Prognostic value of preoperative border-zone (watershed) infarcts on the early postoperative outcomes of carotid endarterectomy after acute ischemic stroke.

OBJECTIVES: To evaluate the prognostic value of cerebral border-zone infarctions (watershed infarctions) on the early postoperative outcomes of patients undergoing carotid endarterectomy (CEA) after acute ischemic stroke (AIS). METHODS: Sixty-six (66) patients with symptomatic carotid stenosis (SCS) that underwent ipsilateral CEA after AIS from January 2007 to March 2012 were included in this study. They were divided into two groups according to the topographic patterns of the stroke: group 1, Territorial Cerebral Ischemic Strokes (TCIS) caused by emboli of carotid origin; group 2, cerebral border-zone infarctions (CBZI) related to an SCS associated with hemodynamic impairment. All data was collected in a prospective database and analyzed. Outcome measures included postoperative neurological morbidity and 30-day mortality. RESULTS: Forty-three (43) patients (65.15%) experienced TCIS and were included in group 1, 23 patients (34.85%) had a CBZI and were included in group 2. There were no postoperative deaths. The postoperative neurologic morbidity rate was significantly higher in the CBZI group (22% vs. 2%, p = 0.02). Multivariate analysis demonstrates that CBZI was the only independent predictive factor of neurologic morbidity after CEA for AIS related to an SCS. Furthermore, the risk of postoperative neurologic morbidity remained significantly higher for patients with CBZI after adjustment for age, sex, initial NHISS scores, and associated contralateral carotid occlusion (HR: 0.059, 95% CI 0.004-0.85; p = 0.03). CONCLUSION: CBZIs, compared to TCIS, were associated with a higher neurological complication rate during the postoperative period after CEA for SCS in cases of AIS. Further studies are required to better define the timing and the best treatment modality for patients with CBZI related to an SCS in order to reduce associated procedural complications.

Arm composite autogenous vascular access using the great saphenous vein and the femoral vein: results from a single-centre study.

OBJECTIVES: The objective is to report our results with the arm composite autogenous vascular access (ACAVA) using the great saphenous vein (GSV) and the femoral vein (FV) in tertiary vascular access surgery. DESIGN: Retrospective single-centre study. Prospectively collected clinical database. METHODS: Between August 2009 and March 2011, 17 patients with no suitable upper extremity vein, repeated prosthetic access failure and/or infection underwent the construction of an ACAVA. Outcome measures included the graft patency and complication rates. RESULTS: The median follow-up was 25 months (5-32). Thirty-day morbidity affected 10 patients (59%): four wound-healing issues, three lower limb swelling, two early thromboses and one upper limb haematoma. No postoperative death occurred. At 3 months, the primary patency rate was 88% ± 8%. At 6 months, the assisted-primary patency rate was 82.4% ± 9.2%. At 12 months, the secondary patency rate was 81.6% ± 9.6%. Twenty-four secondary interventions were performed. Steal syndrome occurred in one patient following a secondary procedure. Swelling of the lower limb remained in two patients at the end of their follow-up. Three ACAVAs developed irreversible occlusion leading to loss of access. CONCLUSION: With a high rate of postoperative morbidity and re-intervention, the ACAVA is a useful additional technique that should be restricted to difficult cases with limited vascular access options.

In-situ revascularisation for patients with aortic graft infection: a single centre experience with silver coated polyester grafts.

OBJECTIVE: The aim of this study was to evaluate the early and mid term outcome of patients with aortic graft infection who underwent in-situ revascularisation with a silver coated prosthesis. MATERIAL: From January 2000 to December 2006, 24 consecutive patients (22 male, 2 female) with mean age 67 years were prospectively entered in this study of aortic graft infection at our single centre. Infection was managed with either total (n=19) or partial (n=5) excision of the infected graft and in- situ reconstruction with a silver coated prosthesis, Inter Gard Silver (IGSG). METHODS: The primary endpoint was recurrence of infection. Secondary endpoints were early and late mortality, peri-operative morbidity, primary graft patency, major amputation rates and patient survival. RESULTS: Fourteen patients had a primary graft infection, however 10 of 24 patients had graft infection secondary to aorto digestive (n=9) or aorto urinary (n=1) tract fistulas. Bacteriological cultures were negative in 8 (33%) patients. Most organisms cultivated where virulent and the majority of graft infections were polymicrobial (71%). Silver grafts were placed emergently in 6 (25%) patients. Mean follow up 32.5+/-31.0 months (range 2-78 months). Peri-operative morbidity and mortality were 46% and 21% respectively. Early interventions occurred in 6 (25%) patients and late secondary intervention were required in 3 (15.7%), caused by silver graft reinfection. The late mortality was 26%. CONCLUSION: In-situ reconstruction with the silver graft confirms similarity with other modalities. The greatest advantage for the silver graft is its ease of use but the risk of reinfection remains significant.

Percutaneous closure devices for endovascular repair of infrarenal abdominal aortic aneurysms: a prospective, non-randomized comparative study.

PURPOSE: This study was designed to describe and evaluate our preliminary results with a percutaneous arterial closure device as compared to those obtained with conventional femoral surgical cut down during endovascular repair of abdominal aortic aneurysms (AAA). MATERIAL AND METHODS: Between January 2004 and December 2006, 40 of 86 AAA patients selected for endovascular repair met the criteria for inclusion in this study. Nineteen of these patients (Group A) received a bifurcated endograft placed by direct puncture of the femoral arteries (38 femoral triangles) with closure by a Prostar((R)) percutaneous arterial closure device (Abbott). The other 21 patients (control group B) were managed with a bifurcated endograft placed by conventional open surgery (42 femoral triangles). Data concerning all 40 patients were collected prospectively and analyzed. RESULTS: The technical success rate was 92% (group A) vs 90% (group B), P=0.79. The incidence of perioperative complications was 16% (3/19) in group A and 14% (3/21) in group B (P=0.89). The mean hospital stay was 5.8 days in group A and 7.8 days in group B (P=0.05). The difference in the length of hospitalisation was associated with reduced cost for the percutaneous group (5579.60 euros vs. 7503.60 euros; P=0.04), that counterbalanced the cost induced by the Prostar XL((R)) suture mediated device. Mean follow-up in both groups was 12 months. The overall incidence of locoregional complications after one year of follow-up was 11% (2/19) in group A and 19% (4/21) in group B (P=0.45). CONCLUSION: This study confirms the feasibility and safety of total percutaneous endovascular AAA repair. Our preliminary results suggest that the costs paid by healthcare providers for endovascular AAA repair might not be increased with the selective use of percutaneous closure devices.

Endovascular repair of ruptured aneurysms of the infrarenal abdominal aorta: feasibility and results.

AIM: Endovascular repair may represent an interesting alternative to open surgery for ruptured abdominal aortic aneurysms (AAA). This study evaluated the feasibility and short-term results of endovascular repair of ruptured AAA at our center. METHODS: Between April 2004 and December 2005, all patients admitted to our center for a ruptured AAA were considered for endovascular repair. Patients whose hemodynamic status was too unstable to permit a preoperative CT scan and patients with an unfavorable anatomy for endovascular repair underwent open surgery. Endovascular repair consisted in emergency placement of an aorto-uni-iliac endograft associated with a crossover femoro-femoral bypass and deployment of an occluder in the contralateral common iliac artery. Follow-up postoperative CT scans were obtained 1, 6, 12 and 18 months after intervention and then annually. Data concerning diagnosis, the operative risk, treatment, and follow-up were collated prospectively in a registry and were analyzed on an intention-to-treat basis. RESULTS: Between April 2004 and December 2005, 17 patients were admitted to our Department for a ruptured AAA. Ten patients (59 %) underwent emergency endovascular repair and were included in this study (8 men and 2 women, mean age 81 years, range 51-97). The mean duration of the operation was 167 +/- 37 min. The mean blood transfusion volume was 3 700 +/- 1 400 mL. The mean duration of hospitalization was 19 days (range: 9-60). Mortality at day 30 was 20% (2 patients): one death occurred on day 2 due to multi-organ failure in an 80-year-old patient and another death occurred on day 2 owing to myocardial infarction in an 87-year-old patient. Mean follow-up was 6 months. Late mortality occurred in 2 cases. No endoleaks were observed during follow-up. CONCLUSION: Our initial results using endografts for the repair of ruptured AAA were satisfactory, with a feasibility of 59% and an operative mortality of 20%. Randomized studies are necessary to determine the true value of endovascular repair of ruptured AAA compared to conventional open repair.

Endovascular repair of infrarenal abdominal aortic aneurysms in high-risk-surgical patients.

PURPOSE: Following the publication of a prospective randomized trial (EVAR2) that questioned the benefit of endovascular repair of abdominal aortic aneurysms (AAA) for high-surgical-risk patients, we evaluated our own initial and long-term results with endovascular AAA repair for this patient population. MATERIAL AND METHODS: Between January 2000 and December 2005, 115 patients with an AAA managed by an aortic endograft were entered in a registry. Data concerning diagnosis, operative risk, treatment, and follow-up were analyzed on an intention-to-treat basis for all patients considered to be poor candidates for surgery. Patients with a ruptured AAA and those who were good surgical candidates were excluded from analysis. The main goal was evaluation of the operative mortality and the long-term survival of these patients. Secondary goals were determination of the frequency of secondary operations, the outcome of the aneurysm sac, and primary and secondary patency rates after aortic endograft placement. RESULTS: A total of 92 high-surgical-risk patients treated by an endograft were entered in this study. Sixty-seven patients (73%) were classed ASA III and 18 (20%) were ASA IV (20%). Mean aneurysm diameter was 58 mm+/-9 mm. The technical success rate was 99%. Operative mortality was 4.3% (4 cases). Four patients required re-intervention during the mean follow-up of 18 months. The survival rate at 3 yr was 85%. One type I endoleak (1%) and 9 type II endoleaks (9.7%) occurred during the follow-up period. Primary and secondary patency rates at 3 yr were respectively 96% and 100%. CONCLUSION: Our initial and long-term results with endograft repair of AAA in high-surgical-risk patients were satisfactory. These results appear to justify endovascular repair for this patient population.

[Elderly patients presenting with fever and respiratory problems in an intensive care unit. Diagnostic, therapeutic and prognostic impact of a systematic infectious disease consultation]. / Patients âgés fébriles avec signes respiratoires dans un service d'urgences. Impact diagnostique, thérapeutique et pronostique d'une consultation systématique d'infectiologie.

OBJECTIVE: To measure the impact of an infectious disease consultation on the morbidity and mortality in patients aged over 75 presenting with fever and respiratory signs and treated with antibiotics in an intensive care unit. METHOD: Retrospective study comparing two groups of patients having been seen or not by an infectious disease specialist within the first 24 hours of hospitalisation. The data available before prescription of the antibiotherapy by the intensive care physician were collected, together with the diagnostic and therapeutic proposals of the infectious disease specialist. Morbidity and mortality were assessed from the medical files and nurses charts and included: duration of fever and hospitalisation, complications with antibiotherapy and venous catheters and the cause or causes of death. RESULTS: 169 patients were included, 115 of whom had been seen (study group) and 54 who had not bee seen (control group) by an infectious disease specialist. Sixty-six percent of the infectious disease specialists (76/115) proposed a differential diagnosis, although a diagnostic re-assessment was effective for only 22% of the patients in the control group (p< 0.01). A 50% reduction in antibiotic prescriptions was observed in the study group. The duration of hospitalisation was greater in the study group than in the control group (a mean of 10 versus 7 days, p<0.01), but was unrelated to the consultation with a specialist. The same result was observed with the complications of venous catheterism (16 versus 2 cases, p =0.04). The rate of mortality was of 13% in both groups. CONCLUSION: The over-zealous diagnoses of infection are the primary cause of over-prescription of antibiotics. Despite the population studied, considered as fragile, the 50% reduction in antibiotics is without any negative prognostic impact.

[Laparoscopic aortoiliac surgery for occlusive disease and or aneurysms]. / Chirurgie laparoscopique aorto-iliaque pour lésions occlusives ou anévrismales.

The techniques of video-assisted surgery have been recently applied to aortoiliac surgery. The choices between first the retroperitoneal approach or the transperitoneal approach and the place of video-assisted surgery in relation to totally laparoscopic surgery are at the centre of debates. The aim of this clarification is to relate the evolution of laparoscopic aortoiliac surgery for occlusive disease and aneurysms through a review of the literature on this subject.

Value of stent placement during percutaneous transluminal angioplasty of the iliac arteries.

BACKGROUND: To determine the benefits of stents during percutaneous transluminal angioplasty (PTA) of the iliac arteries. Retrospective analysis of our 10-year surgical experience with iliac PTA from 1988-1997 permitted comparison of results during two consecutive periods: an initial period (1988-1992), during which stents were never used, followed by a second period (1992-1997), when stenting was performed on indication. METHODS: From January 1988 to October 1997, 287 iliac PTA procedures (158 common iliac arteries, 129 external iliac arteries) were performed on 250 patients. Thirty-seven patients had two iliac lesions that were treated simultaneously. Indications for PTA included stenosis (270 cases) and chronic occlusion (17 cases). Thirty-one patients (12.4%) underwent infra-inguinal bypass in addition to PTA owing to the existence of arterial lesions at two levels. Two consecutive patient groups were defined: Group I consisted of 75 patients who underwent 86 iliac PTA procedures between January 1988 and May 1992 without stent placement; Group II consisted of 175 patients who underwent 201 iliac PTA procedures between June 1992 and October 1997, when selective stenting was performed. A total of 55 stents (35 in the common iliac artery, 20 in the external iliac artery) were placed in Group II during PTA due to unsatisfactory immediate results (dissection, residual stenosis) or occlusion. RESULTS: There was no 30-day mortality. There were 15 immediate failures of PTA: 8 in Group I (10.7%) and 7 in Group II (4%). The cumulative initial success rate was 94%. Follow-up ranged from 3 months to 102 months (mean 37 months). The cumulative primary patency rate at 4 years was 62% (58% in Group I, 64% in Group II). The cumulative secondary patency rate at 4 years (including patients who subsequently underwent repeat angioplasty procedures) was 72% (68% in Group I, 74% in Group II). CONCLUSIONS: Stents were an effective means for treatment of initial failures of PTA in patients with iliac artery occlusive disease. However, there were no significant differences in the long term results between PTA alone and PTA with selective stent placement.

Impact of aortic diameter on the outcome of surgical treatment of abdominal aortic aneurysm.

Several recent articles have discussed ultrasonographic surveillance of small abdominal aortic aneurysms (AAA). The purpose of this study was to evaluate the impact of lesion size on immediate morbidity and mortality after surgical treatment of AAA. More specifically we investigated whether the mortality rate was lower after treatment of AAA measuring

Renal artery revascularization in combination with infrarenal aortic reconstruction.

Associated stenosis of one or both renal arteries is not uncommon in patients with infrarenal aortic disease (aneurysm or occlusive disease) requiring surgical repair. The purpose of this retrospective study was to analyze the short- and long-term outcome of concomitant renal artery and aortic reconstruction. The present series includes 39 consecutive concomitant procedures. Simultaneous aortic and renal artery reconstruction was performed in a total of 39 (7.2%) of the 540 patients who underwent elective infrarenal abdominal aortic repair between 1987 and 1996. There were 33 men and 6 women with a mean age of 66.7 years. Twenty-eight patients presented hypertension and 7 presented renal insufficiency associated with hypertension. In all cases, the indication for operative treatment was aortic disease, i.e., aortic aneurysm in 20 cases and occlusive aortoiliac disease in 19 cases. A total of 51 renal artery revascularization procedures were performed, including bypass in 40 cases, transposition in 7, and endarterectomy in 4. Combined aortic and renal artery reconstruction gives good short- and long-term results comparable to those of isolated aortic surgery. On the basis of these findings, we think that concomitant repair is the strategy of choice for patients presenting renal artery stenosis associated with infrarenal aortic disease requiring surgical therapy.

Surgical management of atherosclerotic carotid artery stenosis after cervical radiation therapy.

Carotid surgery following external cervical irradiation has not been a treatment of choice. The purpose of this retrospective study was to describe the immediate and long-term outcome in a series of 17 consecutive patients who underwent operative treatment for carotid artery stenosis after radiation therapy. From 1989 to 1997, surgical treatment of carotid artery disease was carried out in a total of 723 patients. Seventeen of these patients, 14 men and 3 women, had undergone previous external cervical irradiation; their mean age was 61.7 years. The indication for radiation therapy was ear-nose-throat cancer in 14 patients and lymphoma in 3 patients. In 10 patients, irradiation was associated with cervical surgery. The mean delay between radiation therapy and carotid artery repair was 10 years. All 17 patients were considered to be in remission at the time of carotid repair. The indication for carotid surgery was asymptomatic stenosis in 6 cases (33%) and symptomatic stenosis in 12 (67%). The procedure consisted of endarterectomy in 12 cases (67%) and venous bypass in 6 (33%). The outcome for these patients was favorable, indicating that carotid artery repair following cervical radiation therapy is safe. Results are comparable to those of procedures performed in patients with no history of cervical irradiation.

Late survival after abdominal aortic aneurysm repair.

OBJECTIVES: This study was undertaken to determine the late survival of patients operated successfully for abdominal aortic aneurysm (AAA) repair, to compare survival data with that of the age- and sex-matched general population, to identify the causes of late death, and to determine the factors influencing late survival. MATERIALS AND METHODS: A total of 187 consecutive patients underwent elective surgical AAA repair between January 1987 and December 1991. There were 11 postoperative deaths (early mortality rate 5.9%). The remaining 176 patients formed the basis of this cohort-based retrospective study. Six patients (3.4%) were lost to follow-up. Mean follow-up was 71 months. RESULTS: A total of 70 patients (39.8%) died during the study period. Coronary artery disease (CAD) and cancer were the two main causes. The survival rate at five years (71.6%) was lower than that of the sex- and age-matched general population (90.6%). Neither arterial hypertension nor CAD had any influence on late survival. In contrast, age and chronic renal failure were predictive variables of late survival. CONCLUSIONS: The life expectancy of patients who undergo successful AAA repair is not as good as that of the age- and sex-matched general population. Late survival depends on the patients' age at the time of surgery and the existence of preoperative chronic renal failure.

Anatomic bases for compression of the superior gluteal artery at the level of the gluteal canal.

Based on dissections, angiograms, frozen sections, anatomopathologic examination, and CT reconstructions, this anatomic study demonstrates the potential causes of compression of the superior gluteal artery (SGA) at the level of the gluteal canal. Findings suggest the existence of an osseofibromuscular trap responsible for stenosis of the SGA.

Aortoiliac reconstruction and kidney transplantation: a multicenter study.

The occurrence of aortoiliac lesions with renal transplantation is an increasingly common combination that causes problems regarding operative strategy and indications for aortoiliac reconstruction and renal transplantation. To gain greater insight into these problems we undertook a retrospective multicenter study based on data from 24 kidney transplantation centers in France. A total of 83 patients who underwent both aortoiliac reconstruction and kidney transplantation were enrolled. Patients were divided into two groups according to the order in which the two procedures were performed. Group I included 36 patients in whom aortoiliac reconstruction was performed before kidney transplantation-either during the same procedure (6 patients) or as separate procedures (30 patients). Group II included 47 patients in whom aortoiliac reconstruction was performed after kidney transplantation. The mean age was 49.9 years. There were 43 abdominal aortic aneurysms (51.8%), 36 occlusive aortoiliac lesions (43.4%), and 4 aortoiliac dissections (4.8%). Prosthetic bypass grafting was performed in 72 cases (86.8%), transluminal angioplasty in 6 cases (7.2%), endarterectomy in 3 cases (3.6%), and arterial autograft bypass in 1 case. Renal transplant protection was used during aortoiliac clamping in only 3 patients in group II (7.3%). One month after the second procedure (i.e., kidney transplantation in group I and aortoiliac reconstruction in group II), creatinemia was <200 micromol/L in 27 patients (87.1%) in group I and in 37 patients (88.1%) in group II. The graft survival rate was 86.1% in group I and 89.3% in group II. The overall postoperative morbidity rate was 36.1% (13 cases) in group I and 36.1% (17 cases) in group II. One year after the second procedure creatinemia was <200 micromol/L in 29 patients (93.5%) in group I and 36 patients (93%) in group II. The graft survival rate was 86.1% in group I and 85.1% in group II. The outcome of kidney transplantation is comparable regardless of whether the procedure is performed alone or in association with aortoiliac reconstruction. This finding indicates that kidney transplantation should be performed in patients presenting indications for prior aortoiliac reconstruction. The outcome of aortoiliac reconstruction without graft protection in kidney transplant patients is comparable to the outcome of conventional aortoiliac reconstruction in patients with native kidneys.

Revascularization of internal iliac arteries during aortoiliac surgery: a multicenter study.

In 1995, a total of 1785 patients underwent elective aortoiliac surgery at 35 centers in France, including 1024 for abdominal aortic aneurysm (57.4%) and 761 for occlusive aortoiliac lesions (42.6%). Direct revascularization of the internal iliac artery was performed in 11.2% of patients with both distal anastomoses located below the iliac bifurcations (18.4% with aneurysm vs. 6.8% with occlusive lesions, p < 0.001). Associated revascularization of the inferior mesenteric artery was performed in 9% of patients (11.5% with aneurysms vs. 5.5% with occlusive lesions, p < 0.001). Postoperative colonic ischemia was observed in 21 patients (1.2%) (1.2% with aneurysms vs. 1.2% with occlusive lesions) and claudication in the gluteal region was observed in 31 patients (1.7%) (1.5% with aneurysms vs. 2.1% with occlusive lesions). Revascularization of the internal iliac artery, regardless of the technique, had no significant effect on the incidence of postoperative colonic ischemia and claudication in the gluteal region-neither after surgery for aneurysm (0.6% vs. 2.1% and 1.2% vs. 1.9%, respectively) nor after surgery for occlusive lesions (0.9% vs. 0.4% and 1.5% vs. 2.6%, respectively). Whether performed routinely or not, revascularization of the mesenteric artery has no significant effect on the incidence of postoperative colonic ischemia (1.1% vs. 1.3%).

Role of direct revascularization of the internal iliac artery during aortoiliac surgery.

The purpose of this retrospective study was to determine the indications and efficacy of direct revascularization of the internal iliac arteries during aortoiliac reconstruction in the prevention of postoperative colonic and pelvic ischemia. This study included 540 patients who underwent aortoiliac reconstruction between January 1987 and December 1996 for nonruptured abdominal aortic aneurysm in 341 cases (63%) and occlusive aortoiliac disease in 199 cases (37%). Mean age was 67.4 years. A tubular aortic prosthetic graft was used in 36 patients and a bifurcated prosthetic graft in the remaining 504 patients. Direct revascularization of the internal iliac artery was performed 102 times in 85 patients (72 with aortic aneurysms and 13 with occlusive aortoiliac disease). The indication for direct revascularization was absence of adequate retrograde flow in 54 cases (53%), absence of anterograde flow in 19 cases (19%), and aneurysmal involvement of the origin of one internal iliac artery in 29 cases (28%). Concomitant revascularization of the inferior mesenteric artery was performed in 14 cases (2.5%). Twenty-two patients (4.1%) died during the immediate postoperative period and two (0.4%) presented nonfatal colonic ischemia. Fatal pelvic ischemia occurred in one patient following treatment of an aortoiliac aneurysm with retrograde revascularization of the internal iliac artery. Postoperative rest pain due to buttock ischemia was observed in three patients (0.6%) in whom direct revascularization of the internal iliac artery was not performed. In the subgroup of patients who underwent direct revascularization of the internal iliac artery, there were 3 deaths (3.5%), 13 nonfatal complications (15.3%), and no colonic ischemia. In this series direct revascularization of the internal iliac artery was performed in a high proportion of cases (15.7%) and did not increase the postoperative morbidity/mortality rate. The incidence of postoperative colonic and pelvic ischemia was low (0.6%). Direct revascularization of the internal iliac artery in selected patients appears to be effective in the prevention of postoperative pelvic and colonic ischemia.

[Carotid angioplasty: review of the literature]. / Angioplastie carotidienne: données de la littérature.

PURPOSE: In order to assess the current knowledge of carotid angioplasty and stenting, we reviewed the pertinent literature distinguishing two types of reports on angioplasty for atherosclerotic stenosis of the internal carotid artery: case reports and series with less than 10 cases, and series reporting more than 10 cases. METHODS: Each series was examined individually followed by a general analysis. RESULTS: The 11 largest series in the literature included a total of 912 patients. The rate of transient ischemic attacks ranged from 6 to 14.8%. Stroke rate varied from 1.5 to 9.1%. Restenosis was reported in 4 to 16% of cases. CONCLUSION: Based on the data available in the literature, we cannot recommend carotid angioplasty. Carotid endarterectomy is recognised as safe and is generally considered to be the gold standard. In order to assess carotid angioplasty and stenting accurately, prospective randomized studies comparing surgery and angioplasty are necessary.

[Treatment of iliac artery stenosis and obliteration by transluminal angioplasty]. / Traitement des sténoses et des oblitérations iliaques par angioplastie transluminale.

PURPOSE: Percutaneous transluminal angioplasty (PTA) has an established and valuable role in the treatment of iliac stenoses and occlusions. The use of stents may improve the results of PTA. The aim of this study is to report our surgical experience of iliac angioplasty over the past 5 years. PATIENTS AND METHODS: From January 1993 to October 1997, 201 iliac PTA were performed in 175 patients, at the level of the common iliac artery (n = 111) and external iliac artery (n = 90). In 26 cases, two iliac lesions were treated simultaneously. There were 188 stenoses and 13 chronic occlusions. During PTA, 55 stents were used, because of unsatisfactory results (dissection, residual stenosis) or in case of total occlusion, in the common iliac artery in 35 cases and in the external iliac artery in 20 cases. In 15 cases (8.6%), a femoro-popliteal bypass was associated to the iliac PTA, because of multilevel occlusive disease. RESULTS: There were no early deaths. There were seven initial failures. The initial success rate was 96%. The clinical follow-up has been achieved in 163 patients, (range: 3 to 48 months, mean: 28 months). The primary patency rates were 84%, 79% and 63% respectively at 1, 2, and 4 years. The secondary patency rates were 87%, 85% and 73% respectively at 1, 2, and 4 years.

Lower limb trauma caused by power-driven cultivators: report of 23 cases.

OBJECTIVE: To determine the mechanism and the severity of injuries caused by power-driven cultivators. METHODS: This retrospective study analyzed the clinical records of 20 patients treated from 1984 to 1996 for a total of 23 lower limb injuries caused by power-driven cultivators (three patients had bilateral injuries) in the Nice University Hospital. RESULTS: A total of 90% of the accidents occurred when the machine was put into reverse and the limb was caught by the rotary blades; the cause of the remaining accidents was unknown. Of the 23 patients, 10 patients (43.5%) suffered posterior dislocation of the knee due to forced hyperextension. Injuries were classed in two groups as a function of their prognosis: group I consisted of osteomuscular lesions without vascular or nerve involvement (11 lower limbs, 11 patients). The mortality rate in this group was 9%, the rate of major amputation was 18%, and the prognosis was favorable in 82% of the cases. Group II corresponded to lower limb injuries with neurovascular involvement (12 lower limb injuries in 10 patients: one patient belonged to both group I and group II). Acute lower limb ischemia was constant in group II; the mortality rate was 20% (two of 10 patients), and the rate of major amputation was 41.6% (five of 12 patients; three emergency amputations and two secondary amputations). CONCLUSION: These agricultural machines can cause severe trauma, and the resulting wounds are contaminated by telluric germs in rural areas. Paradoxically, power-driven cultivators are not legally classified as "dangerous machines." Modification of existing legislation in this field would seem advisable.