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For more than 20 years it has been generally acknowledged that operation for inflammatory abdominal aortic aneurysm (IAAA) using the common in-lay-graft procedure will induce the regression of peri-aortic fibrosis. However in prospective studies, after a 2 years follow-up, no regression appeared in approximated 8% of the cases (table I). Moreover in some IAAA a corticosteroid treatment (CS) was prescribed and it produced a regression of fibrosis and therefore facilitated the operation. Nevertheless the usefulness of the CS remains debated. We report 4 new cases of IAAA with CS. Based on our cases and an analysis of the literature we conclude that when there is no urgency to operate (diameter inferior to 50 mm) CS is the best option in IAAA with either severe inflammation or ureter involvement. Due to the regression of the fibrosis it can facilitate the surgical procedure. However it needs to be conducted with an adequate dose and duration. Finally the CS is the only possibility when the inflammation persist following the treatment of the IAAA.

Endoscopic surgery has been used as a new procedure to simplify different surgical processes. The goal of this study was to evaluate the benefits of endoscopic retroperitoneal surgery for lumbar sympathectomies. Between February 93 and November 95 we performed 35 lumbar sympathectomies using this technique. All patients were arteritic. The results were as follows: for 25% of the patients, conversion classical open technique was required; 6% complications (septic); 3% of the patients died. In comparing the various techniques of sympathectomy and sympatholysis, it would appear that the endoscopic technique produces fewer complications. However we believe that a learning period is necessary before this technique can be fully mastered.

A 42-year-old man was consulted because of a pain in his left leg. He was a highly trained biker since 20 years. The echo-Doppler and arteriography evidenced a stenosis, probably due to endofibrosis of the external iliac artery. In addition, it showed an aneurysm and an intimal dissection of this artery. The arteriography confirmed this diagnosis, and normal aspect of the other arteries. Neither conservative nor endovascular treatments were possible because of the anatomic lesions. We resected the external iliac artery and performed a by-pass with the great saphenous. The result at the 5th month was clinically good. The echo-Doppler control did not show any abnormality. The natural course of the endofibrosis of athletes is unknown, although stenosis, revealed by intermittent claudication is usually observed. Only a few cases of dissection and no aneurysmal degeneration have been described before.

High prevalence of coronary artery disease in patients with AAA leads to a high rate of peri-operative cardiac complications. Coronary insufficiency is thus the cause of 40 to 60% of post-operative deaths after aortic surgery. Demonstration of coronary insufficiency depends on the clinical history, electrocardiographic evidence, non-invasive examinations and coronarography. Diagnosis is based on non-invasive tests, and of primary importance exercise tests, which have a high sensitivity. Specificity for predicting post-operative cardiac complications remains low but can be improved by combining with other tests (for example exercise test and Holter recording) or with other clinical parameters. Coronarography provides a precise map of the coronary status but gives little information on functional impairment of encountered lesions. Finally, besides the cost and a certain degree of morbidity, coronarography increases the number of indications for revascularizations with the inconvenience of its intrinsic mortality and also retards the operation increasing the risk of rupture. The evaluation of cardiac risk before surgery must be based on correct use of non-invasive tests, limiting coronarography to cases with frankly positive tests.

Eleven thrombo aspirations were performed in ten patients with lower limb acute ischemia. Three were performed under local and 8 under general anesthesia. They were associated with 4 thrombectomies, 6 transluminal angioplasty procedures, 1 limb infusion, 1 treatment of a false aneurysm, 1 aponeurotomy, 1 angioscopy. Clinical and radiological success was achieved in 9 patients whereas there was one immediate failure requiring a popliteal distal bypass. Late partial rethrombosis requiring medical treatment occurred in one patient. Thrombo aspiration is a safe effective technique which can be combined with other endoluminal procedures in patients with acute lower limb ischemia.

We report a case of spontaneous regression of a cystic adventicial disease of a popliteal artery in a 37 years old man. The peroperative resection of the adventicia give us the histologic confirmation of the diagnostic. The cyst's content may have gone through either in the peri-arterial space or through a communication with the articulation of the knee. For us, it seems to confirm the embryologic theory for the pathogenic of this disease.

Only four cases of per-operative pulmonary embolus of parasites during surgery for hydatic cysts of the liver have been reported. Embolus usually occurs in patients who already have lung metastasis of hepatic cysts, suggesting a hepatic cyst in direct communication with the vena cava or suprahepatic vein. We report the first case which occurred in a patient in which there was no evidence of such communication.

Recklinghausen disease which usually appears by tumors of the nervous system peripheral and central can present anomalies of other systems, particularly vascular anomalies. The damage of renal arteries is well known. Intracerebral aneurysms are rare. Multiple intracerebral aneurysm has been reported in only four cases. We report a case of a patient presenting three intracerebral aneurysms. The patient died of a meningial haemorrhage. This leads us to search for intracerebral aneurysms in Recklinghausen's disease, specially in presence of arterial hypertension.

We report a case of cystic adventicial disease of the popliteal artery in a 67 years old man. The realisation of the intra arterial pressure measurements, and the peroperative echography permit to diagnose important associated lesions of the intimal part of the arterial wall.

The authors report about one case of type I aortic dissection disclosed as bilateral lower limb ischemia. The rarity of this way of expression of dissections may result in a delay in diagnosis that can be highly pejorative in such diseases where mortality is high without surgical treatment. The timing and tactics of the surgery to be implemented between the cure of dissection and the removal of ischemia is discussed. Lastly the choice of the mode of arterial cannulation in a patient who had had an axillo-bifemoral bypass ten days earlier also makes this case interesting.

We report two cases of renal vein thrombosis, unusual because of acute expression, right renal vein localization, absence of the usual renal or perirenal causes, surgical management and a never before reported etiology. In one case the thrombosis was secondary to primary antiphospholipid syndrome, in the other it was secondary to heparin associated thrombocythemia. In this case surgical management was performed during prostacyclin infusion.

From 1975 to 1987, 68 patients were operated with repeated subinguinal bypass (SIB) following early or late thrombosis os an initial bypass graft; 10 were operated with a third SIB, 4 with a fourth SIB. The indication for the second SIB was acute ischemia in 15 cases and chronic ischemia in 53. The graft material used was venous in 21 cases, prosthetic in 29 cases and mixed in 53. The distal anastomosis was performed on the upper popliteal artery in 12 cases, the lower popliteal artery in 34 cases or an artery in leg in 22 cases. The actuarial permeability rate of 84 repeated SIBs, whatever the material, was 21.7% at 1 year (50.2% for venous grafts and 13.6% for prosthetic grafts). The limb preservation rate was 47.9% at 5 years. Operative mortality was about 1%. The analysis of the results suggests that the repeated SIB should be performed only: for limb salvage, if the downstream arterial bed is in good condition, with usable venous material. The risk of having to perform a thigh amputation rather than a leg amputation when attempting repeated SIB is of 13.9% only.

The mechanism of thrombosis early after subinguinal bypass and outcome after revision surgery have been rarely analyzed. Results are reported of revision surgery for early thrombosis in 50 cases (10% of subinguinal bypass operations during the same period). Initial indication in the 40 men and 9 women (mean age 66.9 +/- 1.74 (SEM) years), was severe chronic or acute ischemia in 82%. The 50 thrombosed bypasses included 40 femoropopliteal, 8 femorotibial and 2 short bypasses. The bypass was by saphenous in situ (21 times), an inversed saphenous (9 times), a mixed bypass (12 times) and a prosthesis (8 times). The distal arterial bed was evaluated as good in 50% of cases. Analysis of cause of thrombosis, of the operative procedure and of the time before surgery enabled a technical cause to be determined in 31 of the 50 cases. Corrective surgery produced 16 permeable bypasses and 34 definitive thromboses complicated by 21 amputations and a 10% mortality. Improved results were related to a venous bypass (p less than 0.05), to a time before operation of less than 24 hours (p less than 0.02) and to a good distal bed. The 1 year actuarial permeability for the 50 bypass operations was 35%. Mixed bypass procedures and technical problems during surgery appear to be the principal predisposing factors of early thrombosis. In this series, the preoperative distal pressure index and intraoperative flowmetric recordings were not reliable predictive elements.

Infra-inguinal endarterectomy and by-pass (PSI) are the oldest and more frequently done restorative arterial operations. Here are described the evolution of patients, limbs and PSI and the factors that could interfere with them from the facts gathered since 30 years in literature. Prognosis is serious.

Retrospective study of 38 cases of serious intestinal or rectal hemorrhage in the adult occurring between 1974 and 1987 demonstrated a wide variety of lesions responsible. Malignant tumours (21%) and ischemic lesions (13%) were most often implicated. Colonic diverticulosis and angiodysplasia were each responsible for 8% of cases. The most effective means of exploration were rectosigmoidoscopy and coelio-mesenteric arteriography together with per-operative endoscopy. The diagnosis remained uncertain in only 8% of cases. Treatment was essentially surgical (32 patients). Post-operative mortality (26%) was high, in keeping with the severity of the lesion responsible for the hemorrhage. Serious lower intestinal hemorrhage requires a two-fold management: the institution of intensive care resuscitation and as soon as the patient state permits, etiological investigation. After recto-sigmoidoscopy, which generally allows lower intestinal hemorrhage to be eliminated, arteriography and per-operative colonoscopy have in our experience a high diagnostic yield in cases of persistent hemorrhage. Where bleeding stops spontaneously, colonoscopic examination, after suitable preparation, remains a worthwhile investigation.