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Revascularization of a limb after a severe and prolonged period of ischemia may be associated with high rates of mortality and amputation, because of the development of a postrevascularization syndrome, regardless the cause of occlusion (ischemia, trauma, iatrogenic) or the methods used to achieve reperfusion (fibrinolysis, surgery, resuscitative therapy). This "revascularization" syndrome includes several complications, both local (explosive swelling of the limb, compartment syndrome and skeletal muscle infarction (rhabdomyolysis) and general (acidosis, hypercalcemia, hypovolaemic shock, renal, hepatointestinal and pulmonary failures, arrhythmias and cardiac arrest (multiple organ dysfunction). Current therapies are directed against complications after they occurred, once revascularization is completed: fasciotomy, mannitol and diuretics administration for forced diuresis, fluid administration to correct hypovolaemia, use of resins, insulin and glucose or haemodialysis to deal with hypercalcemia, administration of buffers (THAM, bicarbonate) to correct acidosis, control of hypercalcaemia with orthophosphates and calcitonin.... Nevertheless, a substantial percentage of the injury is generated upon reperfusion and the muscle may remain viable after prolonged period of ischemia. Intra and extraacellular swelling, tissue acidosis, free radical mediated damage, loss of adenine nucleotide precursors, and intracellular calcium overload have been suggested to be the mechanisms responsible for reperfusion injury. Careful control of both the composition and the physical conditions of the initial reperfusion (controlled reperfusion) may result, in selected cases, in improvements in the metabolism, structure and function of the limb after reperfusion.

The routine use of arterial grafts in coronary surgery is facilitated by peroperative adjunction of antispasmodic drug to reduce the event of spasm. Diltiazem has been favoured in most clinical studies devoted to the radial artery graft. The aim of this study was to assess the efficacy of a spasm preventing protocol associating hydrostatic dilation of the graft with a diluted solution of papaverine and nicardipine infusion, starting preoperatively and continued postoperatively in i.v. and per os forms. Between September 1996 and March 1997, a consecutive series of 50 patients underwent myocardial revascularization using the radial artery. The radial artery was prepared by hydrostatic dilation with papaverine (1%) and nicardipine was administrated at 0.25 microgram/kg/min and titrated according to the arterial systemic pressure. Operative mortality was 4% (sepsis). There was no evidence of perioperative MI nor hypoperfusion syndrome. Mean CKMB level at 18 hours was 36 micrograms/l. No ischaemic anomalies of the ECG were detected. Angiography performed in the last 20 patients showed a 98% (51/52) permeability rate for all graft; 19/20 radial grafts (95%) were patent. One radial graft presented a 50% stenosis at the proximal anastomosis, and another a moderate spasm (40%) in the middle part of the conduit. This study confirms that the radial artery conduit can be used with satisfactory results for routine coronary artery bypass. The use of nicardipine allows the control the vasoreactivity of the radial graft without totally obviating at least angiographic spasm. This drug is easy to titrate, and well tolerated in association to beta-blockers in the routine perioperative management of the coronary patients.

Revascularization of a limb after a severe and prolonged period of ischemia may be associated with high rates of mortality and amputation, because of the development of a postrevascularization syndrome, regardless the cause of occlusion (ischemia, trauma, iatrogenic) or the methods used to achieve reperfusion (fibrinolysis, surgery, resuscitative therapy). This "revascularization" syndrome includes several complications, both local (explosive swelling of the limb, compartment syndrome and skeletal muscle infarction (rhabdomyolysis) and general (acidosis, hypercalcemia, hypovolaemic shock, renal, hepatointestinal and pulmonary failures, arrhythmias and cardiac arrest (multiple organ dysfunction). Current therapies are directed against complications after they occurred, once revascularization is completed: fasciotomy, mannitol and diuretics administration for forced diuresis, fluid administration to correct hypovolaemia, use of resins, insulin and glucose or haemodialysis to deal with hypercalcemia, administration of buffers (THAM, bicarbonate) to correct acidosis, control of hypercalcaemia with orthophosphates and calcitonin.... Nevertheless, a substantial percentage of the injury is generated upon reperfusion and the muscle may remain viable after prolonged period of ischemia. Intra and extraacellular swelling, tissue acidosis, free radical mediated damage, loss of adenine nucleotide precursors, and intracellular calcium overload have been suggested to be the mechanisms responsible for reperfusion injury. Careful control of both the composition and the physical conditions of the initial reperfusion (controlled reperfusion) may result, in selected cases, in improvements in the metabolism, structure and function of the limb after reperfusion.

Biventricular assistance with the Thoratec ventricular assist device was performed in a 48-year-old man waiting heart transplantation since 6 months. Indication for circulatory support was considered because of the development of progressive irreversible right heart failure with deterioration of the hepatic and renal functions. Orthotopic heart transplantation was performed after 13 days of circulatory support. No complications occurred during the assistance and in the posttransplant period. The patient was discharged on day 21 after transplantation. Five months after transplantation he is well and alive.

The medical records of nine patients (five female and four male, mean age 58 +/- 5 years) presenting with a carotid chemodectoma between 1983 and 1995 were reviewed. In two cases (22%) the diagnostic was not suspected at the time of initial presentation. The most common complaint was a swelling in the anterolateral region of the neck. One patient (11%) presented with a preoperative peripheral nerves deficits (vagus and hypoglossal palsies and Horner's syndrome). Two tumours were embolized preoperatively with polyvinyl alcohol particles. Complete surgical excision was possible in each patient and the plane of resection was adventitial. In three cases, early ligation of the external carotid artery facilitated the resection. In two patients, the vagus nerve was sacrificed because of tumour involvement. No operative mortality was observed and no vascular complication occurred. In addition to the patient with preoperative neurologic symptoms, three patients developed peripheral nerve deficits (vagus and hypoglossal nerves) postoperatively. Two of these deficits were transient. These peripheral neurologic complications were observed with the largest tumour sizes. Two cases were malignant (lymph nodes and bony metastases). These two patients received postoperative radiotherapy. The mean follow-up period 63 +/- 19 months. No patient developed local recurrence during the follow-up. Two patients died during the follow-up, one for condition unrelated to their disease and the second from metastatic dissemination. In conclusion, carotid chemodectomas may be safely resected. The best way to minimize the rate of complications is to operate them at an early stage of evolution.

A 76-year-old man underwent surgery for an infrarenal aortic aneurysm reaching 6 cm in maximal transverse diameter. The aorta was crossclamped below the level of the renal arteries. A tube graft was interposed and tend between the infrarenal aorta and the aortic bifurcation. Due to leakage on the suture line two consecutive episodes of crossclamping for a total duration of 40 min. were required. No hypotension was noted during or after the procedure. After operation, the patient complained of difficulties to move both legs and neurologic examination demonstrated paraparesis, with mild sensory deficit. Faecal and urinary incontinences were also noted and urodynamic testing demonstrated sphincterovesical palsy. Nuclear magnetic resonance imaging detected an ischaemic zone in the spinal cord at the level of T11. Faecal incontinence and motor deficit partially resolved but no bladder function recovery was observed. Spinal ischaemia is a rare complication after abdominal aortic surgery. Several risk factors have been suggested which include level and duration of the aortic crossclamping, possible interruption of the spinal cord blood supply via the greater medullary artery (the so-called artery of Adamkiewicz), presence of intra- or postoperative episodes of hypotension, atheromatous embolization, underlying occlusive arteriosclerosis of spinal arteries, and respect or not of the hypogastric circulation. In our case, the duration of the crossclamping and interruption of the blood flow in lumbar arteries probably supplying the distal spinal cord were likely contributive factors.

A case of type III aortic dissection which occurred fourteen months after heart transplantation is presented. Medical therapy was instituted to achieve controlled hypotension. The evolution was favorable and the patient could be discharged after one month. Hypertension and increased ejection fraction after transplantation could have been predisposing factors via an increase of the shear stress in the aorta.

A 73-year-old man was admitted for rupture of an atherosclerotic aneurysm of the profunda femoris artery associated to popliteal and bilateral axillary arteries aneurysms. The aneurysm of the profunda femoris artery was developed between the branches of the crural nerves. Considering the patency of the superficial femoral artery and of the leg arterie, and to avoid injury to the crural nerve, no reconstruction of the profunda femoris was attempted. The aneurysm was ligated proximally and buttress sutures were placed on the site of rupture to achieve thrombosis of the aneurysms. Most of the published cases of aneurysm of the profunda femoris artery are false aneurysms developed after various trauma. Atherosclerotic aneurysm of the profunda femoris artery is a rare lesion and rupture is exceptional.

A case of successful tricuspid valve replacement with a mechanical prosthesis and pulmonary valvulotomy for carcinoid heart disease is reported. The patient was a 61 years old women. The primary tumor was in the terminal ileum. Liver metastasis and carcinoid syndrome were present since 8 years. After cardiac surgery, the patient survived 38 months and late death was related to disseminated metastasis. Even in case of metastasis, carcinoid tumor is slow growing. Without cardiac operation for correction of valvular lesions, terminal symptoms and death may often be related to cardiac operation for correction of valvular lesions, terminal symptoms and death may often be related to cardiac failure rather than to tumoral growth. Thus, even in presence of metastasis, cardiac surgery may be mandatory to improve both quality of life and survival.

At the moment, the place of experimental surgery within the clinical surgical cores is questioned. However, its role in the progresses of surgical practice and training of surgeons is undisputable. It is through research that surgeons can keep some critical mind, essential in their daily activities. However, too often actually, the surgeons abandon research. Two essential reasons explain the phenomenon: on the one hand, the weight of the clinical tasks and on the other hand the complexity of research founded on more and more specialized basic notions. In fact, the part of a surgical investigator must be to form a link between basic research and clinical activities. As such, work in collaboration with motivated basic investigators is cardinal. Also, the success of research depends upon the will of the departments to maintain a research activity, but it meets often with the difficulty in obtaining sufficient research credits. Finally, research can play an essential part in the education of the trainees and partly fill some gaps in their clinical training.

Among 60 patients who received OHT at our institution between November 1986 and January 1990, 4 actually needed implantation of a permanent pacemaker. Three patients with symptomatic early sinus node dysfunction were identified and were satisfactorily paced on the VVIR mode. All three showed sinus recovery within three months following implantation and had their pacemaker switched from the VVIR mode to a simple ventricular demand pacing. Interestingly, administration of beta-blocking drugs quickly reinstituted pace dependence. The patients' outcome is excellent (18 to 48 months follow-up). No difference with the global cohort of our OHT recipients was noticed, apart from an apparent high incidence of infections (3/3) with (2/3) CMV and severe rejection (3/3) during the first month postoperatively. This data suggests that sinus dysfunction may be the result of a multifactorial (rejection, CMV, ...) injury to the conduction system, and is only clinically relevant beyond a threshold level. Denervation hypersensitivity, together with correction of these factors, may account for the restoration of a sufficient reserve of conduction system, and therefore appropriate sinus node function in basal conditions.

The association between aortic stenosis and digestive angiodysplasia has been described for the first time by Heyde in 1958. This entity is thus known as Heyde's syndrome. In many instances, the recurrent small intestinal bleeding originating from angiodysplasia stopped after aortic valve replacement. We report two cases of patients presenting with a recurrent small intestinal bleeding originating from digestive angiodysplasia and suffering from aortic stenosis. Diagnosis of both pathologies is well documented in both cases. The replacement of the aortic valve by a biologic prosthesis stopped the bleeding. Prior to aortic valve replacement, the two patients suffered severe recurrent blood loss from intestinal angiodysplasia. The treatment of aortic stenosis greatly favored both cardiac and general status. We recommend aortic valve replacement with a biologic prosthesis prior to intestinal resection in patients presenting with Heyde's syndrome. We stress on the fact that anticoagulants must be stopped in order to minimize the risk of further bleeding.

From 1980 to 1990, 18 patients underwent trans-sternal repair for occlusive disease of the brachiocephalic artery. The mean age was 57 years (43-72). Most of the patients were women (n = 10). All but two patients had one or more symptoms related to the stenosis of the brachiocephalic trunk: right-sided upper limb ischemia (n = 7), transient ischemic attacks (n = 8), vertebrobasilar insufficiency (n = 6), left sided minor stroke (n = 1). Only two patients were asymptomatic before operation. Angiography revealed a tight stenosis (n = 14) or an occlusion (n = 3); in one patient it concerned an ulcerated non-stenotic plaque of the brachiocephalic artery. Eleven patients had coexistent involvement of other supraaortic vessels. Angiographically, clinically and intraoperatively, there was evidence of Takayasu arteritis in three female patients. All patients had direct repair by trans-sternal approach. Six patients with short lesions had thromboendarterectomy with patch angioplasty of the innominate artery. In eleven cases, aorto-brachiocephalic bypass grafting was performed. In one patient, aortic calcification precluded proximal anastomosis, and a carotid-to-carotid bypass was done. In five patients, simultaneous revascularization of subclavian (n = 3), left common carotid (n = 2) or internal carotid artery (n = 2) completed the procedure. In one patient, concomitant coronary revascularization was done. There was no operative mortality. Postoperative morbidity was limited to pulmonary infection (n = 2), transient neurologic deficit (n = 1) and renal insufficiency (n = 1). All patients had relief of symptoms. Duplex echo scan confirmed patency of all reconstructions at a mean follow-up of 46 months.(ABSTRACT TRUNCATED AT 250 WORDS)

From 1983 to 1990, 65 axillobifemoral and 20 axillofemoral bypasses have been performed in 85 patients (77 men and 8 women), with a mean age of 69 +/- 9 years. Indications for surgery were: severe aortoiliac occlusive disease (87%), sepsis of previous aortoiliac prosthesis, abdominal aorta aneurysm. Anatomic bypass was precluded for general (81%) or local (19%) conditions. In the last group, 9 patients have had previous laparotomy. Four patients presented with aortoenteric fistulas. Eighteen patients were operated on in emergency. The operative mortality was 12%, with 50% cardiac related deaths. Early primary patency was 98%. Early secondary patency was 100%. The mean follow-up is 28 +/- 15 months. The 3 years survival is 77%. The cumulative patency rates at 1 and 3 years are 89% and 76% respectively. Although axillobifemoral bypasses achieve poor long-term results when compared with aortoiliac bypasses, they can be considered in high risk patients. In this group of patients, the cumulative patency rate and the survival curves tend to be parallel.

Although rare, left atrial myxoma is an entity from anatomopathological and clinical aspects. Seven cases of left atrial myxoma operated on the last ten years were reviewed. We also report a rare presentation of right atrial myxoma, where the tumor was responsible of a dramatic hemodynamic shock due to right ventricular inflow obstruction. Six patients were female, with a mean age of 53 years. All but one consulted for exertional dyspnea of recent onset. Two patients with left atrial myxoma and the patient with right atrial myxoma had experienced embolism. Five patients had systemic symptoms. Echocardiography was the most performant diagnostic procedure. All but the patient with right atrial myxoma were operated by the left atrial access. The mitral valve was replaced in two patients. The histological aspect of this benign tumor is illustrated but the lack of frank border between the tumor and the myocardium is emphasized. We conclude that surgical management is primordial. We give anatomopathological rationale for resection of implantation pedicle. The operative mortality was nul in this series of 8 patients; major improvement of cardiac status was constant. No recurrence has occurred during the follow-up period.

From 1985 to 1990, 27 patients older than 55 years (extremes 55-65 years; 21 men and 6 women) received a cardiac transplant. The cause of cardiopathy was ischemic in 70%. Postoperative immunosuppressive therapy consisted of Cyclosporin A, steroids, azathioprine and antilymphocytic serum. Rejection episodes were monitored by endomyocardial biopsies and treated by pulses of steroids or monoclonal antibodies (OKT3). The operative mortality is 7.4% (n = 2). The one and two year survivals are 71% and 62% respectively. The incidence of infection and/or rejection were 0.71 +/- 0.4 and 1.4 +/- 0.7 episodes/patient year. Age beyond 55 years does not contraindicate heart transplantation. This change in recipient selection policy should lead to parallel changes in donor selection criteria.

From 1981 to 1987, 29 patients (14 women and 15 men, with a mean age of 56 +/- 15 years) underwent a carotid-subclavian bypass for occlusive lesion of the subclavian artery (or of the left common carotid artery). The symptomatology included vertebrobasilar insufficiency, arm ischemic symptoms, or combination of both symptoms. Twelve patients (42%) have had a previous transient ischemic attack, or a cerebrovascular accident. There were 22 stenoses or occlusions of the left subclavian artery, and 6 of the right subclavian artery. On arteriography, 9 patients had significant associated lesions on the internal carotid artery, either homolateral (n = 7), or heterolateral, or bilateral. Carotid to subclavian bypasses were performed either with autogenous saphenous vein (n = 15), or with prosthetic graft (n = 14). In 5 cases, a carotid endarterectomy was done simultaneously to the bypass. Operative mortality was 3.4% (1/29). Early patency (less than 1 month) was 97% and late patency 89%, with a mean follow-up of 40 +/- 24 months. The patency rates were not significantly different whether a prosthesis or a vein was used for the bypass. All patients were improved and complete relief of symptoms was achieved in 92%. No patient experienced symptoms of carotid steal after the bypass. We concluded that carotid-subclavian bypass is a safe and efficient method for revascularization of the subclavian artery of of the left common carotid artery in selected cases.

A series of 73 simultaneous carotid and coronary revascularizations (Group I) is presented (January 1980-December 1988). Age, sex, risk factors, severity of angina, coronarography, neurological symptoms, angiographic carotid lesions and operative outcome of these 73 patients are compared with the aspects of 3544 coronary bypass patients (Group II) and 1001 carotid endarterectomized patients (Group III) during the same period. The angina in Group I is more severe, with 22% belonging to NYHA class IV and 26% having a stenosis of the left main coronary artery, vs 14% and 13% in Group II. Seventy percent of the carotid lesions in Group I are asymptomatic vs 33% in Group III. Group I patients had more problems in the perioperative period, with 16.4% needing prolonged high-doses analeptics and 5.4% intraaortic counterpulsation balloon. Operative mortality is higher (7%) in Group I compared with Group II (2.3%) and Group III (1.7%). These results permit to define a population of polyvascular patients with concomitant coronary and carotid disease, characterized by a more diffuse atherosclerosis and a higher operative risk. Operative morbidity and mortality after combined myocardial and cerebral revascularization remains nevertheless inferior to the cumulated surgical risk of the sequential procedures (74 patients with coexistant coronary and carotid lesions operated in two sessions before 1986).

From 1985 to 1989, 6 patients underwent a pulmonary surgical procedure simultaneously with a cardiac operation. All patients were male with a mean age of 60 +/- 8 years. The cardiac procedures included: 1 aortic and 1 mitral valve replacement, 3 coronary artery bypass grafts and 1 closure of an atrial septal defect. Four patients had primary pulmonary nodules: 2 bronchogenic carcinomas and 2 benign hamartomas. They presented with cardiac symptoms, and lung nodules were incidentally found on preoperative Chest X-Rays. The 2 last patients had pulmonary metastases of colonic neoplasms previously resected, respectively 3 and 6 years before. After completion of the cardiac procedures, during the rewarming of the patient, the pulmonary resection was performed on a deflated lung, via the median sternotomy. Pulmonary procedures included: right upper segmentectomy (n = 1), left pneumonectomy (n = 1), left interior lobectomy (n = 1), right middle lobectomy (n = 1), left upper wedge resection (n = 1), and right upper lobe wedge resection (n = 1). All patients were extubated on day one. One patient died from rythm disturbances on day 13. All other patients are alive with a mean survival of 30 months. The authors conclude that combined surgery is feasible in selected cases. Sternal approach is not a limitation to pulmonary resection.

The authors report their recent experience with renal autotransplantation (3 cases). In one case it concerned a complex aneurysm of the renal artery involving secondary arterial renal branches, and associated with hydronephrosis (case 1); another patient presented a high ureteral injury unsuccessfully repaired by previous surgery (case 2), and the third patient had diffuse fibrodysplasia of intrahilar arterial branches (case 3). The procedures were technically successful and gave good functional results. They describe the technique of kidney refrigeration, extracorporeal vessel repair and ureteral preservation or reimplantation. Indications and technical advantages of this organ-saving reconstructive approach are discussed.

A case of intraluminal duodenal diverticulum (IDD) in a young man with chronic abdominal pain is reported. Diagnosis was done by a barium meal. Surgical excision was performed. Associated ectopic pancreatic tissue was found at operation. IDD is of congenital origin and it coexists with other anatomical abnormalities in 40%. Complications include chronic abdominal pain, duodenal obstruction, gastrointestinal bleeding, pancreatitis. Endoscopic resection is feasible, but surgical resection is safest. Peroperative localization of the papilla of Vater is mandatory to avoid its injury during resection of the mucosal attaches of the IDD.

Intrapericardial ruptured aneurysm of the right anterior sinus of Valsalva. A intrapericardial ruptured aneurysm of the right anterior sinus of Valsalva is presented. An infectious origin was suspected. The aneurysm was treated by plication, which allowed to correct the preoperative insufficiency. Aneurysms of the Valsalva sinus can remain asymptomatic. When they are small, a conservative treatment is conceivable. Many complications can occur: rupture (more often in right cavities), aortic insufficiency, coronary insufficiency, cardiac failure, rhythm disturbances. This complications necessitate a surgical treatment. Aortic valvular replacement is indicated only when the structure of the valve is altered.

Two cases of lymphangiosarcomas which arose 4 and 14 years after a mastectomy are reported (Stewart-Treves syndrome). One of the patients was treated by shoulder disarticulation and the other by chemotherapy (using Melphalan, Cyclophosphamide and 5-fluorouracil). Disseminated metastases and deaths occurred 6 and 18 months after the onset of the lesion. Stewart-Treves syndrome occurs in approximately 0.07 to 0.45% of mastectomy. Prognosis is worse: survival at five year is fewer than 10%. Early diagnosis is mandatory. Surgical resection of the lesions and adjunctive chemotherapy seem the best treatment.

Between 1977 and 1987, eleven isthmic ruptures and three chronic posttraumatic pseudoaneurysms of the thoracic aorta have been seen in our cardiovascular surgery service. The hemorrhagic intraabdominal wounds were treated first during the same or a staged procedure. Two patients died prior to the vascular intervention. In the other cases, partial femorofemoral extracorporeal circulation has been used after systemic heparinization (3 mg/kg). The perfusion flow was approximately 2 to 3 l/min. Three patients (25%) died following operation. Only one death caused by decerebration is potentially related to heparinization. No paraplegia occurred. The partial extracorporeal circulation is a reliable method to prevent paraplegia and to diminish the left ventricular post-charge during aortic clamp time.