Anatomy of the Hunter's canal and its role in the venous outlet syndrome of the lower limb.

BACKGROUND: The "Adductor canal syndrome" has been described as an unusual cause of acute arterial occlusion inside the Hunter's canal in young sportsmen. It may also produce a compressive neuropathy of the saphenous nerve. To our knowledge, femoral vein compression in the canal has never been reported. OBJECTIVE: To describe the anatomy, to propose a physiology of this canal, and to show that the femoral vein is much more exposed than the artery to compression inside this adductor hiatus, particularly at the outlet. MATERIAL AND METHODS: The whole adductor canal was exposed in 100 limbs for anatomical study following latex injection. A series of 200 phlebographies and 100 CT venograms were also analyzed. RESULTS: Anatomically, we found a musculotendinous band called the "vastoadductor membrane," which jointed the adductor tendon to the vastus medialis in all the cases. The femoral vein, located more posteriorly, was frequently narrowed at this level. This band can create a notch with a venous stenosis at the outlet of the Hunter's canal, usually located 12-14 cm above the femoral condyle. Two femoral valves constitute the landmark of the canal on the venograms: the lower is just below the outlet, 9 cm above the condyle. The second valve is 3 cm higher inside the canal.Functionally, the cadaveric simulations showed that the contraction of the adductor longus closes the hiatus, while the adductor magnus opens it. Our hypothesis is that Hunter's canal prevents femoropopliteal axis reflux by synchronizing with calf pump ejection during ambulation. CONCLUSION: Compression of the femoral vein inside the adductor's canal is an underestimated and misdiagnosed cause of postural stenosis of the femoral vein. Ultrasound investigation of both limbs in patients with chronic venous disease (CVD) should be systematically carried out at this precise level in order to prevent future occlusion and onset of acute deep vein thrombosis.

Treating diabetes with islet transplantation: lessons from the past decade in Lille.

Type 1 diabetes (T1D) is due to the loss of both beta-cell insulin secretion and glucose sensing, leading to glucose variability and a lack of predictability, a daily issue for patients. Guidelines for the treatment of T1D have become stricter as results from the Diabetes Control and Complications Trial (DCCT) demonstrated the close relationship between microangiopathy and HbA1c levels. In this regard, glucometers, ambulatory continuous glucose monitoring, and subcutaneous and intraperitoneal pumps have been major developments in the management of glucose imbalance. Besides this technological approach, islet transplantation (IT) has emerged as an acceptable safe procedure with results that continue to improve. Research in the last decade of the 20th century focused on the feasibility of islet isolation and transplantation and, since 2000, the success and reproducibility of the Edmonton protocol have been proven, and the mid-term (5-year) benefit-risk ratio evaluated. Currently, a 5-year 50% rate of insulin independence can be expected, with stabilization of microangiopathy and macroangiopathy, but the possible side-effects of immunosuppressants, limited availability of islets and still limited duration of insulin independence restrict the procedure to cases of brittle diabetes in patients who are not overweight or have no associated insulin resistance. However, various prognostic factors have been identified that may extend islet graft survival and reduce the number of islet injections required; these include graft quality, autoimmunity, immunosuppressant regimen and non-specific inflammatory reactions. Finally, alternative injection sites and unlimited sources of islets are likely to make IT a routine procedure in the future.

Anatomy of the foot venous pump: physiology and influence on chronic venous disease.

The aim of this paper is to demonstrate the location of the venous foot pump using an anatomical study. Four hundred cadaveric feet were injected with green neoprene latex followed by a dissection. A coloured segmentation of the venous system was achieved. The Lejars' concept of the venous sole of the foot is incorrect: the true blood venous reservoir of the foot is located deeply in the plantar veins, between the plantar muscles. The medial and mostly lateral plantar veins converge into the plexus shaped calcaneal crossroad, where the blood is ejected upwards into the two posterior tibial veins. In addition, the several medial perforators of the foot directly connect the deep system (medial plantar veins) to the superficial venous system (medial marginal vein). This forms a true 'medial functional unit' which is unique in the limb given its directional flow is from deep to superficial. In conclusion, the plantar veins play an important role in the physiology of the venous return since a venous reservoir of 25 mL of blood is mobilized upwards with each step during walking. Therefore, the impairment of the foot pump by a static foot disorder should be considered as an important risk factor for chronic venous disease, and should be evaluated and corrected in any patient with venous insufficiency.

Anatomical and radiological evidence for the iliolumbar vein as an inferior lumbar venous system.

The purpose of this work was to study an inferior lumbar venous system, which turned out to be the vertical component of the iliolumbar vein as defined in early works by Bourgery and Jacob, though there is a terminological ambiguity between the iliolumbar vein and the ascending lumbar vein in the literature. However, the iliolumbar vein is most commonly defined as a vein draining the fourth and fifth lumbar vertebral segments. Cadaver studies, including one injection-corrosion, and in vivo venograms were analyzed by visual inspection and measurements. Whether the injection was made via the axillary or the saphenous veins, the inferior lumbar vein was always filled, demonstrating that it is part of the vertebral venous system. An interruption or a plexiform shape of the venous system at the level of the third lumbar vertebra, and an increase in caliber as this vein runs downwards, allowed differentiating the inferior lumbar vein from the ascending lumbar vein. The inferior lumbar vein and the superior iliac vein drained into the iliac veins, either external or internal iliac vein, but typically into the common iliac vein, separately or with a single common trunk. This common trunk was observed in 92% of the dissected cases on the right side and in 46% on the left, whereas it was seen in 50% of the radiological studies on the right side and 52% on the left. Consequently, the inferior lumbar vein was the main component of the iliolumbar vein, and as such should be differentiated from the ascending lumbar vein.

Embryology and three-dimensional anatomy of the superficial venous system of the lower limbs.

OBJECTIVES: The purpose of this study is to better understand the anatomy of the venous network of the lower limbs by using new imaging techniques, particularly the three-dimensional modelling by computerized tomographic (CT) venography. This new tool is combined with anatomical dissection techniques and the results of Duplex ultrasound imaging. METHODS: The embryogenesis of the venous network, which explains the main variations of the venous system, and a description using the new terminology of the veins. RESULTS: Physiologically, the muscular veins play a crucial role, owing to the effect of the muscular pumps by their aspiration power on the superficial system via the perforators. They always act at the same level. This explains the fixity of the main perforator veins and the interest of their anatomical knowledge. CONCLUSION: The new imaging techniques and treatments dedicated to the venous system of the lower limbs make their descriptive anatomy increasingly useful. It will be the basis of a common language between radiologists, phlebologists and surgeons.

Subcutaneous emphysema and mediastinitis: unusual complications of tonsillectomy.

INTRODUCTION: Subcutaneous emphysema and mediastinitis are rarely reported complications of tonsillectomy. CASE REPORT: We describe two patients who developed subcutaneous emphysema, one of them with mediastinitis, within a few days after tonsillectomy. The diagnosis was based on the clinical presentation and confirmed by computed tomography (CT). For the patient without mediastinitis, the emphysema disappeared after a short period of reintubation and administration of antibiotics. For the patient with mediastinitis, surgical drainage of a cervico-mediastinal purulent collection was necessary to obtain healing. DISCUSSION: The events leading to subcutaneous emphysema and mediastinitis have not been entirely clarified. They probably include direct introduction of air into the neck via either the tonsillar bed or a laryngeal or pharyngeal wound caused by intubation. The clinical presentation, treatment and possible pathophysiology of subcutaneous emphysema and medisastinits are discussed. CONCLUSION: Emphysema and mediastinitis after tonsillectomy occur seldomly. If rapidly recognised and appropriately managed, mortality can be avoided.

[Nocardia otitidiscaviarum, cutaneous infection in a patient receiving long-term corticosteroid treatment]. / Nocardiose cutanée à Nocardia otitidiscaviarum chez un patient traité par corticothérapie au long cours.

A 62-year-old man, under long-term corticosteroid therapy for pigeon breeder's disease, was admitted to endocrinology disease department for cutaneous abscess on back, limbs and scalp. Culture of various bacteriological samples (cutaneous abscess, blood culture) isolated Nocardia otitidiscaviarum. The patient was treated by trimethoprime-sulfametoxazole during several weeks with abscess disappearance. Our laboratory quickly identificatied a bacteria belonging to the Nocardia genus, with simple technique, later confirmed by a specialized laboratory (Pr. Boiron Claude Bernard University Lyon I) with identification of Nocardia otitidiscaviarum. The proof of pulmonary nocardiosis could not be established despite the existente of several risk factors. Prognosis is poor for immunocompromised patients, but the secondary cutaneous dissemination phase presented a favourable evolution under antibiotic therapy.

[Microscopic vascular study of the colon with the corrosion casting technique]. / Etude vasculaire microscopique du colon par la technique d'injection-corrosion.

The aim of this study is, firstly, to assess the accuracy of vascular casts obtained at various times after death and secondly to describe the mucosal microvascular architecture of the cat colon. Two injections were realized, the first one on a non-embalmed human corpse, 12 days after the death, and the other one on a cat, immediately following euthanasia. Results show that this second cast seems finer and more detailed than the cast stemming from the human corpse; indeed, the finest vessels obtained are about 6 microns while they are about 15 microns on the human corpse. This could be explained by a post-mortem obstruction of microvessels, that prevented the passage of the injected product or by an insufficient amount of product injected. Finally, the vascular cast of the cat colic mucosa presents a regular honeycomb-like network that bounds the colonic mucosal glands, a finding consistent with the results reported previously.

The origin of the azygos venous system, as deduced from an anatomical and radiological study employing a corrosion technique.

The aim of this study is not only to describe the origin of the human azygos venous system by performing a 3-D reconstruction of a CT scan but also to evaluate the value of the techniques employed in investigating the topographical anatomy of a venous system in the body. Following perfusion with saline to wash away the blood, we injected an ALTUFIX/MINIUM mixture into the azygos vein of a cadaver. The head and trunk were subsequently corroded with hydrochloric acid (HCl). A CT scan of the trunk was obtained both before and after corrosion. According to the spatial resolution of the CT scan, the thinnest identifiable detail was measurable as 0.5 mm. The vertebral lumbar venous system was described, specifying the nomenclature of the lumbar veins (the lumbar veins being designated according to the vertebral body along which they run). On the right side, the lumbar veins at L2 and at L3 formed the lateral root of the azygos vein. On the left side, the vein at L2 formed the reno-azygo-lumbar arch (of Lejars). The lumbar veins, and the origin of the azygos system, were described and compared with previous studies. The 3-D reconstruction showed the importance of veins associated with the posterior paravertebral muscles. This description poses the problem of the metamerisation of the veins, but further evidence is required. Comparisons of the CT scans, 3-D reconstructions, and the ALTUFIX models of the veins obtained from the corrosion technique allowed verification of the 3-D reconstruction and correction of the errors inherent in a computer reconstruction. It is concluded that the description, and understanding, of such a complex system as the vertebral venous system is more valid when the results obtained using different techniques are compared.

[Superficial veins of the leg]. / Les veines superficielles du membre inférieur.

This clinical work studies the normal pattern of the saphenous veins, their main variations with a short embryological reference. Some pathological cases are described; the perforator veins are very important; the role of the valves at the groin is emphasized.

[The lumbar vein at L2 and the reno-azygo-lumbar arch: anatomic and radiologic studies]. / La veine lombaire en L2 et l'arc réno-azygo-lombaire: étude anatomique et radiologique.

The lumbar vein at L2 was described by C. Gillot and B. Singer (1974). On the right side, after drawing off the 12th intercostal vein, it forms the lateral root of the azygos vein. Its way is as a frame, transverse going along the body of the 2nd lumbar vertebra, then upward along the spine after having integrated the veins of the L2-L3 intervertebral foramen. In its typical form, the vein is at L2 but it can be at L1 or L3. It takes the name of lateral root of the azygos vein only after receiving the 12th intercostal vein. Because of its diameter (5 mm), it forms a cavo-caval anastomosis via the azygos vein. The renal azygo-lumbar arch of Lejars is the equivalent on the left side of the right vein at L2. This arch contributes to the formation of the lateral root of the hemi-azygos vein. The right vein at L2 and the reno-azygo-lumbar arch were studied by dissections and by radiologic protocols. The radiologic studies (CT, MRI, 3D reconstructions) were carried out after injections of gelatin-gadolinium-minimum and altufix-minimum mixtures. The results showed the numerous variations of origin of the azygos system. The use of multiple and complementary technics are very helpful to describe these variations.

[Organ procurement from cardiac arrest donors: outcome of kidney grafts and recommendations]. / Prélèvements d'organes sur donneurs décédés à coeur arrêté: devenir des greffons rénaux, propositions.

OBJECTIVES: To compare literature data with results obtained with organs procured from donors who died from cardiac arrest and to make proposals for this mode of organ procurement in France. METHODS: Over the last 10 years, 10 organ donors (2%) among a series of 486 donors in a state of brain death, had died of cardiac arrest. The arrest were perfused with double-balloon catheters. The outcome of the subsequent kidney grafts was compared with data in the literature. RESULTS: Fifteen of the 18 kidneys from cardiac arrest donors were functioning 1 month after implantation compared with 17 of the 20 kidneys from braindeath donors with beating hearts. The rate of acute tubular necrosis was 55% in the cardiac arrest kidneys and 40% in the beating-heart kidneys. Serum creatinine at 1 yeart was 145 +/- 69 mumol/l 17 +/- 29 mumol/l respectively. DISCUSSION: These results and those reported in the literature demonstrate that kidney procurement from cardiac arrest donors is feasible. If intensive care and surgery units are well organized, this type of organ procurement could provide a larger number of organs for transplantation. Emergency teams must be available for preparing and transferring the organs.

Technique for injection of the lumbar vertebral venous plexuses employed in anatomic, computed tomography and magnetic resonance imaging studies.

The aim of this study was to develop a technique for injection of the vertebral venous plexuses allowing anatomic, computed tomography (CT) and magnetic resonance imaging (MRI) studies of the same anatomic specimen. It proved in practice that only a correctly adjusted mixture of different agents allowed attainment of this objective. This mixture, composed of gelatin, gadolinium and minium, enabled us to attain this end. The description of the technique of injecting the vertebral venous plexuses, the difficulties encountered and the results of the different imaging techniques are analysed in this study without entering into details of the anatomic description. The core of the study consists of 11 unembalmed subjects. Three were injected with gelatin mixed with gadolinium, one with latex mixed with minium, one with latex mixed with gadolinium, and 6 with gelatin mixed with both gadolinium and minium. Only the mixture of gelatin-gadolinium-minium allowed study of the same anatomic specimen in terms of anatomy, CT and MRI. Two different MRI sequences are described, evidence of the different properties of the injection mixture (gelatin, gadolinium). The latex-minium mixture gave good CT density but was unsuitable for MRI studies. Numerous artifacts caused interference with the radiologic images, calling for perfect injection technique. The use of several radiologic techniques for a single cadaveric injection allows better correlation of the images, and comparison and verification of results between the techniques.

Anatomy of spontaneous splenorenal and gastrorenal venous anastomoses. Review of the literature.

Portal hypertension is characterised by the development of a collateral portocaval circulation. Among these venous reroutings, some are situated posteriorly in the left subphrenic compartment. These are the spontaneous splenorenal and gastrorenal anastomoses. Their incidence is estimated at around 16%. On the one hand, there are the direct shunts, which anastomose the spelling v. to the left renal v., of an anecdotal nature, and on the other the spontaneous indirect splenorenal shunts, characterised by the presence of a complete neurovascular pedicle traversing the gastrophrenic ligament. This relates to the gastric collateral v., which is connected to the left renal v. via the inferior v. of the left crus of the diaphragm and the middle capsular v., hence the name "gastro-phreno-capsulo-renal shunt". At an advanced stage of portal hypertension these splenorenal shunts may acquire a major caliber and behave like actual surgical shunts.

[Superficial veins of the lower limbs]. / Les veines superficielles du membre inférieur.

This study, limited to the superficial veins of 123 limbs (108 normal and 15 suffering from frank varicose disease) and only vessels with a caliber of at least 2 mm, reveals a certain degree of constancy of anatomical pattern. The initial network is defined embryologically and subsequent haemodynamic phenomena model the final veins. In particular, the topography of the main perforating veins is relatively fixed. Due to their double antihypertensive valve and aspirating pump function while walking, these vessels drain into saphenous veins. They are beneficial when they return reflux into the deep vessels. Conversely, perforator incompetence contaminates the superficial network in the case of deep reflux. The perforating vessels also have a relatively fixed position in relation to other structures: the main saphenous collateral veins, their duplicated branches, their communicating veins and the main valves. This results in large junctions typically associating a saphenous valve, one or several collateral veins, one or several communicating veins, and one or several perforating veins. Typical examples are the garter junction for the long saphenous vein, and the junction of the tip of the calf for the short saphenous vein. Other haemodynamic levels are situated at various sites, particularly in the leg, reflecting the existence, in some cases, of symmetrical "mirror", medial and lateral perforating veins. Morphological analysis of 15 limbs with obvious varicose veins of the trunk of the long saphenous vein defined the routes of transmission of reflux to the leg. Finally, the authors present several technical considerations which they hope will be useful for Doppler operators and surgeons.

The lumbar anterior epidural cavity: the posterior longitudinal ligament, the anterior ligaments of the dura mater and the anterior internal vertebral venous plexus.

The contents of the anterior epidural cavity were studied to elucidate the relationship between veins, ligaments, and membranous formations. Anatomical, radiological and histological studies on human specimens after latex or gelatin/gadolinium venous injection at the level of the lumbar spine show that the posterior longitudinal ligament is a cross-shaped formation which includes the septum, the superficial part extending into the intervertebral foramen and the anterior ligaments of the dura mater. The anterior epidural cavity contains two medial and two lateral spaces. The two medial cavities enclose anterior and medial venous plexuses, which together receive the basivertebral veins; the two lateral cavities receive the anterior longitudinal veins. Contents of the medial and lateral cavities pass freely between the two. The lateral cavity connects with the intervertebral canal and dorsally into the posterior epidural space.

The pterygoid venous plexuses.

The pterygoid venous plexuses are closely adjacent to the lateral pterygoid m. and occupy a considerable part of the infratemporal fossa (ITF). We have conducted a study after injection of colored latex in 10 unemblamed subjects in order to define the arrangement of the venous network and to assess the frequency of the different types of plexuses found. In all the subjects symmetry was noted between the right and left plexuses, with predominance of the venous layer in the upper part of the ITF. The pattern most often encountered was plexiform and complex. The development of these plexuses follows that of the masticatory muscles, whose contraction promotes drainage and represents an alternative venous pathway for drainage of the cranial cavity.

MRI of the epidural space after gelatin/gadolinium venous injection.

The head and vertebral column from two human cadavers were injected with a solution of gelatin and gadolinium (Dotarem) and imaged using magnetic resonance imaging (MRI). Comparisons between gross anatomic slices and corresponding images of the lumbar vertebral column confirmed the usefulness of a paramagnetic agent for visualising the epidural venous plexus. This technique provides accurate images of the posterior longitudinal ligament.

[Role of endoscopy and vascular decompression in the treatment of hemifacial spasm]. / Place de l'endoscopie et de la décompression vasculaire dans le traitement du spasme de l'hémiface.

Although it has long been hypothesized that hemifacial spasm could arise from a conflict between the nerve and the artery, it is very difficult to distinguish between a normal arterial loop and a pathological conflict leading to facial symptoms. Several new elements would help in the definition of the cause and allow less traumatic treatment of idiopathic hemifacial spasm. They include magnetic resonance imagery with CISS sequences, limited retrosigmoid approach, endoscopy of the cerebellopontine angle and monitoring the facial nerve. In our experience with 20 cases, retrosigmoid approach with a combined surgical and endoscopic procedure has led to total involution of the spasms in 80% of the cases.