[Arterialization of the distal veins of the foot for limb salvage in arteritis. Techniques and results]. / L'artérialisation des veines du pied pour sauvetage de membre chez l'artéritique. Technique et résultats.

STUDY AIM: The aim of this retrospective study was to report the long term results with arterialisation of the veins of the foot as the final attempt to save an ischaemic limb when classical techniques have proved ineffective or impossible. PATIENTS AND METHOD: From January 1974 to July 2000, 60 arterialisations of the distal veins of the foot were performed in 59 patients with arteritis, associated in 25 of them with diabetes mellitus. There were 41 men and 18 women, their mean age was 72 years (range from 49 to 95 years). There were 50 stage IV patients and 9 stage III patients. The arterialisation was performed by a reversed venous bypass between the femoral or popliteal artery and an internal vein of the foot, after destruction of the valvulas of the forefoot veins. The distal anastomosis was made termino lateral in order to provide tissular nutrition and to avoid blood congestion. RESULTS: The result was considered good when a major amputation was avoided during one year at least, with a bypass permeability longer than one month. Among the 60 arterialisations, 36 were successful (60%), 7 in the short term (between one month and one year), 15 in the medium term (between one and five years), 14 in the long term (more than 5 years). Among the 15 medium-term good results, the mean time of bypass permeability was one year; three patients died, six were lost of follow-up, and six were still alive, four of them with a permeable bypass, at the time of the study. Among the 14 long term results, spontaneous bypass occlusion occurred after a 26-month mean time; despite this occlusion, the favourable result persisted till the death of the patient after a mean delay of 9 years (range from 5 to 15 years). The 24 other patients had a poor result followed by a major amputation. There were no deaths in relation with the reversed circulation. CONCLUSION: These results suggest that the arterialisation of the distal veins of the foot may be considered a useful revascularization technique for limb salvage when all the classical methods have failed or are impossible.

Arteriovenous revascularization for lower limb salvage in unreconstructible arterial occlusive disease (long-term outcome).

Between February 1983 and June 1994 we attempted surgically to salvage twenty-six legs in twenty-five patients with insufficient distal run-off and severely ischemic feet; all of them had resting pain, and 23 had tissue necrosis. A saphenous venous graft was interposed between an artery of the lower extremity (femoral or popliteal) and the veins of the foot with obligatory end-to-side distal anastomosis. The patency of the venous circulation of the ischemic foot was ascertained by retrograde phlebography. Patients were followed from 3 months to 11 years (an average of 3 years and 5 months). In 19 legs (73%), surgery succeeded in preventing extensive gangrene of the foot, and allowed postponing or avoiding major amputation. The purpose of this paper is to analyze this experience, and stimulate further interest and study of the reversed microcirculation in critical ischemia.

[Can distal vein arterialization be beneficial for the diabetic foot with necrosis?]. / Le pontage d'artérialisation veineuse distale peut-il être bénéfique au pied diabétique avec nécrose?

When arterial bypass cannot be used in cases of diabetic arteriopathy of the lower limbs, we have, since 1974, relied on the former method using the veins. Arterial blood is brought to the zone of ischaemia via an internal saphenous vein graft anastomosed distally to a vein in the foot, thus creating an arteriovenous fistula. Improvements in the technique include removing the valves in the dorsal venous arcade. Fourteen bypasses were performed in 13 diabetic patients with foot necrosis, including 12 with non-insulin dependent diabetes. There were 7 men and 6 women with a mean age of 83 years. The bypass was patent with a mean follow-up 15 months. At mean follow-up of 4 years (range 4 months-12 years), there were 9 successful operations and 5 failures. Two-thirds of the feet were saved more than 2 years including one more than 5 years and two more than 10 years. One patient died 4 days after the operation due to myocardial infarction. Heart failure was not observed in any of the patients. This technique can help preserve lower limbs otherwise compromised by insufficient arterial blood supply.

[Comparative study of two methods of arterialization of foot veins in ischemic crisis]. / Etude comparative de deux modalités d'artérialisation des veines du pied en ischémie critique.

Between February 1974 and December 1991, a total of 28 arterializations of the venous network of foot were performed in patients with stage IIIB or IV arteriopathies presenting disseminated femoropopliteal and more distal lesions excluding revascularization by conventional arterial shunt operations. Two groups of patients could be distinguished. The first group, of 8 patients, underwent arterialization by shunt operation with end to end fistula at the distal part of leg and return blood emptying at the dorsal surface of foot (3 cases). The procedure was successful in 50% of cases after a mean follow up of 76 months. The intervention in the second group, of 20 patients, was by end to side fistula of foot after preoperative countercurrent phlebography and the use of a material better adapted for the destruction of the valves. Results were evaluated as successful in 70% of cases at 31 month follow up. After spontaneous closure of the fistula, the collateral circulation provoked by it was sufficient to conserve the acquired benefit. No deaths or cases of cardiac overload were reported as a result of the intervention. Comparative analysis of results showed that the use of the second procedure allowed amputation to be avoided in more than 2/3rds of cases, provided relief from pain, provoked healing of necrosed areas and permitted renewal of walking. The results of this study have demonstrated that venous arterialization of the foot by this method represents an interesting alternative in the saving of a limb destined for amputation.

[Study of the veins of the foot by counter-current phlebography]. / Etude des veines du pied par phlébographie à contre-courant.

83 CF phlebographies of the foot veins were carried out in varicose vein sufferers of both sexes in order to better understand the return venous circulation of the foot in detail, its abnormalities, and also to attempt to explain edema of the foot suffered by many varicose vein patients to varying degrees of severity after saphenous stripping. Films were obtained by direct needle puncture at different sites on the fore-foot, after a tourniquet was placed around the ankle. The route taken by the contrast medium injected was followed on a fluoroscop screen and photographed. Images obtained were classified under 4 headings: 1) slight, 2) moderate, 3) loaded and 4) overloaded opacification. In normal or slightly pathological cases (group 1 and 2), contrast medium was evacuated via a route ranging from level 1 (superficial) to level 3 (deep), this being the "usual evacuation circuit." In frankly pathological cases (groups 3 and 4), a "subsidiary evacuation circuit" may develop. It is also possible that after a degree of stagnation (by obstruction of the main veins of the foot) the contrast medium is very slowly evacuated by a number of small collateral veins. Edema of the foot as seen in some varicose vein patients as well as that which occurs post-operatively in the majority of patients undergoing varicose vein surgery is felt to be more often due to valve incompetence and to hypotonicity of the venous walls rather than to thrombosis of a deep vein of the foot.

[Treatment of fractures of the clavicle by closed pinning inside-out without back-and-forth]. / Traitement des fractures de la clavicule par embrochage à foyer fermé de dedans en dehors sans va-et-vient.

Pinning of fractures of the clavicle is easily and safely done by introducing the pin through the medial fragment. The pointed tip is embedded into the cortex of the lateral fragment and the inner end of the pin is bent at a right angle to fix it to the bone. Insertion is made with image intensification to avoid vascular damage and to guide the passage of the pin through the medial fragment without danger. Of 25 fractures treated in this way, only two, treated at the beginning of the series, required open reduction. No other immobilisation was necessary. All the fractures united uneventfully.

Arteriovenous flow reversal, experimental investigations. I. Complete flow reversal of the small intestine and of the rear extremity of the dog.

Segments of the small intestine and hind extremities of dogs were perfused under the condition of complete arterio-venous flow reversal (AVFR). In the intestinal segments, the peripheral resistance under AVFR conditions was 4.4 times higher than under orthograde perfusion. Petechiae and hemorhagic infarction were observed. The average flow resistance of the hind extremities was 2.4 times higher than the resistance in control extremities. The pO2 and the O2 saturation in the blood, outflowing from the AVFR extremity was lower than in the control extremity, however, the pO2 was higher. The oxygen consumption was somewhat lower than in the control extremity. It is concluded that by complete AVFR an extremity may be supplied sufficiently with oxygen at least temporarily.

Arteriovenous flow reversal, experimental investigations. II. Hemodynamic and blood gas analyses in incomplete arteriovenous flow reversal in hind extremities of dogs.

2 types of incomplete arteriovenous flow reversal were tested. When the major arteries were patent, 20% of the blood shunted into a peripheral vein was drained via the arteries whereas 80% was drained via the veins of the leg. If the pressure in the arteries was raised, the flow through the arteries was stopped when the outflow pressure reached 25% of the systemic blood pressure. Under these conditions a moderate oxygen consumption of the peripheral tissues was still observed. When the major arteries and their branches were obstructed by the injection of collagen flocculi the oxygen supply to the tissues was again reduced but not completely abolished. It is concluded that the AVFR procedure may be helpful in avoiding peripheral gangrene in very severe cases of arterial disease. In the first paper of this series (Gottlob and Kunlin, 1985) the hemodynamics of complete arteriovenous flow reversal (AVFR) were studied. In the present communication experiments with incomplete AVFR will be reported on. The animal models described resemble the clinical condition in so far as incomplete AVFR is established and as in both models the flow through the peripheral arteries was hampered.

Arterialization of the venous network of the foot through a bypass in severe arteriopathic ischemia.

With the object of saving a very ischemic extremity, when the classic procedures have been unsuccessful or impossible, the authors are using a modification of San Martin's operation. At present, we are making an A-V fistula with a graft interposed between the femoral or popliteal artery and the peripheral long saphenous vein at the foot or near to it. The distal valves are ruptured. In order to prevent the noxious venous overloading resulting from the distal end-to-end anastomosis, it is important to replace it by an end-to-side anastomosis. Eight patients with intense continuous rest pain and necrotic lesions of the toes and heel have been operated on: 3 failures in spite of well functioning A-V fistula; 2 temporary improvements lasted 7 and 16 months when distal thrombosis of the A-V fistula occurred; 3 good results, maintained during 5 months, 4 3/4 years and 9 1/2 years respectively. Postoperative angiography and scintillography reveal a satisfactory retrograde distribution of blood in the fore foot except in the necrotic tissues.

[New experimental documents on circulatory reversal by arteriovenous fistula in ischemia of the extremities]. / Nouveaux documents expérimentaux sur l'inversion circulatoire par fistule artério-veineuse dans l'ischémie du membre.

The beneficial effects of circulatory reversal by lateral a.-v. fistula was confirmed in 20 hind limbs of dogs made ischaemic by Collagen embolisation. Although not done in the experiments presented here, rupture of the distal venous valves is advisable. The peripheral circulation was studied by measurement of venous pressures and by angiography. Retrograde infusions, with proximal tourniquet, confirmed reversal of flow veins to arteries. Return routes to the heart remain unknown.

[Plea for better terminology in surgery of the profunda femoris artery (author's transl)]. / Plaidoyer pour une meilleure terminologie de la chirurgie de l'artère fémorale profonde.

Surgical publications on the profunda femoris artery rarely give information on the site of the operation and the technic used. Experience of 356 operations carried out from 1949 to 1978 by the authors and anatomical dissection of 100 profunda femoris arteries is reported. They suggest the elimination of all imprecise terms at present attached to these operations and their replacement by a more lengthy but more understandable vocabulary, together with an attempt to classify the profunda femoris artery in two groups and its nomenclature in 4 segments, more adaptable to surgery of this artery.

[Destruction of residual varicose collaterals by subcutaneous dilaceration with a needle]. / Destruction des collatérales variqueuses résiduelles par dilacération sous-cutanée a l'aiguille.

The persistence of collaterals after a properly conducted surgical treatment of varicose veins of the lower limbs often presents a problem which is difficult to resolve. The authors put forward a simple and original method, in which a long and slightly curved triangular needle is used, without incisions, to destroy by dilaceration the collaterals whatever their degree of dilatation and their location. This technique has also been used as a first stage preceding stripping, and over a 5 year period has given results in 70 patients which are very satisfactory both from the point of view of efficacy as well as from the aesthetic point of view.

[New technic of retro-peritoneal renal transplantation in the left lumbar position in the child. Report of two cases (author's transl)]. / Technique nouvelle de transplantation rénale rétro-péritonéale en situation lombaire gauche chez l'enfant. A propos de deux cas.

In the child, renal transplantation is almost always carried out by placing the kidney within the peritoneum for a simple reason: the donors being adults, the kidneys are too large to be placed in extra-peritoneal position. However, all authors agree that placing the kidney in an extra-peritoneal position offers undoubted advantages.

[Arterialization technic of the venous net work in the foot]. / Technique d'artérialisation du réseau veineux du pied

The amputation of the lower extermity can be avoided in many patients, particularly in diabetics by means of the arterialization of thevenous net of the foot, whenever the classic techniques of revascularization cannot been used for the magnitud of the arterial lesions below the knee. This arterialization uses two venous autografts: one in the leg functionning as a channel and the second functionning as a regulator or a temporary discharge. This technique, used in three diabetic patients with gangrenous lesions of the foot, has allowed to avoid amputation in two of them.