Beware of suboptimal medical management of patients with atherosclerosis requiring revascularization.

AIM: The aim of this paper was to assess a daily-life evaluation of vascular risk factor control, pharmacological treatment and prognosis in patients with atherosclerosis referred for revascularization. METHODS: Prospective observational study conducted in a French University Hospital with collection of atherosclerosis referral site information, reported patient history, documented atherosclerosis sites seen on examination, biological data, and clinical outcomes. RESULTS: 956 patients (82.6% men, 64.5±10.1 years) were enrolled for supra-aortic vessel disease (SVD, 24.6%), coronary heart disease (CHD, 40.4%), peripheral artery occlusive disease (PAOD, 34.2%), and visceral artery disease (1.7%). Involvement of >2 vascular territories was documented in 85%. Vascular risk factor frequency results were: previous (65.7%) or current (10.6%) tobacco use, hypertension (64.3%), hyperlipidaemia (75.4%), diabetes (25.8%), overweight (43.8%), and obesity (25.2%). LDL-cholesterol was >100 mg/dL for 38.1%, most frequently seen in patients with PAOD referral (P<0.001) or history (P=0.002), and for 29.2% of the patients taking a statin. HbA1c levels were >6.5% for 53.8% of patients with diabetes. The triple combination of an antiplatelet agent, a statin, and a renin-angiotensin-system inhibitor was not prescribed often enough, especially for PAOD referrals (PAOD referrals, 45.1%; SVD referrals, 48.1%; CHD referrals, 65.9%). Independent risk factors for all-cause mortality were: a previous CHD or PAOD clinical event, body mass index <25 kg/m2, HbA1c >6.5%, and no aspirin treatment. CONCLUSION: Even at the time of revascularization, medical management of atherosclerosis was not optimal. The need for continuing education of physicians and patients remains essential.

[A negative first-line work-up of Raynaud's phenomenon: And what if it were cancer?]. / Phénomène de Raynaud avec négativité du bilan de première intention : et si c'était un cancer ?

Raynaud's phenomenon is a transient paroxysmal vasomotor phenomenon affecting the extremities including manifestations of ischemia. It is a common phenomenon in the general population. In a routine clinical situation, the first step is to differentiate Raynaud's disease from a secondary Raynaud's phenomenon, the latter requiring complementary investigations. We report here the case of an 80-year-old woman who presented a secondary Raynaud's phenomenon. First-line investigations remained negative. A mammography was performed and revealed breast cancer. Raynaud's phenomenon disappeared after treatment of the breast carcinoma and did not recur during the 2-year follow-up.

Prevalence of peripheral arterial disease in high-risk patients using ankle-brachial index in general practice: a cross-sectional study.

AIMS: The deleterious nature of peripheral arterial disease (PAD) is compounded by a status of underdiagnosed and undertreated disease. We evaluated the prevalence and predictive factors of PAD in high-risk patients using the ankle-brachial index (ABI). METHODS: The ABI was measured by general practitioners in France (May 2005-February 2006) in 5679 adults aged 55 years or older and considered at high risk. The primary outcome was prevalence of PAD (ABI strictly below 0.90). RESULTS: In all, 21.3% patients had signs or symptoms suggestive of PAD, 42.1% had previous history of atherothrombotic disease and 36.6% had two or more cardiovascular risk factors. Prevalence of PAD was 27.8% overall, ranging from 10.4% in patients with cardiovascular risk factors only to approximately 38% in each other subgroup. Prevalence differed depending on the localization of atherothrombotic events: it was 57.1-75.0% in patients with past history of symptomatic PAD; 24.6-31.1% in those who had experienced cerebrovascular and/or coronary events. Regarding the classical cardiovascular risk factors, PAD was more frequent when smoking and hypercholesterolemia history were reported. PAD prevalence was also higher in patients with history of abdominal aortic aneurysm, renal hypertension or atherothrombotic event. Intermittent claudication, lack of one pulse in the lower limbs, smoking, diabetes and renovascular hypertension were the main factors predictive of low ABI. CONCLUSIONS: Given the elevated prevalence of PAD in high-risk patients and easiness of diagnosis using ABI in primary care, undoubtedly better awareness would help preserve individual cardiovascular health and achieve public health goals.

[Elbow dislocation in children associated with proximal radioulnar translocation]. / Luxation du coude chez l'enfant associée à une translocation radio-ulnaire proximale.

We report a unique case of posterior elbow dislocation with proximal radioulnar translocation in a six-year-old child with 3D reconstruction CT images. Five other cases of this type of association have been reported in the literature. Diagnosis is often established late. Our case illustrates the diagnostic and therapeutic difficulties. The CT scan demonstrated the presence of the proximal radioulnar translocation and contributed greatly to understanding the pathogenic mechanism: the radius crossed over the ulna anteriorly. The CT-scan can reveal associated lesions missed on the plain x-rays. Surgical reduction is generally needed, preferably via a medial approach.

[Does antiaggregant therapy have a place in type II heparin-induced thrombocytopenia?]. / L'antiagrégation a-t-elle une place en cas de thrombopénie tardive induite par l'héparine?

We report a case of type II heparin-induced thrombocytopenia, which occurred after heart surgery in a 71-year-old female patient with several cardiovascular risk factors. The diagnosis of heparin-induced thrombopenia was suspected because association of multifocal arterial and venous thrombosis and detection of antiplatelet-factor 4 antibodies with a drop of more than 50% in the platelet count. Until diagnostic of heparin-induced thrombocytopenia was made, clopidogrel was introduced because of well-documented ischemia in middle-cerebral artery territory. The platelets subsequently increased by near 30%. The diagnosis of heparin-induced thrombocytopenia was finally confirmed a few days later by detection of antiplatelet-factor 4 antibodies associated with a positive platelet aggregation test for unfractionated heparin. Heparin was replaced by sodium danaparoid. These measures did not change the unfavorable outcome and death of the patient. The increase in the platelet count after fortuitous clopidogrel introduction raises the question of the role of antiaggregant agents in association with anticoagulants for the treatment of type II heparin-induced thrombocytopenia.

Surgical treatment of recurrent carotid artery stenosis and carotid artery stenosis after neck irradiation: evaluation of operative risk.

Surgical treatment of recurrent carotid artery stenosis after endarterectomy and carotid artery stenosis after neck irradiation purportedly has a higher complication rate than primary carotid endarterectomy (CEA). Accordingly, carotid angioplasty has been proposed as a safer alternative. The purpose of this study was to evaluate operative risks on the basis of our experience with these lesions. A series of 679 carotid revascularizations (CRV) performed over a period of 9 years was retrospectively reviewed. Immediate outcome and operative technique was analyzed in three groups: group 1 included 549 "routine" CRV, group 2 included 8 CRV for recurrent stenosis after CEA, and group 3 consisted of 11 CRV for stenosis after neck irradiation. No difference in revascularization techniques was found between groups 1 and 2. In contrast there were fewer CEA and resection-anastomosis procedures in group 2 than in group 1 (62.5% vs. 98.2%; p < 0.0006) and more bypass procedures (37.5% vs. 1.8%; p = 0.0015). The cumulative neurological morbidity/mortality rate (CMMR) was 0% in groups 2 and 3 as compared to 4.4% in group 1. In comparison with group 1, early and permanent neurological morbidity rates were significantly higher in both group 2 (2.2% vs. 25.0%; p = 0.015 and 0.2% vs. 12.5%; p = 0.028, respectively) and group 3 (2.2% vs. 18.2%; p = 0.028 and 0.2% vs. 9.1%; p = 0.039, respectively). Surgical treatment of recurrent stenosis after CEA and stenosis after neck irradiation is not associated with a higher CMMR. The only potentially valid justification for using percutaneous transluminal angioplasty in these patients would be a higher risk of cervical neurological morbidity.

Lower limb giant cell arteritis and temporal arteritis: followup of 8 cases.

Among 8 patients with giant cell arteritis (GCA) (6 women, 2 men) whose clinical presentations were compatible with temporal arteritis (TA), 6 were followed for 37-105 (mean 74.9) months, one died shortly after treatment onset, and the last was asymptomatic (10 mg steroids/day) when lost to followup at 29 months. All 8 patients had bilateral leg claudication of recent onset; for 6 patients, this was the first symptom. All leg angiograms showed multiple, bilateral, long and smooth stenoses, thromboses, or both. Biopsies of diseased leg arteries from 4 patients provided histological proof of GCA; another case was histologically proven post mortem. Among the 5 patients who met at least 3 American College of Rheumatology criteria of GCA or TA, 3 without histologically documented leg GCA also had biopsy proven temporal GCA (n = 1), or headaches and claudication and angiographic inflammatory arteritis of the arms (n = 2). All patients received steroids; 3 had bypasses, one with endarterectomy. Five are asymptomatic after 24-100 months of steroids (mean 50.6). Revascularization was not successful; one amputation was necessary. Large artery involvement in GCA can affect the legs. Bilateral and rapidly progressive intermittent claudication of recent onset is the most common symptom, even in the absence of headaches or the presence of a silent inflammatory syndrome. Early diagnosis allows rapid initiation of steroid therapy, which is usually able to generate a sufficiently good response to avoid vascular surgery.

Long-term outcome of 121 iliofemoral endarterectomy procedures.

Iliofemoral endarterectomy (EA) is now considered by most vascular surgeons to be an obsolete technique that is difficult and unreliable. The purpose of this retrospective study was to reassess the place of iliofemoral EA on the basis of long-term outcome in our experience. From 1982 to 1995, we performed a total of 121 iliofemoral EA procedures on 98 patients with a mean age of 57 years. The anatomical presentation involved iliac occlusion in 55 cases and complex iliac stenosis in 63. The indication for treatment was critical ischemia in 28 cases. Operative mortality was nil. Major amputation was required in only one patient because of contralateral thrombosis during the procedure. Postoperative thrombosis requiring early thrombectomy occurred in five cases. At 5 and 10 years, actuarial rates were 77.6% and 61.3%, respectively, for survival, 98.3% and 90.1%, respectively, for limb salvage, 78.9% and 65.1%, respectively, for primary patency, and 88.2% and 73.8%, respectively, for secondary patency. On the basis of these findings, we consider iliofemoral EA to be a viable alternative to iliac bypass in patients ineligible for transluminal angioplasty.

[Aorto-iliac aneurysms rupturing into the vena cava. A retrospective multicenter study]. / Anévrysmes aorto-iliaques rompus dans la veine cave. Etude rétrospective multicentrique portant sur 15 ans.

Eleven of the 28 centers participating in the French inter-university association for surgical research (AURC) collected retrospective data on abdominal aortic aneurysms ruptured into the vena cava. Thirty-nine cases were observed between 1979 and 1989. The signs and symptoms reported varied greatly. The pathognomonic triad associating aneurysm, abdominal pain and continuous abdominal murmur was found in one-third of the cases: 25.6% of the patients had signs of global heart failure. The diagnosis was preoperative in 74.4% of the cases. Mean delay of symptomatology before diagnosis was 7 +/- 12 hours. The analysis of operative procedures included 37 patients as 2 patients died before vascular repair could be attempted. Venous repair was done by direct suture in 76% of the cases. Peroperative blood loss was 4 600 +/- 3 500 ml. Perioperative mortality was 11 cases (28.2%). Cardiac and respiratory disorders were the cause of death in 54.4% of the fatal cases.

[Coronary revascularization provides confirmation of coronary and aortic giant-cell vasculitis]. / Revascularisation coronarienne apportant la confirmation d'une vascularite giganto-cellulaire coronarienne et aortique.

The present report describes a 58-year-old woman who had unstable angina pectoris 28 months after the end of corticosteroid treatment prescribed for biopsy-proven temporal arteritis. Coronary angiogram disclosed critical left main coronary artery stenosis. Despite a 3-week corticosteroid regimen no improvement was obtained and an aortocoronary bypass was performed. Histological examination of the affected artery showed vasculitis. Corticosteroid treatment was continued. Six months later, symptoms had not recurred and the coronary bypass graft was permeable. The stress test was negative fifteen months after surgery and the patient remained clinically well thirty months later. For any patient with current or previous temporal arteritis, any cardiovascular manifestation might be a new episode of giant-cell arteritis.

Results of surgical management of internal carotid artery aneurysm by the cervical approach.

From 1981 to 1995 a total of 14 patients with a mean age of 52 years (range: 23-71) underwent surgery for 15 aneurysms of the extracranial internal carotid artery. Fusiform aneurysms of the carotid bifurcation were not included in this study. Aneurysm led to brain ischemia in 10 cases and rupture in one case. In the remaining four cases, aneurysm was asymptomatic including three that were detected following hemispheric stroke related to a contralateral aneurysm. The etiology was spontaneous dissection in four cases, blunt trauma in three cases, fibromuscular disease in five cases, and atheroma in three cases. The upper limit of the aneurysm was located at C1-C2 in six cases, at C1 in three cases, and above C1 (at the base of the skull) in six cases. The cervical approach was used to successfully perform 12 revascularizations and three ligations (including one after extra-intracranial bypass). There were no postoperative deaths. One transient ischemic attack (TIA) occurred after ligation. Peripheral facial paralysis (PFP) occurred in four of the nine cases in which an extended cervical approach was used. No patients were lost to follow-up. Mean duration of follow-up was 4 years (range: 2 months-10 years). Two patients died at 2 and 4 years of causes unrelated to the procedure. All carotid reconstructions are currently patent and no neurologic manifestations have occurred. PFP persisted in one case. The results of this series confirm that surgical therapy of aneurysms of the extracranial internal carotid artery achieves satisfactory short- and medium-term results and that the extended cervical approach allows treatment of lesions near the base of the skull.

Pulsed transthrombotic fibrinolysis: technique and results in the management of occluded lower limb bypass grafts.

Between March 1987 and March 1993 we used pulsed transthrombotic fibrinolysis to treat 58 symptomatic thrombotic occlusions of lower limb bypass grafts in 45 patients. There were 17 suprainguinal grafts and 28 infrainguinal grafts. Treatment consisted of pulsed infusion of fibrinolytic agents into the thrombus followed by continuous infusion using an electric pump. Minor percutaneous or surgical procedures were often associated. The mean delay to treatment was 7 days. The mean duration of treatment was 150 +/- 66 minutes. Immediate patency was achieved in 88% of cases with no significant difference between suprainguinal and infrainguinal grafts. The clinical success rate was 55%. Actuarial patency at 1 year was 54% +/- 11% for suprainguinal grafts and 26% +/- 7% for infrainguinal grafts. The probability of patency was much lower in patients whose grafts had been implanted within 3 months before occlusion and in patients in whom an adjuvant procedure had not been performed. This study demonstrates that, in cases not requiring immediate surgery, pulsed transthrombotic fibrinolysis can achieve durable patency by treating both the bypass and distal arterial network. This technique allows identification of lesions causing thrombosis and adaptation of treatment specifically to these lesions.

Dynamic gadolinium-enhanced subtraction MR imaging--a simple technique for the early diagnosis of Legg-Calvé-Perthes disease: preliminary results.

PURPOSE: To determine whether the simple technique of dynamic gadolinium-enhanced subtraction MR imaging, which is available on standard MR units, can detect ischemia of the femoral head in children with early Legg-Calvé-Perthes disease (LCP). MATERIALS AND METHODS: Bone perfusion of eight hips in four patients (mean age 7.5 years) was studied using dynamic gadolinium-enhanced subtraction MR imaging at the onset of proven LCP (with initial negative plain films). Enhancement of subtracted images was compared with that on standard MR images and with bone scintigraphy findings. RESULTS: Subtraction MR imaging depicted ischemia as a widespread absence of enhancement and was in good agreement with bone scintigraphy. The subtraction technique improved the sensitivity and the specificity of MR imaging in two children. Furthermore, subtraction MR imaging allowed recognition of the pattern of early reperfusion. CONCLUSION: Our preliminary results indicate that dynamic gadolinium-enhanced subtraction MRI is a simple and promising means of early recognition of ischemia in LCP.

Transpericardial inferior vena caval cannulation in thoracic aorta operations.

Surgical treatment of thoracic aneurysms is frequently performed with the aid of partial cardiopulmonary bypass. When profound hypothermia and circulatory arrest are employed, inadequate venous drainage may represent a major problem. We herein describe a technique of inferior vena caval cannulation that allows steady performance when high pump flows are imposed.

[Acute carotid occlusion: thrombolytic treatment]. / Occlusion carotidienne aiguë: traitement par thrombolyse.

The occurrence of a neurologic deficit at the time of an acute obstruction of the internal carotid does not equate with neurons death. The size of the residual infarct depend on the duration and the depth of ischemia. The goal of fibrinolytic therapy is to obtain a fast reperfusin of the ischemic areas to limit the size of the residual infarct. The risk of reperfusion depend on the depth of the blood-brain barrier ischemia. The indications of reperfusion in emergency settings are based on pretherapeutic CTscan and angiographic assessment with cerebral digitalized parenchymography. Between 1984 and 1994, 100 ischemic strokes have been treated on emergency by local intra-arterial thrombolysis. The results depend on the condition of lenticulostriate arteries: --when the lenticulostriate arteries are not involved in the occlusion, arterial thrombolysis is very efficient (75% good results; 0% bad results) and has been performed up to the 12th hour. --when the lenticulostriate arteries are involved, the results are not as good (58% good results; 23% bad results); the hemorrhagic risk has dramatically dropped in this group when the decision was taken to do not treat the patients after the 5th hour (16.7% to 2.3%). There has been 7 deaths, 6 were due to non efficient revascularization of the parenchyma with vasogenic oedema. In conclusion, we think that ischemic stroke is an emergency; the cerebral digitalized parenchymography appears to be a major diagnostic and prognostic tool; intra-arterial thrombolysis is a very efficient technique when used at the right site and time.

Ultrasonographic approach to the neonatal foot: preliminary study.

We report our preliminary experience with use of ultrasound in clubfoot and describe our protocol and initial results in the use of this technique.