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Dysplasia of the renal and cervical arteries are well known, but dysplasia of the superior mesenteric artery (SMA) is less frequent and has specific presentation. There have been few reports on the different types of presentations. We report a series of 38 cases and present the characteristic features together with a comparison with data in the literature. These non-atheromatous non-inflammatory lesions of the arterial wall occurred either in a context of fibromuscular disease which cause is unknown (30/38 patients) or in patients with genetic disease such as neurofibromatosis (3/38) or Ehlers-Danlos disease (5/38). The fibromuscular disease presented three aspects with specific characteristics. a) stenosing lesions found predominantly in women with a different morphology than in the other localization (usually associated): irregular diffuse stenosis discovered in patients with hypertension, or ischemic digestive symptoms (6/14 patients). b) Aneurysms, also found predominantly in women, but less frequently associated with other dysplasias. These aneurysms were generally sacciform. Unlike data in the literature, our series only included rupture in 1/8 cases. The aneurysm was discovered during the exploration of abdominal pain or hypertension. c) The third type of fibromuscular disease concerned dissections which were observed in the male population, (except one case of segmental dysplasia), and presented with signs of digestive ischemia in the other seven patients, four in an emergency context requiring immediate treatment. Two genetic diseases were observed. a) Neurofibromatosis led to dysplasia analogous to fibromuscular disease, but with abnormal nerve formations in the wall. For the three cases observed, one involved only the visceral arteries and the two others thoraco-abdominal coarctation. b) We had five patients with Ehlers-Danlos syndrome, with dysplasia of the superior mesenteric artery. For three there was a fusiform dilatation and in one small aneurysms along the arterial trunk, which only required surveillance. There was only one aneurysm which required treatment by resection and venous graft. In these young patients, revascularization was generally achieved with autologous material and the prognosis was favorable. Embolization was successful in treating the sacciform aneurysm in one patient. In conclusion, dysplasia of the superior mesenteric artery has a specific presentation which must be recognized to enable diagnosis of this not uncommon condition in young subjects (even children) who often present with an acute abdomen requiring urgent treatment.

Post-irradiation axillo-subclavian arteriopathy can develop 6 months to 20 years after radiotherapy. Incidence estimated from duplex scan screening is about 30%, half of the cases having no hemodynamic significance. In our experience, asymptomatic lesions are the most common. Nevertheless, we have observed since 1978, 38 symptomatic patients including 23 with either acute ischemia (8 patients), or chronic ischemia (15 patients) requiring revascularization. We used an endovascular approach in 8 and open surgery in 15. A bypass graft was performed in 13 patients, using a vein (8 patients) rather than a prosthesis (5 patients), implanted in healthy territory, proximally or in the common carotid (11 patients) or the proximal subclavian (2 patients), and distally in the axillary artery (5 patients) or the brachial artery (8 patients). One venous bypass became occluded postoperatively. The other bypasses remained patent during follow-up of over 10 years. There of the five prosthetic bypassess gradually failed without recurrence of critical ischemia. Other revascularization procedures included endarterectomy and thrombectomy. In the long term, functional prognosis mainly depended on the frequently associated involvement of the plexus in the post-irradiation changes, which, together with the revascularization procedure, also required neurolysis in 11 patients, two omental covers and a free musculocutaneous transfer in 9 patients.

Five inflammatory aortopathies were disclosed 3 to 16 years after inaugural giant cell arteritis. Three patients were symptomatic: one aneurysm of the subrenal abdominal aorta discovered at work-up for an inferior arteriopathy, one thoraco-abdominal aneurysm with a "fissuration" episode, one calcified thoraco-abdominal aortopathy suggesting dissection. In these three cases, there was a severe inflammatory syndrome with asthenia, fever, elevated erythrocyte sedimentation rate and a large inflammatory crown around the aortopathy. In the two asymptomatic cases, the diagnosis was made during the follow-up of Horton's disease, in one patient with active disease, the other late after the initial episode. Two aneurysms required surgical cure, with resection-prosthesis of the thoraco-abdominal aneurysm and revascularization of the digestive and renal arteries. In the 4 active cases, corticosteroid therapy cured the inflammatory process both on the basis of laboratory results and the involution of the periaortic crown and, in one case, the total regression of ureteral compression causing pyeloureteral dilatation on the left. The diagnosis of giant cell arteritis was confirmed histologically in the two operated cases. Extra-cervical localizations of aortic aneurysm of dissection in patients with giant cell arteritis is not a fortuitous coincidence but an association as demonstrated by the Mayo Clinic epidemiology. On the basis of these reported cases and data in the literature, the practical conclusions are: in case of aorta involvement, particularly with inflammation in subjects under 50, giant cell arteritis should be entertained as a possible diagnosis; in patients with giant cell arteritis, follow-up should include yearly thoracic radiograms to search for thoracic aorta involvement and Doppler and ultrasound explorations to identify any abdomino-iliac lesions. This protocol is required to avoid the life-threatening complications of dissection or rupture of an aortic aneurysm.

Type 1 neurofibromatosis (NF1) is the most frequently observed phacomatosis, but involvement of arterial trunks is uncommon. Expression depends on the localization and is not easily related to the causal condition. Seven patients with type 1 neurofibromatosis developed vascular manifestations (table I) disclosed by hypertension (n = 2) digestive angina (n = 1), arterial rupture (n = 1) and aneurysm of the subrenal aorta (n = 1). The diagnosis of NF1 was clear in 5 cases; in 2 cases, the diagnosis could only be established on the basis of pathology findings demonstrating dysplasia of the media with voluminous periadventitial hypertrophic nerves (table II). All the large arteries can be involved in NF1. A complete vascular work-up is needed to identify multiple arterial localizations as found in two of our cases. Thoraco-abdominal stenosis was observed in 5 cases leading, in 2 cases, to coarctation with a hemodynamic and functional impact requiring aortic revascularization. The most frequently observed localization involves the renal arteries: 3 of our patient had occlusive lesions of the renal arteries and in 2, aneurysms were observed. Three of our patients (including 2 of the preceding), had major occlusion of digestive arteries. Three other cases revealed an aneurysm of inflammatory subrenal aorta, a rupture of the iliac into the inferior vena cava and a rupture covered by a subclavian aneurysm. The indication for surgery depends on the arterial signs of associated complications (5 of our cases). In one case surgery was indicated to prevent rupture of a splenic artery aneurysm and an aneurysm of the subrenal abdominal aorta. Two cases were treated by exclusion (ilio-cava fistula) or excision (splenic aneurysm); renal or digestive revascularization was performed with arterial or venous autografts in young patients (3 cases). One extensive abdominal coarctation was repaired with a PTFE graft as were the subclavian and subrenal aorta aneurysms. One patient with an ilio-cava fistula died from collapsus. Long-term results of the revascularizations are satisfactory with good control of the hypertension and total regression of the digestive angina. Fibrodysplasia of the renal or digestive media occurring alone or thoraco-abdominal coarctation should suggest NF1 and lead to a complete work-up to identify other arterial localizations. Patients should be followed regularly to prevent complications which in case of rupture can be life-threatening.

Popliteal venous aneurysms are uncommon. We reviewed 101 cases reported in the literature and our series of 11 operated cases to study the nosology and therapeutic indications. In our series, there were 7 cases of unique dystrophic aneurysms, 4 cases involving locoregional angiodysplasia: 3 cases with venous hemodynamics and 1 case with arteriovenous flow. Pulmonary embolism developed in 2 cases. Ultrasonography provided the diagnosis. A sacciform aneurysm was found in 10 cases and a fusiform aneurysm in 1 case. Venous repair was performed in all cases: 9 endoaneurysmal sutures, 1 interposition of the medial gastrocnemius vein, and 1 PTFE graft. Permeability was confirmed in all cases with no recurrent embolism. These cases and the histological correlations describe the nosology of dysplastic venous aneurysms which should be distinguished from dystrophic ectasia of incompetent veins which is not associated with pulmonary embolism. Indeed, pulmonary embolism is the most common complication revealing venous aneurysms (table I). Doppler ultrasonography can provide early diagnosis before such complications develop. Surgery is required for emergency cure in case of pulmonary embolism and is warranted for preventive cure, generally by endoaneurysmorraphic repair allowing venous permeability without the risk of iterative embolism.

During a 6-year period six patients had combined revascularizations for an abdominal aortic aneurysm and a high-grade (> 80%) stenosis of either the superior mesenteric artery (N = 14) and/or a renal artery (N = 60 including 6 bilateral revascularizations). Revascularizations of a visceral artery were done more often with a bypass graft (N = 61) than by endarterectomy (N = 6), reimplantation (N = 4) or endovascular technique (N = 3). Fifty patients had concomitant repair of the aorta and of the visceral artery, and ten had a staged repair, favored in-high risk patients and in cases of multiple visceral artery revascularizations. Four patients (7.5%) died (2 myocardial infarctions and 2 multisystem organ failure) and twelve (20%) had a non-fatal complication in the postoperative period. Survival was 91% at one year and 81% at 5 years. Our experience emphasizes the option of a staged approach in these high-risk patients, with the availability of extra-anatomic reconstruction, and the limited value of endovascular revascularization of the visceral arteries.

Emboligenic aortopathies are defined as lesions of the aortic wall leading to the production of thromboatheromatous material which can migrate in fragments or entirely. Emboligenic aortopathy can occur in all parts of the aorta. Localized lesions are rare and usually involve the subrenal abdominal aorta or the isthma. Diffuse lesions involving several segments of the aorta are encountered more often. There are three anatomic types of lesions: ulcerated plaques, atheromatous ulcerations, an evrysmal disease of the aorta. Therapeutic indications depend on: 1) clinical presentation: fibrinocruoric emboli, distal microemboli, disseminated cholesterol emboli; 2) the unique or multiple nature of the emboli; 3) the anatomic lesion; 4) localization.

Whether or not to operate an asymptomatic aneurysm of the aorta in a patient over 80 years of age is a question increasingly facing the surgeon: longer life span (about 7 years), aneurysm discovered on a sonogram or scan ordered for digestive, urologic or pelvic disorders. This discussion is based on a personal retrospective series of 800 patients who underwent elective operation for non-ruptured aneurysms of the subrenal abdominal aorta between January 1985 and June 1990. For the 732 patients under 80, mortality was 1.9% and for the 68 patients over 80, it was 8.8%, emphasising that in this group survival at 6 months was reduced by 10%. The operative risk, as for younger subjects, results from coronary risk (reversible ischaemia), the quality of the heart muscle (ejection fraction < 35%), respiratory and renal function. Increased age raises mortality when one of these factors is severely jeopardized but associated lesions, such as digestive disorders or arterial lesions (severe occlusion of the downstream vessels, occlusion of the mesenteric and hypogastric arteries increases the risk of acute ischaemia of a limb or the intestine), should also be taken into consideration. Indications for operation should be discussed in light of these factors in patients at risk (large aneurysm > 60 mm or increasing in size, "images" suggesting risk of rupture: bleb or bubble ectasia, flotting mural thrombus, "digitiform" lysis of a mural thrombus, rupture of the calcified shell or covered rupture). When there is a high risk of lesion and the operative risk prohibits conventional surgery, other procedures can be discussed: axillo-bifemoral bypass with exclusion of the iliac and secondary embolization or subrenal exclusion, substitution with an endoaortic prosthesis allowing wider indications.

We report the case of a 25-year old woman presenting with disabling pain of the left calf, associated with lower left limb angiodysplasia. Dynamic testing (duplex scan and phlebography) showed a popliteal vein ectasia, with reflux into an incompetent lesser saphenous vein: the venous drainage of this ectasia was an embryonic femoropopliteal vein going to the profunda femoris vein. As long as patency and competence of deep veins and of the superficial femoral vein were confirmed by dynamic testing with compressions, curative surgery was considered: en-bloc resection of lesser saphenous vein and of embryonic femoropopliteal vein combined with lateral suture of the popliteal vein. One-year follow-up confirms the absence of recurrent symptoms. Dynamic testing allows safe surgical therapy of persisting embryonic abnormalities associated with incompetent veins, in cases where such testing clearly demonstrates that a sufficient venous drainage of the affected limb will be provided after surgery.

Femoro-tibial bypasses are not always feasible in patients presenting with "critical" chronic ischemia. The results of endovascular therapies carried out over a 2-year period are analyzed. Twenty-three patients with critical ischemia (rest pain 13%, gangrene 87%) had 25 procedures on 29 leg arteries: percutaneous transluminal angioplasty in 17 arteries, rotational atherectomy in 10 arteries, laser recanalization (1 artery), directional atherectomy (1 artery). The hospital mortality rate was 4.3%. The cumulative patency and limb salvage rates were respectively 51% and 77% at 6 months, 34% and 71% at 12 months. Candidates for tibial-peroneal endovascular techniques should have a threatened limb, as long as the consequences of failed procedures on patients presenting with claudication can be disastrous, and as long as mid-term patency rates reported in the literature are not fair enough. In localized stenosis or short occlusions with adequate runoff, endovascular techniques are a good alternative to femorotibial bypasses for limb salvage. In diffuse lesions with no possibility of bypass, endovascular techniques can facilitate limb salvage, even if the mid-term arterial patency rate is poor. When conventional therapies cannot face critical ischemia, endovascular therapies can provide a fair limb salvage rate.

Thromboendarterectomy is the most popular technique of carotid restoration for atheromatous lesions. In some cases, endarterectomy may be difficult or hazardous to perform, when atherosclerotic lesions involve the proximal common carotid artery and/or the distal internal carotid artery, when they are radiation induced, and when they are associated with fibromuscular dysplasia, loops or kinking. In other cases, result of endarterectomy may be unsatisfactory, because of a traumatic lesion of the arterial wall during endarterectomy, or a stenosis of the arteriotomy closure. Postoperative and late restenosis and occlusion rate range between 10 and 50% after primary closure of the carotid arteriotomy. Some of these complications may be reduced by alternative techniques such as eversion endarterectomy or patch angioplasty closure. Reversed saphenous bypass may also be performed. In our experience, only suitable autologous greater saphenous vein shall be harvested, including adequate length, absence of valves, diameter greater than 4 mm, and excellent wall texture. Distal anastomosis on the internal carotid artery shall be performed end-to-side with ligation of the internal carotid stump, and not end-to-end. Thus, in that location, venous grafts have excellent long-term patency with less than 5% late restenosis or occlusion rate. Thus, venous graft bypass may be an alternative technique to carotid endarterectomy, especially in young patients and women, who are more often exposed to late complications.

Unlabelled: Femoro-distal bypasses are not always feasible in patients presenting with "critical" chronic ischemia. The results of endovascular therapies carried out over a 2-year period were analyzed., Patients--Methods: 23 patients with critical ischemia (rest pain 13%, gangrene 87%) had 25 procedures on 29 leg arteries; percutaneous transluminal angioplasty in 17 arteries, rotational atherectomy in 10 arteries, laser recanalization (1 artery), directional atherectomy (1 artery)., Results: The hospital mortality rate was 4.3%. The cumulative patency and limb salvage rates are respectively 51% and 77% at 6 months, 34% and 71% at 12 months., Discussion: Candidates for tibial-peroneal endovascular techniques should have a threatened limb, as long as the consequences of failed procedures on patients presenting with claudication can be disastrous, and as long as mid-term patency rates reported in the literature are not fair enough. In localized stenoses or short occlusions with adequate runoff, endovascular techniques are a good alternative to femorotibial bypasses for limb salvage. In diffuse lesions with no possibility of bypass, endovascular techniques can facilitate limb salvage, even if the mid-term patency rate is poor. When conventional therapies cannot face critical ischemia, endovascular therapies can provide a fair limb salvage rate.

Surgical appliances have a place of choice in the care of the foot with trophic lesions in diabetics, after partial amputation and as a preventive measure when it is free from trophic disorders. The type of appliance will depend on the footwear and the possibility of wearing orthopedic soles, whatever the stage of the affection. For the foot free from trophic disorders the shoes should be wide fitting, in soft leather and of the seamless type. Made to measure shoes should be reserved for badly deformed feet. The soles should be molded in silicone or polyurethane to distribute weight bearing and to avoid it over zones at risk. Appliances for the foot with trophic lesions should allow the resumption of walking. If the lesions are too extensive an orthosis is performed or a specific type of slipper with molded soles is worn to avoid pressure on the wounds. After amputation of toes a silicone orthoplasty is used to fill the interdigital space to avoid deformity of the other toes. If a front of foot has been amputated a corrected silicone molded sole with false extremity is applied. For a back of foot amputation an orthoprosthesis is made, preferentially in silicone introductible in a regular high sided shoe. In order to fulfil its preventive or temporary role, the appliance should evolve with time and be followed up regularly with close collaboration between the diabetic specialist the podologist and the orthotist.

Unlabelled: Femoro-distal bypasses are not always feasible or indicated in patients presenting with "critical" chronic ischemia. The results of nutrient flaps carried out over a 2-year period are analyzed., Patients--Methods: 12 patients had extensive gangrene compromising limb salvage (heel, dorsal or lateral aspect of foot or ankle at high risk of tendon or joint sepsis). Coverage of tissue loss was provided by a latissimus dorsi flap in 8 patients, a radial artery free flap in 1 patient, a supra-malleolar flap in 3 patients., Results: The hospital mortality rate was 8.3%. The cumulative patency and limb salvage rates are respectively 58% and 67% at 6 months, 44% and 67% at 12 months., Discussion: The challenge of inframalleolar reconstruction in patients presenting with critical ischemia is not always amenable to surgical revascularization to the foot, due to the lack of a suitable artery for bypass implantation or due to the lack of run-off, when arteriosclerosis of the plantar arch, or when distal embolisms are present. Some patients present with extensive gangrene, and in most of cases infection of the foot, and carry a high risk of arthritis: they are not likely to heal properly if surgical bypass alone to a foot artery is done. Bypass surgery is not indicated in diabetic patients with extensive foot infection, in whom no significant macroangiopathy is present. These 3 situations are a good indication for flaps, in order to cover the tissue loss, to fight the infection, and to provide a vascular supply to the foot. When conventional therapies cannot face critical ischemia, nutrient flaps can provide a fair limb salvage rate.

In diabetic patients the foot is the focal point of neurologic, arterial and infectious complications. Affections of the foot are generally synonymous with a diabetic trophic disorder: the risk of gangrene is 17 times greater in diabetics than in non diabetics. Trophic disorders can affect the functional prognosis when they lead to amputation with subsequent altered weight bearing. They can provoke worsening of a subjacent arteriopathy, until then partially or totally asymptomatic, when the excision wound lacks the hemodynamic capacity for healing because of the associated arteriopathy. They can also induce local, regional (cellulitis) or even general (septicemia) infectious complications. They have a major socio-economic effect, by the loss of quality of life, the inability to work, and the cost of hospital and general care they engender. Finally, they have to be experienced by the patient and the treating team as a failure since, in the majority of cases, they imply an insufficient a priori knowledge of the predisposing factors: arteriopathy of legs and neuropathy with loss of sensitivity depriving the patient of the pain alarm signal if cutaneous lesions develop, and a delay in the recognition of triggering factors represented by microtrauma caused by shoes, particularly burns, frostbite or infections.(ABSTRACT TRUNCATED AT 250 WORDS)

Fifty-three atheromatous carotid stenosis in a previously irradiated zone were operated upon between January 1983 and December 1991. A case control (retrospective) study confirmed the reality, even within the context of multiple artery atheromatous localizations, of an atypical profile suggestive of incrimination of the radiation: extension of the atheromatous lesions distally in the common carotid, proximally beyond the bulb. An isolated atheromatous lesion in the common carotid is very suggestive of postradiation atheroma, which also presents specific histologic features: peri-adventitial inflammation, adventitial and medial sclerosis. These changes are not accompanied by any particular neurologic clinical manifestations, but require frequent changes in surgical strategy: bypass rather than endarterectomy; the extent of the lesions decides whether the proximal implantation of the bypass is in the lower part of the common carotid or the subclavian. Radiotherapy adds to the difficulty of dissection and provokes a slight increase in morbidity, but the long term prognosis is analogous to that of usual atheromatous lesions with, however, the risk of atherosclerotic changes proximally.

Results are reported of a retrospective analysis of transluminal angioplasty (TLA) interventions in 20 diabetic patients, 16 men and 4 women, mean age 56 years (range 32 to 82 years), with 24 dilated lesions, 16 patients having insulin-dependent diabetes. In 12 cases the lesions were at the intermittent claudication stage, trophic lesions being present in 8 cases. Stenotic lesions were iliac (12 cases), superficial femoral (2 cases), popliteal (6 cases) and tibial (4 cases). One patient developed an acute occlusion following popliteal-anterior tibial recanalization, the only direct complication of the angioplasty. Angiography showed immediate satisfactory results in 22 of the 24 dilated lesions. Functional and hemodynamic improvement was a constant finding in patients with intermittent claudication, trophic lesions being healed in 4 cases (50%) the other patient showing either no change or requiring an unavoidable amputation (2 cases). These overall findings suggest that at the intermittent claudication stage no differences exist in the results of TLA when compared with a non diabetic population; inversely, in the presence of trophic disorders, the local conditions (distal bed, infection, gangrene) interfere considerably in the course of the dilatation. Transluminal angioplasty should therefore be carried out as early as possible in diabetics; arteriography should be performed as soon as even minimal claudication appears and, a fortiori, even at the onset of a trophic lesion.

Our experience with 91 operated cases in 84 patients (47 men, 37 women) relates essentially to arterial diseases resulting from overloading and diabetic arteriopathy. Diagnosis of critical ischemia is easy in clinical conditions, but it is advisable to rely on universally recognized hemodynamic standards to define this condition. Ankle pressure should be less than 400 mmHg and the Doppler trace flat or barely perceptible. Patients in our series had a mean ankle pressure of 32.4 mmHg. Local examination can determine the extent of gangrene, whereas general examination detects numerous, often associated defects diabetes, coronary artery disease, rhythm disorders, arterial hypertension, etc. As far as possible, these defects are to be corrected before surgery. X-ray examination (M. Kasbarian) is frequently done in conjunction with conventional aorto-arteriography and digital angiography. The later technique allows arteries to be visualized which are not seen with the conventional technique. The x-ray examination will indicate whether revascularization is feasible, although it cannot show whether it will be efficient. In our series, opacification of the plantar arches was predictive neither of success nor failure. But do tests exist which can predict the success of a revascularization attempt? It would be necessary to be able to estimate ankle pressure after the operation, and several methods have tried to do this. TcPO2 would seem to be a good examination. The possibilities of nuclear magnetic resonance are being studied, and the results thus far are promising. Preoperative explorations are carried out in a different situation. Arteriography performed in the operating room is a simple act which can reveal a usable downstream bed not indicated in preoperative X-rays, although it provides no hemodynamic data. Measurement of peripheral resistances would appear to be a very good predictive examination. Flow measurements by infusion or electronic flowmeter also seem to be predictive for bypass results. Unfortunately, these measurements are at present not widely performed and the critical threshold is assessed differently. Given the difficulty of correctly estimating the value of these numerous methods, many surgeons, ourselves included, have chosen to revascularize patients whenever the upstream bed as evaluated by X-ray indicates the presence of at least one viable artery.

220 lumbar sympathectomies were performed in 206 patients. Postoperative mortality morbidity were essentially related to the cardiovascular past history of the patients and indications for surgery must be very carefully weighed, in particular after the age of 70 years. Sympathectomy markedly increases the chances of healing of patients with ischaemic trophic disturbances. It shortens the time required for healing, whatever the type of gangrene.

Both the possibility and prognosis of procedures for revascularization of lower limbs are still the subject of discussion. In 1976, Tingaud et al. emphasized the deceptive nature of femorotibial bypass operations, whereas more recently, the inverse position was taken by Logerfo who considered that therapy should be identical for diabetic and non-diabetic arterial diseases. As a function of experience gained in the Hospital Saint-Joseph with vascular surgery in diabetics, results of revascularization in diabetics were compared with those in non-diabetic patients (the possible influence of the type of diabetes-particularly whether insulin-dependent or not- could not be assessed because of the variable use of insulin apart from precise cases).

Close cooperation between radiologist and surgeon is essential to prevent major complications of intra-luminal angioplasty, an only mildly aggressive revascularization procedure. Though evolution of an arteritis of the lower limbs can be halted by relief of the stenosis in some cases, the problem remains as to whether this technique is justified at the stage of claudication, even severe. The wider indications for dilatation at the iliac in relation to the femoropopliteal levels in this most recent series reported, testify this tendency.

Reparative surgery of an iliac axis was conducted on 35 patients with atheromatous aorto-iliac lesions, and was completed by a contralateral shunt as an "alternative" between a prosthesis and a bifemoro-aortic thromboendarteriectomy. Reconstructive surgery on the donor axis included a thromboendarteriectomy alone or combined with a venous graft in 31 cases, an aorto-femoral vein graft in 3 cases, and an external iliac angioplasty in 1 case. The contralateral shunt was by a vein graft in 29 patients, and a prosthesis in the other 6 cases. Two complications occurred, one due to progression of the atheromatous lesions on the unobstructed aorto-iliac axis, the other being related to fibrous stenosis of a crossed vein graft. Post-operative follow-up over periods ranging from 6 months to 6 years confirmed the good vascular prognosis.

Popliteal artery compression may be due to trapping of the artery, a tumor, or a subadventricial cyst. Diagnosis is suggested by the discovery of ischemia in a subject who is often young, this being an unusual finding. It is confirmed by dynamic doppler tests, ultrasonography, and vascular opacification. Eight cases of trapped popliteal, three of osteochondroma, and seven cases due to cysts were observed. Surgical treatment is regularly effective and can prevent complications of embolism and acute thrombosis.

497 cases of carotid stenosis were operated upon with 2 operative series: one with a venous graft technique and the other by thromboendarterectomy (T.E.). 228 grafts were thus compared with 192 T.E. during the initial postoperative period and 2 and a 1/2 years follow up. The prevalence of immediate postoperative complications was lower in the venous graft group than in the T.E. group but the distribution of patients in terms of neurological symptomatology was not strictly identical. By contrast, comparison of the asymptomatic patients in the two groups showed no morbidity nor mortality. It is thus not possible to state that vein graft is superior to T.E. in the prevention in particular of early embolic complications with the thromboendarterectomized zone as the point of departure and the follow up period is too short to assess the superiority of one or other method in the long term. During the 2 and a 1/2 year follow up period of the present study no pathology related to the vein graft has been seen, confirming the trial already reported.

Lesions localized to the vessels arising from the aortic arch and those in the upper limbs were observed in 72 out of 84 patients with Takayasu's disease. In 54% of these 72 cases, other regions were affected, while only the vessels arising from the arch of the aorta were the site of lesions in the other 46% (isolated axillo-post-vertebral subclavian lesions were present in 14% of cases). Semiological features, long-term complications, and prognosis are discussed. 53 revascularizations were performed in 47 patients without mortality. Surgery is definitely indicated when severe stenosis of the brachiocephalic vessels or the main carotid arteries or their division exists. Revascularization of a subclavian artery stenosis should be limited to cases with ischemia of the upper limb on effort or when a histological diagnosis is required. Controversy exists as to the need for this operation in ectatic forms.

Between 1977 and 1981, 104 patients underwent 115 axillo-femoral bypass operations (AFB). All the indications were based upon limb salvage. Ninety-nine unilateral bypasses and only 8 axillo-bi-femoral procedures were performed. Prolongation of revascularisation by femoro-popliteal bypass was necessary in 10 cases, in 1 or 2 stages. Secondary bilateralisation of an unilateral bypass was required in only 6 cases because of the development of gangrene of the other limb. The postoperative mortality was 6% (5 patients) in the gangrene group and was 33% (6 patients) in the acute ischaemia group. Study of the cumulative permeability of bypasses until the time of their first thrombosis showed that 62% were permeable at 1 year and 44% at 4 years. Thrombectomy was followed by a percentage permeability of 10%. Weight bearing was still possible by 75% of limbs after 5 years. In conclusion to this study: axillo-femoral bypass remains reserved for salvage of the limb; extension of implantations to the distal and/or pathological artery remains legitimate; PTFE seems the most suitable material at present; the development of a thrombosis in the first 18 months should be treated by thrombectomy in order to decrease the number of amputations.

416 cases of diabetic arterial disease were treated over a period of 5 years, the majority of patients (71%) having trophic problems from the outset. -- Clinically, distinction must be drawn between patients suffering from "ischemic" disturbances, where healing is obtained after an appropriate surgical procedure (reconstructive surgery, if not lumbar sympathectomy) and so-called "diabetic" gangrene, where cure is obtained only by isolated excision. -- Few of the patients had lesions making reconstructive surgery possible, and the latter was thus only rarely indicated (13% of cases). -- So-called "major" amputations through leg or thigh were necessary in 16% of cases. Distal excision, if necessary atypical, thus in 84% of cases led to healing with preservation of weight-bearing.

Efficacy of two methods for interruption of inferior vena cava was compared after insertion of 95 Adams de Weese clips by the sub or trans-peritoneal route and of 72 Greenfield filters usually by a jugular approach. Introducing Greenfield's filter to produce caval interruption did not require modification of operative indications. In contrast, it allowed caval blockade to be performed in more elderly patients, generally in a poorer condition, at the price of higher mortality, due more to the clinical circumstances of the interruption rather than the caval blockade itself. Postoperative follow up showed fewer caval thromboses after Greenfield's filter (15%) than after the pericaval clip (35%).

The technique used for an isolated lesion, involving an emptying-graft procedure, is discussed initially, together with particular features related to proximal and distal lesions. The treatment of multiple aneurysms is then evoked, including the attitudes necessary when confronted with either atheromatous disease or aneurysmal polydystrophy.

The data of 124 observations of atheroma associated lesions of the aorta and its visceral branches, renal and mesenteric was collated. This retrospective study makes it clear that cases of atheromatous lesions involving the renal and mesenteric arteries can be considered as a special group. Aortic lesions above the level of the renal arteries have a variable outcome--the most commonly seen pattern is that of a thick circumferential plaque which encroaches on the openings of the visceral arteries. These lesions are either ulcerated or smooth and sometimes overlain by voluminous mural thrombus above the renal arteries. This group is associated with widespread atheromatous disease in the coronary and cerebral circulations. The prognosis is poor. A special approach to management is thus required since many arteries are affected and since usually, associated revascularization of the aorta and these four visceral branches is not present. This form of treatment is justified by a post-operative mortality of nil. There is a 50% mortality at three years, almost completely due to coronary disease.