with the control population, the decrease of long-term mortality in patients who survived coronary bypass was due not only to the decrease of cardiovascular deaths (16 vs 24) but also of deaths due to cancer (15 vs 27) or to other causes (16 vs 26). This suggests that a more hygienic life and a correct medical follow-up contribute to a large extent to the long-term survival of these surgical patients.

[Long-term clinical results of coronary surgery. Apropos of 400 patients followed for 5 to 11 years]. / Les résultats cliniques à long terme de la chirurgie coronaire. A propos de 400 malades suivis de 5 à 11 ans.

Between 1976 and 1982 four hundred consecutive patients underwent coronary artery bypass surgery and were operated by the same surgical team: 345 men (88.5%) and 46 women (11.5%). The average age was 56 years (7.5% were over 75 years of age); 86% of patients were infunctional classes III and IV; 46% had triple vessel disease and 9.25% had severe stenosis of the left main stem. Left ventricular ejection fractions were decreased in 26% and very poor in 4.5% of patients. The average number of bypass grafts was 1.72 per patient and the operative mortality was 3.5%. The 10 year survival rate was 81% and 75% of these patients still thought that their condition had been improved by surgery although only 30% were completely asymptomatic and had had no further coronary event. A comparison with a control population of the same age showed better survival in the surgical group in patients surviving operation. Contrary to traditional thinking, the surgical patients suffered relatively few deaths of cardiac causes but as many, if not more, of cancer. The operated patients died of approximately the same diseases as the control population of the same age but in lower proportions for each cause of death (17 cardiovascular deaths in the control population compared with 13 in the operated group; 18 versus 10 deaths of cancer, and 18 versus 8 deaths of other causes in the control and operated patients, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgery of the aortic arch in coronary patients. 400 surgically treated patients]. / Chirurgie du carrefour aortique chez les malades coronariens. 400 malades opérés.

Out of 400 consecutive patients who underwent aorto-iliac surgery 45 (11.25 per cent) were known to have coronary disease at the time of the operation. Pre-operative coronary arteriography was carried out in the 11 patients (2.75 per cent) who had unstable or recently worsened angina. Aorto-coronary bypass was performed preventively in 7 patients (1.75 per cent of surgical patients). Mortality from preventive aorto-coronary bypass and secondary aorto-iliac surgery was nil. A study of post-operative mortality (2.75 per cent overall) showed that only one patient (0.25 per cent of surgical patients) died of myocardial infarction. The low rate of post-operative morbidity and mortality of coronary origin therefore does not incline to extend the indications for preventive aorto-coronary bypass. However, it seems desirable to improve the indications for pre-operative coronary arteriography by performing thallium 201 myocardial scintigraphy with dipyridamole infusion in all coronary patients about to undergo aorto-iliac surgery when no exercise electrocardiogram can be obtained because of intermittent claudication. This type of examination will probably broaden the indications for pre-operative coronary arteriography and preventive aorto-coronary bypass, though presumably to a very small extent. Among these 400 patients who underwent aorto-iliac surgery and were all followed up for 2 to 12 years, only a few (0.25 per cent) benefited secondarily from coronary surgery, no doubt because the physiological age of that population was often too high. In fact, these patients were mainly at risk of cancer aggravated by both alcohol and smoking, for in this study, and rather in contrast with most publications, cancer was responsible for 44 per cent of secondary deaths, i.e. more than twice the percentage (20 per cent) of secondary deaths of cardiac origin.

[Double coronary revascularization using the internal mammary arteries. Mid-term results of 74 cases]. / Doubles revascularisations coronariennes par les artères mammaires internes. Résultats à moyen terme de 74 cas.

This study reports our experience of 74 multiple coronary artery bypass, using either the two internal mammary arteries (IMA) (43 cases), or the left internal mammary artery (LIMA), alone for sequential bypass (31 cases). Comparison with a series of 200 patients operated upon in a previous period (1981-83), when the LIMA was used alone for single bypass, showed that post-operative mortality, post-operative infarction and mediastinitis were significantly more frequent with double bypass using the two IMA; similarly, the mid-term results seemed to be less satisfactory with the double IMA bypass technique. This difference was due to the fact that using the right and left IMA means longer dissection time, greater problems of haemostasis, stronger surgical trauma and prolonged exposure of the sternum, which is a source of infection. In addition, the right internal mammary artery (RIMA) being further away from the sites of coronary grafting lends itself less readily than the LIMA to this type of bypass, and it is often used for the right and marginal coronary artery which is less suitable for surgery. Using the LIMA alone for sequential bypass does not seem to produce more complications than using that vessel for single bypass. On the basis of the results obtained, we consider that the double IMA bypass should only be used when the internal saphenous vein bypass is contraindicated (past history of stripping, varices, fragile aorta forewarning of difficult grafting).(ABSTRACT TRUNCATED AT 250 WORDS)

[Left internal mammary artery. Choice graft for coronary bypass]. / L'artère mammaire interne gauche. Greffon de choix pour les pontages coronaires.

The left internal mammary artery is a vessel with relatively constant anatomical features and which in almost all subjects is congruent with their own anterior interventricular artery. In addition, atheromatous lesions of this artery are exceptional; when grafted onto the anterior interventricular artery, it adjusts itself to the diastolic coronary flow. Finally, and this is remarkable, once grafted onto the anterior interventricular artery it virtually never undergoes long-term alterations in contrast with the internal saphenous vein. For these reasons, the left internal mammary artery should be used as often as possible to revascularize the anterior intraventricular artery. Preoperative angiography of the left internal mammary artery to evaluate its quality does not seem to be necessary; what is important in the choice of a graft is the quality of the spurt after the vessel is dissected and its distal end is severed. However, the left internal maxillary artery is smaller and more friable in women, in hypotrophic subjects and in elderly people, especially when hypertensive. In these cases, it should be used with caution or not at all, particularly for bypass with a fairly wide, atheromatous and calcified anterior intraventricular artery. Accounting for these restrictions and with some experience at least 90% of anterior interventricular arteries can be revascularized by the left internal mammary artery.

[Follow-up angiography of 100 revascularizations of the anterior interventricular artery by the left internal mammary artery]. / Contrôle angiographique de 100 revascularisations de l'interventriculaire antérieure par l'artère mammaire interne gauche.

One hundred and fifty patients who underwent revascularisation of the left anterior descending artery (LAD) by the left internal mammary artery (LIMA) between 1981 and 1983 were recalled for control coronary angiography one year after surgery. One hundred patients gave consent. The patency rate in these 100 patients was 90 per cent. The presumed causes of the 10 thromboses observed were: for LAD (5 cases), technical problems (3 cases), competitive flow (2 cases). Ten per cent of the patent LIMA grafts were abnormal: moderate stenosis of the anastomosis (5 cases), small LIMA (3 cases), stenosis of the middle segment of the LIMA (1 case). In addition, we observed 7 cases of competitive flows: 3 cases with a LAD which was not sufficiently stenotic, 4 cases with a large saphenous diagonal bypass graft. If a diagonal artery bypass is necessary, it is better to revascularize by either a latero-lateral anastomosis with the LIMA or by using the right IMA. Ninety per cent of the patent grafts were quite satisfactory ar 1 year: regular, supple, and perfectly congruent with the bypassed artery which was injected massively. As a number of North American teams have shown, this good patency rate seems to be maintained at long term, which is not the case with saphenous vein bypass grafts.

[Medium-term results of 200 consecutive systematic operations for revascularization of the anterior interventricular artery by the internal mammary artery]. / Résultats à moyen terme de 200 interventions de revascularisation consécutives et systématiques de l'IVA par l'artére mammaire interne.

This study presents the preliminary results of systematic revascularisation of the left anterior descending (LAD) by the internal mammary (IM) artery. Between 1981 and 1983, 200 IM bypass procedures were performed (88.5% of bypassed LAD arteries during the same period). With experience, the contraindications of IM bypass surgery progressively decreased (none in the latter 100 cases). The IM bypass grafting was an isolated procedure in 35% of cases and associated with one or more saphenous vein (SV) bypass grafts in 64.5% of cases with an average of 1.9 grafts per patient. The surgical results were better than those of SV bypass grafting alone in the period 1978-1980 with a mortality of 2.5% and a perioperative infarction rate of 2.5% compared to 4.3% and 7% respectively. The medium term results (average follow up 2.5 years) show that more patients undergoing IM bypass surgery were asymptomatic (75%) than those undergoing SV bypass (46%). However, the patients operated more recently by IM bypass benefitted from the latest technical advances in bypass surgery. An unselected sample of 55 volunteers (out of 90 recalled patients) underwent angiography at 1 year. The patency rate was 93% with a very satisfactory angiographic appearance of the graft in nearly all patients suggesting the likelihood of a good long term result. It was possible to demonstrate graft patency by Doppler ultrasound and digitised intravenous angiography in some cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Indications and results of coronary surgery in patients aged 70 or more]. / Indications et résultats de la chirurgie coronaire à 70 ans et plus.

Among 400 consecutive patients who underwent coronary bypass performed by the same surgical team, 20 (5%) were aged 70 or more (mean: 71.52 years). This group represented one-third of coronary arteriographies carried out at that age. Most patients had stage III or IV coronary disease. All were seriously invalidated but in good general condition without systemic disease or dangerous arterial lesions. Coronary arteriography showed highly surgical lesions in all 20 cases, with 3-vessel lesions in 45% and tight stenosis of the main vessel in 25%. Ventricular function was generally normal. The average number of bypasses per patient (1.65) was distinctly lower than in younger subjects. The results obtained were most encouraging, with no death and no myocardial infarction either postoperatively or during a mean follow-up period of 2.5 years. Only 2 patients had residual angina. Compared with operated patients under 70, this group was characterized by a longer duration of the disease prior to surgery and by a higher percentage of severe clinical stages and life-threatening and highly surgical lesions. Post-operative and medium-term results were also distinctly better, probably because of stricter selection for surgery. All this has been confirmed in several North American publications which also report excellent results in patients over 70 years of age. To conclude, there are excellent reasons for performing coronary bypass in these elderly patients and age should not preclude pre-surgical arteriography, especially when the patient is seriously invalidated and when his general condition is sufficiently good to tolerate cardiopulmonary bypass.

[Role of preventive surgery in patients with multiple arterial disease. 700 patients successively treated by revascularization operations]. / Place des interventions préventives chez le polyartériel. Septcents malades traités de façon consécutive par une intervention de revascularisation.

In a series of 700 patients who underwent successive recanalizations, 1.8% of patients who had coronary bypass and 8.1% of those operated upon for arteritis presented with associated lesions of the carotid arteries; 10% of patients with arteritis and 25.7% of patients with carotid artery lesions had a history of coronary artery disease. Although associated arterial lesions were relatively frequent, no coronary bypass was carried out preventively. Seven patients had preventive endarteriectomy of the carotid artery (6 before surgery for arteritis and 1 concomitantly with coronary bypass) without complications ascribable to angiography or surgery. Post-operative or medium-term complications of coronary artery and carotid artery lesions were exceptional. Except for one questionable case, the patients' general condition was so poor that they could not have benefited from preventive surgery. No post-operative complications due to associated lesions of the renal or gastrointestinal arteries occurred in this series. Only one patient had bilateral recanalization of the renal arteries during surgical treatment of the aortic bifurcation. In view of these findings, systematic exploration by invasive methods of asymptomatic or clinically stable associated arterial lesions seems to be unnecessary. This view is shared by most authors. The best way of preventing complications from associated arterial lesions resides in the quality and improvement of modern intensive care techniques.