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Objectives Several plaque and lesion characteristics have been associated with an increased risk for procedural stroke during or shortly after carotid artery stenting (CAS). While technical advancements in stent design and cerebral protection devices (CPD) may help reduce the procedural stroke risk, and anatomy remains important, tailoring stenting procedures according to plaque and lesion characteristics might be a useful strategy in reducing stroke associated with CAS. In this descriptive report of the ongoing Asymptomatic Carotid Surgery Trial-2 (ACST-2), it was assessed whether choice for stent and use or type of CPD was influenced by plaque and lesion characteristics. Materials and methods Trial patients who underwent CAS between 2008 and 2015 were included in this study. Chi-square statistics were used to study the effects of plaque echolucency, ipsilateral preocclusive disease (90–99%), and contralateral high-grade stenosis (>50%) or occlusion of the carotid artery on interventionalists' choice for stent and CPD. Differences in treatment preference between specialties were also analysed. Results In this study, 831 patients from 88 ACST-2 centres were included. Almost all procedures were performed by either interventional radiologists (50%) or vascular surgeons (45%). Plaque echolucency, ipsilateral preocclusive disease (90–99%), and significant contralateral stenosis (>50%) or occlusion did not affect the choice of stent or either the use of cerebral protection and type of CPD employed (i.e., filter/flow reversal). Vascular surgeons used a CPD significantly more often than interventional radiologists (98.6% vs. 76.3%; p < .001), but this choice did not appear to be dependent on patient characteristics. Conclusions In ACST-2, plaque characteristics and severity of stenosis did not primarily determine interventionalists' choice of stent or use or type of CPD, suggesting that other factors, such as vascular anatomy or personal and centre preference, may be more important. Stent and CPD use was highly heterogeneous among participating European centres.

Background and Purpose— Randomized clinical trials show higher 30-day risk of stroke or death after carotid artery stenting compared with surgery. We examined whether operator experience is associated with 30-day risk of stroke or death in the Carotid Stenting Trialists’ Collaboration database. Methods— The Carotid Stenting Trialists’ Collaboration is a pooled individual patient database including all patients recruited in 3 randomized trials of stenting versus endarterectomy for symptomatic carotid stenosis (Endarterectomy Versus Angioplasty in patients with Symptomatic Severe Carotid Stenosis trial, Stent-Protected Angioplasty versus Carotid Endarterectomy trial, and International Carotid Stenting Study). Lifetime carotid artery stenting experience, lifetime experience in stenting procedures excluding the carotid, and annual number of procedures performed within the trial (in-trial volume), divided into tertiles, were used to measure operator experience. The outcome event was the occurrence of any stroke or death within 30 days of the procedure. The analysis was done per protocol. Results— Among 1546 patients who underwent carotid artery stenting, 120 (7.8%) had a stroke or death within 30 days of the procedure. The 30-day risk of stroke or death did not differ according to operator lifetime carotid artery stenting experience ( P =0.8) or operator lifetime stenting experience excluding the carotid ( P =0.7). In contrast, the 30-day risk of stroke or death was significantly higher in patients treated by operators with low (mean ≤3.2 procedures/y; risk 10.1%; adjusted risk ratio=2.30 [1.36–3.87]) and intermediate annual in-trial volumes (3.2–5.6 procedures/y; 8.4%; adjusted risk ratio=1.93 [1.14–3.27]) compared with patients treated by high annual in-trial volume operators (>5.6 procedures/y; 5.1%). Conclusions— Carotid stenting should only be performed by operators with annual procedure volume ≥6 cases per year.

Background The aim of this retrospective study was to examine the impact of graft oversizing on gutter area and stent compression in chimney graft (CG) for complex abdominal aortic aneurysm (CAAA) repair. The influence of stent-graft oversizing on type Ia endoleaks and bridging stent occlusion rates was also examined. Methods Preoperative and postoperative computed tomographic angiography scans of patients requiring CGs for CAAA between June 2009 and April 2013 in our institution were analyzed. Two groups were identified: proximal oversizing of the stent-graft component 25% (group 2). Relative gutter areas were calculated and compared between both groups. Incidence of target vessel stent compression, target vessel occlusions, and type Ia endoleaks was also analyzed. Results Of 39 patients treated with CG during the study period, 23 fulfilled the selection criteria for analysis. Group 1 included 10 patients and group 2 included 13 patients (mean oversizing: 18.4 ± 4.9% and 34.5 ± 6% respectively). Relative gutter areas were significantly higher in group 1 when compared with group 2 (6.1 ± 2.1% vs. 4.2 ± 3.2%, P = 0.03). No stent compression and no target vessel occlusion occurred in either groups. There was no statistical difference in type Ia endoleak in both groups (group 1 n = 0, group 2 n = 2; P = 0.48). Conclusions In our study, a >25% stent-graft oversizing reduced the gutter area without modifying the bridging stent patency. However, no benefit in terms of type Ia endoleak was observed.

Objectives The aim was to determine whether physician modified stent grafts (PMSGs) are safe and effective for the treatment of high risk patients with thoraco-abdominal aortic aneurysms (TAAAs). Design This was a retrospective single institution study. Material Consecutive patients with TAAA undergoing endovascular repair using a PMSG between January 2012 and June 2014 were evaluated. Methods Fenestrations to preserve branch vessels were created in TX2 thoracic (Cook Medical) stent grafts. Pre- intra- and post-operative data were recorded by means of a prospectively maintained database. Results Eleven high risk patients with TAAA (type I, n = 4; type III, n = 3; type IV, n = 3; type V, n = 1) underwent fenestrated endovascular repair using PMSGs. Indications were painful aneurysm ( n = 5), >70 mm rapidly enlarging aneurysm ( n = 4), saccular aneurysm ( n = 1), and visceral patch false aneurysm after open repair of a type IV TAAA ( n = 1). In four asymptomatic patients, an additional fenestration was created for temporary selective sac perfusion and occluded 2–4 weeks later. Median duration for stent graft modifications was 2 hours (range 1–3 hours). The median number of fenestrations was three (range 2–4). One patient died during the post-operative period from colonic ischemia, giving a 9% in hospital mortality rate. Four (36%) patients presented with moderate to severe complications. One (9%) patient presented with a paraparesis that resolved completely after spinal fluid drainage. Among surviving patients, four required early endovascular re-intervention for type III endoleak ( n = 2), type Ia endoleak ( n = 1), or target vessel cannulation failure ( n = 1). The median follow up time was 6 months (range 3–20 months). During follow up, no other complications occurred and all target vessels remained patent. One patient presented with a persistent type II endoleak. Conclusion PMSGs provided acceptable short-term results and may be a management option for the treatment of TAAA in selected high risk patients. Durability concerns need to be assessed in additional studies with long-term follow up.

The indication for use of drug-eluting stents (DES) in lower limb arteries is still undefined. We report our series of patients treated with Zilver PTS DES, in treating in-stent restenosis (ISR) and Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC) C/D femoropopliteal lesions.The Zilver PTX DES is a self-expanding nitinol stent with a polymer-free Paclitaxel coating. Patients with symptomatic de novo TASC C/D lesions or IRS lesions of femoropopliteal segment were eligible for enrollment. We evaluated patients at one month, six months and one year after treatment. We used clinical evaluation criteria and US Doppler for primary and secondary patency-free rates.From November 2010 to November 2012, we treated 69 patients with DES Zilver PTX. Indication to treat was given in 36 lesions (52%) by an ISR and in 33 cases (48%) by a TASC C/D lesion. Lesions were staged in the superficial femoral artery (SFA) level in 59 patients (85.6%), in the popliteal artery in 6 patients (8.7%), in a femoropopliteal bypass in 4 patients (5.7%). The mean follow-up was 5.3 months (range 1-24). At 12 months the overall primary patency was 85.5%, secondary patency 89.8% and limb salvage 100%.Zilver PTX DES seems to be effective in treating TASC C/D lesions and ISR in femoropopliteal lesions at short term. Therefore DES should be recommended when treating those complex lesions.

To present results and to identify predictive factors of early outcome after fenestrated and/or branched endovascular repair (f/b-EVAR) for complex aortic aneurysms, abdominal (AAA) and thoracoabdominal (TAAA).Feasibility of f/b-EVAR for complex aneurysms is now established, but little is known about which patients will benefit from this technique.Univariate and multivariate analysis of preoperative and intraoperative factors on postoperative mortality and complications was performed on 268 patients (group 1: juxta- and pararenal AAA; group 2: suprarenal and TAAA IV; group 3: TAAA I, II, III) enrolled in a prospective multicenter trial of f/b-EVAR.Thirty-day mortality, in-hospital mortality (IM), and combined mortality and severe complications (CMSC) rates were 6.7%, 10.1%, and 22.0%, respectively. Group belonging (2 or 3 vs 1) was the only preoperative predictive factor of CMSC [hazard ratio (HR) = 2.10; 95% confidence interval (CI): 1.26-3.48; P = 0.0043]. Occurrence of a technical complication and duration of intervention significantly influenced both IM (HR = 4.39; 95% CI: 2.05-9.38; P = 0.0001) and CMSC (HR = 3.07; 95% CI: 1.84-5.11; P0.0001). Postoperative events associated with increased IM were spinal cord ischemia (HR = 9.46; 95% CI: 3.98-22.47; P0.0001), hemodialysis (HR = 27.44; 95% CI: 12.63-59.61; P0.0001), and reintervention (HR = 4.45; 95% CI: 2.03-9.73; P = 0.0002).Although promising, f/b-EVAR still carries a significant rate of mortality and complications, mostly related to the complexity of the procedure. In these complex cases, new strategies should be investigated to improve outcomes.

The reduced physiological impact of endovascular aneurysm repair (EVAR) compared with conventional open repair has been demonstrated. If this technique could be used routinely in patients with ruptured abdominal aortic aneurysm (AAA) it may reduce the high peri-operative mortality. This review of the literature identified the current experience with EVAR of ruptured AAA. Only a small number of case series with selected patients are reported. These patients were selected for their haemodynamic stability, and their suitable aneurysm morphology. The overall anatomic suitability rates for EVAR reported, suggest an applicability of 58% to 80% from an intent-to-treat experience. The average post-operative mortality rate was 24%, ranging from 9 to 45% and may reflect increasing experience and patient selection. Important lessons have been learned from these first experiences that help to define a clear position of EVAR as an additional therapeutic option for ruptured AAA.

The aim of this retrospective study was to evaluate the patency and limb salvage rates after prosthetics or venous bypasses for asymptomatic or mildly symptomatic popliteal aneurysms, in order to determine if small uncomplicated aneurysms (caliber300%) should be operated or periodically controlled when a venous conduit is not available.During a 18 years period, 100 popliteal aneurysms, including 85 asymptomatic and 15 associated with intermittent claudication, were operated on: group I consisted of 80 venous bypasses, and group II consisted of 20 prosthetic bypasses.Demographics and risks factors were similar in both groups. Local complications were more frequent in group I (17% vs 10% p=NS). Early vascular complications were rare in both groups. Late arterial complications were more frequent in group II. Primary patency, assisted primary patency, and secondary patency rates at 2 years were 94.3%, 97.3% and 98.7% in group I, and 61.5%, 89% and 88.4% in group II (p0.05). In contrast, the limbs salvage rates were not significantly different for each type of graft (98.7% vs 100% p=NS).Our data shows that aneurysms treated with a prosthetic graft are at higher risk of late occlusion than those operated with a vein graft. This should be taken into account when facing a small uncomplicated aneurysm without available venous conduit. The presence of a suitable vein should be checked before deciding to operate a small uncomplicated popliteal aneurysm.

Antiphospholipid syndrome may be associated with stroke.We report a case of a symptomatic occlusion of the innominate artery in a 37-year-old patient, who developed primary anti-phospholipid syndrome. This association, to our knowledge, has not been reported in the literature. Occlusion of the innominate artery was treated by angioplasty-stenting. Effective oral anticoagulation was given to prevent a new thrombotic event.Systematic search for antiphospholipid antibodies is needed as part of the etiology work-up in young stroke victims.

In addition to its role in hematopoiesis, bone marrow appears to be a reservoir of stem cells that can differentiate into components of vessel wall. Upon stimulation by factors such as tissue ischemia, bone marrow stem cells can enter into circulating blood, and incorporate into areas of vascular development. Animal models suggest that bone marrow is a cellular source for tissue repair and/or regeneration. Data from humans, and clinical trials using bone marrow stem cells for the treatment of chronic ischemia in limbs and myocardium, support the view that stem cells may represent a new tool for the treatment of ischemia.

Acute pancreatitis after surgical treatment of non ruptured aneurysm of abdominal aorta is a rare complication, considered to be due to pancreatic ischemia or peroperative trauma of pancreas. The aim of this study is to describe 4 new cases of this complication and to discuss its etiology.From January 1995 to November 2000, 365 patients underwent elective surgery for a non ruptured abdominal aorta aneurysm. Four (1.1%) men, aged 66 to 79 years and operated for an aneurysm which diameter ranged from 60 to 77 mm, developed postoperative acute pancreatitis. The abdominal approach was a midline incision in 3 cases and a retroperitoneal lombotomy in one case. Superior pole of the aneurysm always adjoined or involved the right renal artery. The aortic clamping was supra-renal in 3 cases and celiac in one case. Diagnosis of acute pancreatitis was established at days 2, 4, 12, and 23 after surgery on abdominal computed tomography in 3 cases and at reoperation in one case.Three patients died, including 2 from early multiple organ failure and one peroperatively during surgical attempt to treat a prostheto-digestive fistula. One patient was alive and asymptomatic with a 2-years follow-up.Acute pancreatitis is a rare and serious complication after surgical treatment of abdominal aorta aneurysm. Its diagnosis is often delayed. The main etiological factor of this complication could be trauma of pancreas during supra-renal clamping through a midline incision.

A revolutionary technology has totally renovated the treatment of aneurysms of the abdominal aorta. Classical "dissection-graft" procedures require a wide abdominal incision with clamping and declamping times, and often major blood loss. Perioperative mortality varies from 3% to 7% depending on the team's experience and the presence of comorbidities. Complications occur in 30% of the patients; often benign they can be quite serious. As direct consequence of the development of peripheral stents, endoprostheses can now be introduced via the femoral route through a short inguinal incision. Operative trauma is considerably reduced, greatly shortening the recovery time. Mortality is low, of around 1%, and postoperative complications are much less frequent and much less severe. There is also a 3-fold reduction in the duration of the hospital stay.All aneurysms cannot be treated with this method. The anatomy of the aneurysm and the iliac arteries is a determining factor. The iliac vessels must be large enough and devoid of important obstruction (kinks, atheromatous plaques) in order to access the aorta. The subrenal collar must measure at least 1 cm and be free of severe calcifications or thrombi. A rigorous preoperative exploration, using CT-scan with 3D reconstruction and graduated arteriography, is necessary. The length and diameter of the prosthesis is calculated from the results and must be perfectly adapted to avoid failure.Long-term outcome remains unknown. The endoprosthesis excluded the aneurysm from the blood stream, depressurizing the aneurysmal sac. Endoprosthetic leakage can occur in case of defective application or by reflux from lumbar or inferior mesenteric arteries or due to leakage of the endoprosthesis itself. In such cases, the aneurysm can continue to progress. This explains the need for careful follow-up with duplex Doppler and/or CT-scan in treated patients. If the treatment is incomplete, complementary procedures may be necessary, often via an endovascular route or in some cases with conversion to conventional surgery.Improved prosthetic design and durability is an important point. Randomized studies organized in France, as well as in England and Holland and the United States, are currently assessing the contribution of this new technique and its relative role compared with conventional surgery.

Intimal hyperplasia is extensively studied in order to improve arterial reconstruction outcome. The mechanisms leading to stenosis or restenosis may vary according to the technique used for arterial reconstruction. Lesions are mostly made of an accumulation of smooth muscle cells and fibroblasts, with only sparse inflammatory cells. The accumulated material reduces the graft lumen and ultimately induces thrombosis. Intimal hyperplasia with smooth muscle cell and matrix accumulation is the prominent feature in all these situations with evidences of intense cell proliferation and cell death. The purpose of this review is to present the biology of intimal hyperplastic response based on the recently published data. Experiments in the rabbits have shown that the vein wall thickening is mainly regulated by the tangential wall stress which is applied transversely to the vein wall as a blood pressure. Experiments in the rat carotid artery balloon injury suggested that heparin could be used as a treatment to prevent intimal hyperplasia. Treatments for preventing restenosis after angioplasty or stenoses development in bypasses have been disappointing clinical evaluation suffers from insufficient prospective randomized studies. Intimal hyperplasia is the major cause of failure after arterial reconstruction. The biology of intimal hyperplasia is complex, and treatment disappointing. Some types of hyperplasia may need to be preserved in order to prevent functional atrophy and aneurysmal dilatation of vein grafts.

To assess long-term outcome after surgical cure of radiation-induced aorto-ilio-femoral arterial occlusion and to deduce therapeutic indications.Over a 20-year period, 15 patients were treated for occlusion of the aorto-ilio-femoral vessels 4 to 28 years after receiving radiotherapy. Primary treatment was medical (n=1), balloon dilatation (n=5), anatomic revascularization (n=5), and extra-anatomic bypass (n=4). Mean follow-up was 6.8 years.Among the 5 balloon dilatations, there was one failure requiring right axillofemoral bypass that was followed shortly by fatal septic shock; the 4 others have remained patent at 2 to 15 years, one having required stent dilatation at 6 months. Among the 5 patients who had anatomic revascularization, excepting on patient who died shortly after surgery from her cancer, all have required revision; 2 patients died of infection at 9 and 10 years; the two others are alive at 5 and 18 years. Among the 4 patients with extra-anatomic bypass (one aortothoracic-bifemoral bypass, two axillofemoral bypasses and one cross-over bypass), 2 died with prosthetic sepsis at 3 and 7 years and 2 others have had a bypass replacement. Overall, at last follow-up, half of the operated patients have died from infection (n=5) or cancer (n=2).In reports in the literature, revision and infection after conventional surgery is frequent. There is less risk with the endovascular approach, but it can be only applied for short occlusions.Excepting easily accessible occlusions with an apparent minimal risk for percutaneous balloon dilatation, irradiated arteries should be operated on only in case of severe ischemia. Patients with claudication should be treated conservatively because of the high risk of complications for prosthesis implantation with irradiated arteries.

The EUROSTAR (European Collaborators on Stent/graft techniques for aortic aneurysm repair) Registry was established in 1996 to collect data on the outcome of treatment of patients with infrarenal aortic aneurysms with endovascular repair. To date, 88 European centers of vascular surgery have contributed. The purpose of the study was to evaluate the results of this treatment in the medium term (up to 4 years) according to the analysis of "hard" or primary end points of rupture, late conversion, and death.Patients with aortic aneurysms suitable for endovascular aneurysm repair were notified to the EUROSTAR Data Registry Centre before treatment to eliminate bias due to selective reporting. The following information was collected on all patients: (1) demographic details and the anatomic characteristics of their aneurysms, (2) details of the endovascular device used, (3) complications encountered during the procedure and the immediate outcome, (4) results of contrast enhanced computed tomographic imaging at 3, 6, 12, and 18 months after operation and at yearly intervals thereafter, and (5) all adverse events. Life table analysis was performed to determine the cumulative rates of (1) death from all causes, (2) rupture, and (3) late conversion to open repair. Risk factors for rupture and late conversion were identified through regression analysis.By March 2000, 2464 patients had been registered, and their mean duration of follow-up was 12.19 months (SD, 12.3 months). There were 14 patients with confirmed rupture of their aneurysms. The cumulative rate (risk) of rupture was approximately 1% per year. Emergency surgery was undertaken in 12 (86%) patients, of whom five (41.6%) survived. Two patients who were not treated surgically also died, which resulted in an overall death rate of 64.5% (9/14) of the patients. Significant risk factors for rupture were proximal type I endoleak (P =.001), midgraft (type III) endoleak (P =.001), graft migration (P =.001), and postoperative kinking of the endograft (P =.001). Forty-one patients underwent late conversion to open repair with a perioperative mortality rate of 24.4% (10/41). The cumulative rate (risk) of late conversion was approximately 2.1% per year. Risk factors (indications) for late conversion were proximal type I endoleak (P =. 001), midgraft (type III) endoleak (P =.001), type II endoleak (P =. 003), graft migration (P =.001), graft kinking (P =.001), and distal type I endoleak (P =.001).Endovascular repair of infrarenal aortic aneurysms with the first- and second-generation devices that predominated in this study was associated with a risk of late failure, according to an analysis of observed hard end points of 3% per year. Action taken to address the risk factors identified by the study may improve results in the future.

The aim of this retrospective study was to assess the advantages of regional anesthesia over general anesthesia in carotid artery surgery.From January 1989 to December 1998, 670 patients with severe internal carotid artery stenosis were operated in the same center and were classified into two groups according to the type of anesthesia: group I, general anesthesia (n = 312) and group II, regional anesthesia (n = 358). Characteristics of the two groups were almost similar except for a higher rate of unstable heart disease in group I and bypass grafts in group II.A shunt was used in 16.3% of cases in group I and in 8.4% in group II. Complications resulting from the use of a shunt and intraoperative complications observed with regional anesthesia were reported. There was a conversion from regional to general anesthesia in 6 patients. Median duration of clamping was longer in group II (30 min vs 25 min). Cardiac complication rates were similar in the two groups, particularly cardiac mortality (0.6%). There were more pulmonary and miscellaneous complications in group I. Neurological complications were more frequent in group I, particularly fatal strokes (1% versus 0%). Neurological mortality and morbidity cumulative rates were 3.1% and 1.5%, respectively, not significantly different.These results, in agreement with those of the literature, confirm that carotid artery endarterectomy is associated with a low rate of neurological mortality and morbidity. Although regional anesthesia was associated with a lower rate of complications, we are not allowed to conclude to its superiority, as the present study was retrospective and the difference was not statistically significant.

To report the results of a multicenter safety trial of percutaneous carotid stenting performed by vascular surgeons.Symptomatic or asymptomatic patientsor = 65 years of age with internal carotid artery (ICA) stenosesor = 70% andor = 2-cm long were eligible for enrollment. The procedures were performed in an operating room with the choice of anesthesia and the percutaneous access site at the discretion of the surgeon. Only Palmaz stents were used.From January 1, 1996 to December 31, 1997, 99 patients (74 men, mean age 70 years, range 51 to 94) were enrolled in the study. More than half (57 of 99 patients) were asymptomatic. The direct cervical approach was used predominantly (97%). Three (3%) cases were converted to surgery for inability to access the artery or deploy the stent (technical success 97%). No perioperative death or myocardial infarction was reported. Six (6%) procedural complications included 1 reversible arterial spasm, 2 dissections, 1 cervical hematoma, and 2 residual stenoses. One neurological event reversed within 7 days (1% minor stroke rate) and 4 (4%) transient ischemic attacks resolved within 24 hours. One (1%) asymptomatic early occlusion occurred 2 days postoperatively. No neurological event was observed in the 1- to 24-month follow-up (mean 13 months). Two (2%) patients died of nonprocedurally related causes. No stent compression was seen, but 1 asymptomatic occlusion and 3 asymptomatic, non-flow-limiting restenoses (240%, 1 at 60%) were found within 1 year (3% restenosis rate on an intention-to-treat basis). Patency was 98% at 1 year.The results of this trial support the contention that carotid stenting of short ICA lesions can be performed with a low neurological complication rate.

Routine duplex surveillance of patients following an arterial operation includes the scanning of symptomless patients. While the benefits of preventive correction of deteriorations, stenoses or dilatations, following aortic or lower limb arterial reconstruction are undisputed, there is no hard data on the effectiveness of this surveillance in terms of limb salvage, on its cost, and on the optimal frequency and duration.The AA review the literature on this subject and suggest a programme which reconciles the patients' interests with the best use of health care financial resources.The possible complications depend on the type of operation. Some are symptomless. They occur mainly during the first year and less frequently, but regularly so, during the subsequent years. There is therefore no time limit for the duration of the surveillance. The effectiveness of this surveillance is low and thus the examination must be meticulous and its frequency adapted to the risks. Broadly speaking: During the first year, aorto-ilio-femoral reconstructions must be screened at one month, six months and one year; by-passes below the groin with no particular risk at six months and one year; by-passes at risk and those anastomosed to a lower leg or ankle artery require a further check-up at one month and three months. After the first year, aorto-ilio-femoral and similar by-passes must be checked annually; by-passes below the groin, when at risk, must be checked annually; in those without any particular risk, a check-up every two years seems to be sufficient. Any patient found to have a deterioration on screening must be checked every six months.Careful screening is the only way of discovering a symptomless deterioration before the development of serious complications. As every arteriole reconstruction should be followed by a lifelong surveillance, in times of financial constraints the frequency of the check-ups must be tailored according to the risks present and the quality of the surveillance must be faultless.

Thyroid anaplastic carcinoma is associated with a very poor prognosis. The goal of this study was to determine whether an aggressive treatment is worthwhile.Of 22 thyroid anaplastic carcinomas confirmed with immunohistochemistry, 17 were judged eligible for surgery. Total thyroidectomy was planned in all patients. Frozen section of the lower lateral lymph nodes was routinely performed and in case of involvement (n = 9), a modified radical neck dissection was carried out. Fractionated radiotherapy was started within 5 weeks following surgery: 6,000 cGy was delivered on the thyroid area and all involved areas while 4,500 cGy was delivered on the lymph nodes of the neck and of the superior mediastinum when non involved.The three patients without distant metastasis, with thyroid removal considered as complete, were still free of disease 10, 12 and 13 years later. One of these patients had been initially considered inoperable and was operated later when a combination of radiotherapy and chemotherapy obtained a decrease of the tumor. All other patients, 13 with incomplete removal and one with pulmonary metastasis died from their cancer; the median of the survival was 7 months.When anaplastic carcinoma is suspected on clinical appearance, the diagnosis should be rapidly confirmed with percutaneous biopsy and immunohistochemistry. If a lymphoma is found, surgery is not indicated. Our results demonstrate that except for widely infiltrating tumors or distant metastasis, a complete removal of the tumor should be attempted as soon as possible. Surgery should be followed with hyperfractionated radiotherapy. Multimodal therapy may result in long-term survival. A patient free of disease at 5 years may be considered as definitively cured.

In a previous study, we have found that an operation for a combination of internal iliac aneurysms and an abdominal aortic aneurysm carries a heavier mortality than an operation for an abdominal aortic aneurysm alone. The object of this review was to define the prevalence of this combination of aneurysms and the results of the different treatment modalities in order to define the therapeutic choices.A retrospective study of operations on 426 patients with asymptomatic infrarenal aortic aneurysms. The size of the iliac aneurysm was evaluated in terms of the calibre of the artery above and below the aneurysm and these size were classified as2C, = 2C and2C relative to that calibre. Three groups were defined: group 1--with at least 1 aneurysm2C: group 2--with at least 1 aneurysm = 2C, group 3--with at least 1 aneurysm2C.32 patients had combined aneurysms (9 group 1, 13 group 2 and 10 group 3)--i.e. 7%. Treatment consisted of 23 exclusions by ligation, nearly all proximal, 6 bypasses of which 2 eventually required a ligation and 2 wrappings. Three patients aged 78, 82 and 86 years died, but no death was related to the treatment of the internal iliac aneurysms. On the other hand, massive haemorrhages occurred during the operation in a group 2 patient during an attempt at exclusion by ligation above and below the aneurysm and also in a group 3 patient during an unsuccessful attempt at bypassing. One further bypass proved impossible. Later, 2 group 3 patients developed postoperative complications: one buttock claudication and one invalidating paraplegia.It is justifiable not to operate on2C and, in some cases, = 2C, internal iliac aneurysms. Embolisation was not used in this series. Exclusion by ligation is a good procedure when the other internal iliac artery is patent. Bypassing is the ideal method in bilateral aneurysms but it is associated with the risk of venous haemorrhage and of thrombosis. When flow must be maintained in an internal iliac artery, our first choice is wrapping when the size isor = 2C and endoneurysmorrhaphy + wrapping when the size is2C and performing a bypass may be risky. Unoperated internal iliac aneurysms should be periodically controlled with Duplex or CT scan.

During transluminal treatment of an aneurysm of the abdominal aorta, the proximal part of the stent may sometimes lay over the ostia of the renal arteries. Animal studies have shown various scarring patterns depending on the type of stent used and its duration of implantation. The Gianturco and Wallstent appear to be better tolerated than the Palmaz stents. The AA have shown that, with the Strecker stents, a neointima developed between the meshes of the stent over a surface of 43% +/- 30% in 6 weeks. May and Parodi report some occlusions in their clinical series. In the AA's series using Vanguard, no renal artery was thrombosed despite the fact that the stent lay over the artery on 2 occasions in 105 patients. In conclusion, the consequences of the proximal part of a stent laying over the ostium of a renal artery depend mainly on the type of stent used. "Wide mesh" stents are probably the best to use to prevent serious renal complications.

To determine the predictivity of anatomic and co-morbid factors for peri-operative mortality of patients operated for a non-ruptured abdominal aortic aneurysm (AAA).Between 1986 and 1996, data had been collected prospectively in a computerized date base. A chi-square test was performed for 5 anatomic, and 8 co-morbid criteria.25 of 470 patients (5.3%) died within one month after surgery. Aneurysm diameter (P = 0.004) and aneurysmal internal iliac artery (P = 0.019) were associated with an increased mortality whereas upper extension of the disease necessitating a juxta-renal anastomosis, the need for inferior mesenteric artery reimplantation, or a symptomatic ilio-femoral occlusive disease, were not. Age (P = 0.016), obesity (P = 0.03), alteration of left ventricular function (P = 0.0014), and preoperative renal failure (P = 0.0001) were associated with increased mortality.Both anatomic and co-morbid factors can predict outcome after elective surgery for non-ruptured AAA. The criteria might help to selection patients who might benefit from endovascular treatment of AAA.

ADVANTAGES AND RISKS: Widely advocated as reliable and cost-effective, carotid angioplasty offers many advantages. Theoretically, general anesthesia can be avoided and no incision is required, authorizing its indication in patients with a contraindication for conventional open surgery although the risks of vascular complications--emboli, dissection, acute thrombosis--and general complications must not be underestimated. NEED FOR VALID ASSESSMENT: Few studies evaluating this new technique have been published. Among the open trials including over 100 patients, indications have generally been limited to patients with a high surgical risk and combined morbidity and mortality has been reported to vary from 2.8% to 9.6%. No rigorously controlled comparison with conventional surgery has been published although several projects are currently under way or in the planning stages (CAST in Europe and CASET and CREST in North America). LESSONS FROM THE CURRENT SITUATION: Carotid angioplasty requires a highly equipped facility and a multidisciplinary team with competence in catheterization and micro-catheterization, thrombolysis, and stenting techniques. Technical advances in material engineering are also needed to provide flexible, stable and modulable stents. Despite the still imprecise nature of the current situation, one can predict that these techniques will come to be complementary, if not competitive, alternatives to conventional carotid surgery.

This study was performed in order to determine if: 1-- femoral bypasses ending below the popliteal artery are justified in aged patients or in patients with poor general conditions, 2-- if the use of prosthetic material is justified when no vein is available, 3-- if reintervention is beneficial in case of bypass occlusion.Retrospective study of 162 infrapopliteal bypasses followed during 1 to 12 years (mean: 1.5).Vascular Surgery Department of the University Hospital Henri Mondor based in a suburb of Paris, France.All patients who underwent a femoral bypass ending below the popliteal artery for limb salvage from January 1984 to December 1995.These bypasses were performed with a vein in 131 cases and with a PTFE graft (with or without distal cuff) in 31 cases.All patients were followed with clinical evaluation and duplex scan. Primary and secondary patency, limb salvage and patient survival were studied. The survival rates at 1 and 5 years were 87+/-3.8% and 66+/-9.6% respectively. Preoperative mortality was 7.4%. Renal insufficiency requiring dialysis, not age over 80, was associated with high perioperative mortality.The primary patency rates of the total series at 1 and 5 years were 55 and 35% respectively for the total series. For venous bypasses, it was 58 and 37% while for prosthetic bypasses, it was 49 and 15%. The secondary patency rates at 1 and 5 years were 67 and 46% for the total series. For venous bypasses, it was 70 and 49% and for prosthetic bypasses, it was 53 and 21%. Limb salvage rates at 1 and 5 years were 65 and 61% for the total series, 73 and 65% for venous bypasses and 48 and 41% for prosthetic bypasses.1-- Femorotibial or peroneal bypasses are worthwhile for limb salvage even in aged patients but renal insufficiency requiring dialysis may justify primary amputation. 2-- If no vein can be used, prosthetic or composite bypasses should be performed because they are associated with a 41% limb salvage rate at 5 years. 3-- If thrombosis occurs, the increase of patency after re-operation is 12% in case of venous bypass and 6% in case of prosthetic bypass.

Optimal therapy to prevent late occlusion of arterial bypass grafts in the legs has not been determined. We assessed the effect of ticlopidine, an inhibitor of platelet aggregation, on the long-term patency of saphenous-vein bypass grafts for the treatment of peripheral vascular disease.A total of 243 patients with femoropopliteal or femorotibial saphenous-vein bypass grafts were randomly assigned to receive either ticlopidine (250 mg twice a day) or matching placebo for two years. The primary end point was graft patency at two years, as assessed by physical examination, measurement of the ankle brachial index, and duplex ultrasonography or arteriography. The incidence of death and major ischemic events was also analyzed in the two groups.After two years, 66.4 percent of the patients were alive with a patent graft in the ticlopidine group, as compared with 51.2 percent in the placebo group (95 percent confidence interval for the difference between the two groups, 2.9 to 27.4 percent; P=0.02). The two-year cumulative patency rate was 82 percent in the ticlopidine group and 63 percent in the placebo group (P=0.002). There was no significant difference between groups in overall mortality or major ischemic events.Ticlopidine significantly improved the long-term patency of saphenous-vein bypass grafts in the legs. Since the drug was well tolerated, its use can be recommended after peripheral-vein bypass surgery.

To study the long-term results of an aggressive management protocol based on a new-simple classification and to determine the duration for patient follow-up according to this classification.For the 509 patients with differentiated thyroid carcinoma, the classification was: group 1: cancer1 cm (n = 117), group 2A: cancer without extension in patients of age less than 45 years (n = 100), group 2B: cancer without extension in patients aged more than 45 (n = 94), group 3: cancer with nodal extension alone (n = 102), group 4: high risk cancer in patients having either distant metastases or local tissular extension or in whom after iodine-131 ablation, Tg level was3 micrograms/l off hormone therapy (n = 96). Total thyroidectomy was the rule except for group 1 and some patients of group 2A in whom the tumor was solitary, relatively small, well-differentiated, with no capsular or capillary invasion. Iodine 131 ablation was carried out after a total thyroidectomy and repeat treatments with iodine 131 were given whenever necessary.In group 1, 2A and 3, the 20 years death rate of cancer was 0 p. 100. For group 2B, patients cancer death rate was 8 p. 100 and for group 4 it was 32 p. 100. Distant metastases were the cause of death except for one patient who died from local recurrence. Clinical inspection, Tg measurement, iodine 131 whole-body scan and chest X-ray were all useful in discovering local or distant recurrences.Our results justify the use of an aggressive initial management for differentiated thyroid carcinoma and an appropriate scoring system. When this protocol is applied, patients of group 1, 2 and 3 should have an excellent prognosis. However patients follow-up should not be shorter than 15 years for patients of group 1 and 2A and than 20 years for all other groups.

We report the initial French multicenter experience with the Stentor system in the endovascular treatment of AAAs.Between May 1994 and March 1996, 79 patients with AAAs were consecutively treated with an endovascular technique using the Stentor system. There were 71 bifurcated grafts and eight straight grafts. The patients were followed-up from 1 to 18 months (mean, 5.7 months). Patient data and events were retrospectively analyzed.No patients was lost to follow-up. There were no surgical conversions. Four patients died after operation (4.8%). Two of them had been considered inoperable by the standard technique. Four patients (4.8%) had pulmonary complications, and three had colonic ischemia (3.7%). Forty-five patients (57%) had postoperative fever, and a transitory thrombocytopenia (10%) developed in eight patients. In 66 patients (83%) the aneurysm was immediately excluded. The exclusion was definitive in 62 (78%). In 17 patients, there were 13 initial and six delayed endoleaks. In two of these patients, the initial endoleak sealed temporarily and resumed after 1 year of follow-up, requiring an additional straight, covered stent. Over all, seven of the leaks were treated successfully by an additional endovascular graft, one leak required a lumbar artery embolization, eight leaks sealed spontaneously, and one leak was untreated. During follow-up, there was no aneurysm rupture. Two patients died of unrelated causes.The Stentor system can safely and effectively exclude AAAs in the short term. Careful follow-up is required to detect any delayed endoleak, and long-term results are awaited to confirm the efficacy of the method in preventing AAA rupture.

evaluate the benefit of synchronous arterial reconstruction and endoluminal balloon dilatation for occlusive arterial disease during non-urgent procedures.late results of forty arterial reconstructions combining open surgery with simultaneous endoluminal dilatation have been reviewed. Balloon dilatation was performed on iliac (N = 18), femoral (N = 18), popliteal (N = 3) and infra-popliteal arteries (N = 2). Reasons were rapidity in 31 cases, local reasons in five cases (such as brievity of available vein for bypass), heavy operative risk in two cases and partial failure of transluminal angioplasty in two cases.during the first post-operative month, there were one death (due to sepsis) and two reocclusions (one of the dilated artery and the other of the bypass). They were successfully reoperated. At the moment of the study, the mean follow-up being thirty months, seven patients are deceaded (six of them from intercurrent disease), one has been amputated, three suffer intermittent claudication and twenty-nine are cured (but eight of them have been reoperated).synchronous arterial reconstruction and transluminal dilatation are a good option in case of multiple arterial occlusive disease particularly in poor risk patients and when inflow or outflow of bypasses should be improved. Associated balloon dilatation is very useful in case of too short vein graft or arterial stenosis due to a clamp injury. Nowadays in our department, these combined procedures are more and more frequent One stage procedure is associated with less complications, shorter length of hospitalization and lower cost.

The goal of this study was to evaluate the operative hazards, therapeutic procedures, and late results of arterial reconstruction for radiation-induced occlusive disease.Twenty-five patients were referred to our institution for radiation-induced occlusive arterial disease. Group 1: carotid artery stenosis or occlusion was encountered in seven patients. The nine procedures employed included percutaneous transluminal angioplasty (PTA) (n = 2), carotid endarterectomy (n = 3), vein or prosthetic bypass (n = 4). Group 2: four patients presenting with subclavian and axillary artery occlusion were treated with a common carotid to brachial artery vein bypass, one after unsuccessful PTA. Group 3: Thirteen patients had aorto-iliac occlusion. Initial management included medical treatment (n = 1), PTA (n = 2), aorto-bifemoral bypass (n = 4), aortofemoral and iliofemoral bypass (n = 1 each), axillofemoral bypass (n = 3), femorofemoral bypass (n = 1). Group 4: One patient had femoral artery occlusion treated with PTA.Group 1: One of two PTA was successful. Endarterectomy or bypass were successful in all cases. One late vein bypass stenosis was treated by venous patch angioplasty. Group 2: All vein bypasses were successful. Group 3: Limb salvage was achieved in all patients but eight required repeat operations for prosthetic sepsis (n = 3), restenosis (n = 3), or thrombosis (n = 12). Two patients died of late sepsis. Group 4: Outcome after PTA was successful.1) Surgery for radiation-induced arterial lesions is difficult because of arterial, periarterial, and cutaneous sclerosis. Some patients, however, are amenable to PTA or endarterectomy. When bypass is necessary, anastomosis should be performed in healthy arteries, for instance, the thoracic aorta for the proximal anastomosis, or the brachial artery approached through a lateral mid-arm incision. 2) The risk of early or late graft infection is enhanced by the presence of tracheostomy, colostomy, or ureterostomy and by repeat operation for thrombosis. PTA, endarterectomy, or vein bypass should be preferred whenever feasible. When prosthetic material is unavoidable, prevention of infection should include the use of omentoplasty, remote bypass, antibiotic-bonded grafts or, in the case of major sepsis, allografts. 3) As restenosis remains a frequent complication, annual clinical and Duplex-scan surveillance is mandatory.

The authors report a case of penetrating atheromatous ulceration of the descending thoracic aorta complicated by a haemothorax. Atheromatous ulceration of the aorta is usually observed in elderly hypertensives. It is caused by rupture of the internal elastic layer under an atheromatous plaque extending into the media and resulting in a parietal haematoma of the aorta. Clinically, the differential diagnosis is that of a dissection of the aorta or of fissuration of an atheromatous aneurysm. Nowadays, the investigations of choice are a chest CT scan with injection of contrast and MRI. Transoesophageal echocardiography excludes dissection of the aorta but may miss a direct image of penetrating ulcer when the latter is of small size. The treatment of choice is not established because the natural history of the condition is not well known. Penetrating ulcer would seem to progress slowly to development of an aortic aneurysm. Surgery is mainly reserved for forms complicated by painful recurrences or rupture and for cases involving the ascending aorta.

The recording of sympathetic skin responses (SSRs) is a simple, electrophysiological method to assess sympathetic nerve function. Within the last 10 years, SSRs have mainly been applied to delineate peripheral and central nervous system diseases, although the sympathetic nature of these responses was not fully documented, e.g., by a study of sympathectomy. We therefore recorded SSRs before and after 30 cases of endoscopic thoracic sympathectomy. The main indication was palmar hyperhidrosis, in which we found two types of SSR abnormalities. Most patients exhibited normal SSR waveforms but with increased amplitudes. The other patients exhibited abnormal SSRs which did not occur as single responses but as several consecutive waves. Thoracic sympathectomy always led to significant clinical improvement and to the abolition of ipsilateral palmar SSRs, demonstrating the sympathetic origin of these responses. We suggest that the assessment of sympathetic nerve activity by SSR recordings may be useful in sympathectomy.

The aim of this study was to evaluate screening, prevention and treatment of false anastomotic aneurysms (FAA).A retrospective analysis of 95 FAA observed in 72 patients (67 males, 5 females, age range 48 to 93 years was conducted. Mean delay to onset was 7.5 years.Diagnosis was made on the basis of imaging evidence using, since 1978, duplex-scan: 8/15 FAA of the aorta, 4/5 FAA of the iliac arteries and 35/75 FAA of the femoral arteries. Treatment was always difficult due to atherosclerosis. The greatest difficulties were encountered in aortic FAA with 1 death due to septic rupture, 1 nephrectomy by ureteral fistula and 1 graft sepsis successfully treated with an allograft. There were 2 deaths in the iliac FAA, 1 due to ureteral fistula and 1 due to heart failure. For femoral FAA, there were 3 deaths (cerebral hemorrhage, graft sepsis and renal failure after acute aortic thrombosis). Long term results showed 6 recurrent femoral FAA which were reoperated successfully.FAA complicates 2 to 5% of graft procedures and can lead to death and amputations: 1.) Clinical surveillance and regular duplex-scan examinations are essential: the diagnosis should also be entertained in case of digestive hemorrhage. 2.) The threshold of dilatation which suggests the need for surgical repair would appear to be a two-fold dilatation but for the aorta, localized dehiscence requires surgery. 3.) A graft procedure is usually used, stents can by used for end-to-end aortic or iliac anastomoses. 4.) Since FAA remains a risk after graft, revascularization should be entertained when other methods have failed. 5.) Patients should be informed of the risk and of movements to avoid in case of femoral anastomoses and also of required regular checkups.

The quality of the results obtained for a given surgical team cannot be guaranteed by simply applying the recommendations of scientific research and consensus conferences. Self-evaluations is as important as continuous training. It is essential for each surgical team to regularly evaluate its results and compare them with those published in the literature in order to make necessary improvements. Lessons learned from mortality-morbidity sessions studying complications case by case should be completed with an annual assessment of complications for each group of operations, first because knowledge of results is required before modifications in technique and organization can be indicated and secondly because the discussion of all the results with the entire surgical team, including both medical and paramedical personnel, offers the best means of optimizing competency and team cohesion and effort. Useful means include: 1) self-assessment software similar to those used for MSI, 2) a requirement for self-assessment before annual fund allocations, 3) that the self-assessments remain the property of the surgical teams in order to avoid missing the goal which is to optimize surgical indications and results.

Assess the frequency, severity and technical problems raised by iatrogenic trauma to the arteries.A retrospective study of 45 cases of iatrogenic arterial trauma treated over a 25-year period was studied.The most frequent cause was arterial catheterization (n = 32 including 24 of the lower limbs and 8 for the upper limbs) performed for arteriography (n = 16), coronarography (n = 13) or endovascular therapy (n = 3). Thrombectomy was performed in 24 cases, bypass in 4 and endarterectomy in 4. Post-operative period was uneventful in all except two fatal cases.In most cases, iatrogenic arterial trauma can be avoided with proper technique. Prognosis is highly dependent on early care.

Leak-proof polyester grafts impregnated with collagen, gelatine or albumin are routinely used in vascular surgery. Theoretically, there are several advantages: no need for pre-coagulation, reduced operation time and graft manipulation, less blood loss during the operative period, better healing with a potentially greater resistance to infection. We analyzed all the publications in scientific journals to verify whether these theoretical advantages are validated by clinical trials. There have been 12 non-comparative series reporting favourable results but the lack of control groups makes it difficult to draw conclusions. Five comparative series with random assignment of patients have been reported. None of these series showed a substantial benefit from impregnation. Thus the use of an impregnated polyester graft would not appear to be justified for routine standard aorto-iliac surgery. Conversely, although no evidence has been provided by a comparative study, the major risk of haemorrhage in procedures such as extra-corporal circulation, the thoracic or abdominal aorta and in patients with a coagulation disorder, impregnated graft probably constitute an important progress.

Infection is a major complication in vascular stents. Stents impregnated with gelatine and dipped in Rifampicin have been shown to resist methicillin-resistant Staphylococcus aureus in both animal experiments and in man. It has been suggested that all aorto-ilio-femoral stents should be treated. To evaluate this method, we reassessed all stent infections observed in our patients who had undergone revascularization of the lower limbs from January 1985 to 1994. We excluded stents implanted for ruptured aneurysms or implanted in patients with a past history of local infection on vascular stents.The rate of septic complications observed during the first year was 1% for all patients in the series, 0% for aorto-aortic and aorto-biiliac stents and 0.7% for aorto- bifemoral stents. These rates are similar to those reported in the multicentric study directed by Goeau Brissonière using antibiotic impregnated stents. The extra cost involved in using such stents for aorto-ilio-femoral revascularization was estimated in this series at 2,180,000 Francs. The costs resulting from the three infections was estimated at 960,000 Francs.Based on the findings in this series, antibiotic impregnated stents should be indicated only in selected patients due to the extra cost: past history of local infection, ruptured aneurysms, femoro-tibial stents, cross or axillo-femoral revascularization for which the rate of stent infection is 6.3 - 3.2 and 1.4%, immunodeficient patients, multiple reoperations, post-irradiation arteritis and situations known to involve major risk of infection.

Teaching preventive measures to patients which have been operated on for arterial diseases with the goal of preventing recurrent lesions or complications related to the surgical procedure itself is an ethical obligation because of its medical and economic consequences. The aim is to convince the patients of the need to change their lifestyle, to consult their physician rapidly in certain precise circumstances, to present regularly for yearly check-ups and sometimes to avoid certain movements or carefully comply to anticoagulant controls. We have had 25 years experience. Oral explanations were complemented early with a booklet given to the patients before discharge. Since 1991, discussion groups are organized each week around a 20-minute film. An audit has shown that about 80% the patients were well informed. Since 1994, the group sessions were held after distributing a questionnaire. Read before the film, it helps the patients become aware of the problems. After the film, each patient raises personal questions in a guided discussion. Since this method has been used, the percentage of well informed patients has risen to 95%. In a very active surgical unit, transmission of information should not be handled to chance. It should be well organized and periodically evaluated. To be effective it should focus on precise goals, be understandable by all, follow a clear presentation of the problems, involve the entire health care team and rely on well prepared support material. Group discussions around a film help to improve patient comprehension and participation. The booklet and the questionnaire will guide the patients when back home.

To evaluate risk factors for mortality and amputation after arterial embolism of the lower limbs, we reviewed the records of 397 patients (201 men [mean age 69 +/- 14 years] and 196 women [mean age 79 +/- 12 years]) who were enrolled in a prospective study. The degree of ischemia was rated as follows: grade I in 26% of patients, grade II in 46%, and grade III in 27%. Among patients with complete obstruction, the emboli were located above the inguinal ligament in 213 limbs (46%), in the superficial or popliteal artery in 196 (43%), and at the infrapopliteal level in four (3%). The emboli were bilateral in 59 cases (15%). In 11% of patients the emboli also involved either an upper limb or a visceral or cerebral artery. The origin of the embolus was the heart in 55% of patients, an artery in 12%, and was unknown in the remaining cases. Two hundred two patients (50%) had arterial fibrillation, 33 (8%) had cardiac conduction abnormalities, 186 (47%) had ischemic heart disease, 55 (14%) had valvular heart disease, and 43 (11%) had cardiac insufficiency. The in-hospital mortality rate was 15% (n = 60) and major amputations or severe ischemic sequelae were observed in 23% (n = 91). Logistic regression analysis revealed four independent preoperative factors associated with a significantly higher risk of death: associated visceral emboli with a relative risk (RR) of 6.7 (p0.001), invalidism with an RR of 4.3 (p0.001), cardiac insufficiency with an RR of 2.4 (p = 0.001), and creatinemia180 ml/L with an RR of 2.1 (p = 0.01). The variables associated with an increased risk of amputation were invalidism (p = 0.001), severity of ischemia (p = 0.001), infrapopliteal location of the embolus (p = 0.001), delay of more than 12 hours before treatment of severe ischemia was initiated (p = 0.01), failure to restore arterial patency (p = 0.001), and postoperative cardiac complications (p = 0.01).

Preserving sexual function is an important objective in the treatment of aneurysms of the abdominal aorta in men.Two groups of patients with normal sexual function were operated for aneurysms of the abdominal aorta. In group 1 (n = 22) a small opening in the infra-renal aorta was made for insertion of an aorto-bi-iliac prosthesis; in 4 of them, the aneurysm was not opened but simply excluded. In group 2 (n = 22), the aorta was opened longitudinally for insertion of an aorto-aortic tube.Sexual function was totally abolished after operation in 9% of the patients in group 1 and in 36% of those in group 2. Sexual functions were totally preserved in 50% of the patients in group 1 and in 36% of those in group 2, but the differences were not statistically significant.1) It is not always possible to guarantee maintained sexual function after operation for aneurysms of the abdominal aorta and the patients should be advised thereto; 2) aortobi-iliac prostheses with limited opening of the aorta in the upper part of the aneurysm or exclusion of the aneurysm led to a higher rate of preservation than aorto-aortic tubes with total opening of the aneurysm and should be preferred in men with normal sexual function.

Patients requiring radical cure of an aneurysm of the abdominal aorta often have associated conditions increasing the risk of peri-operative complications and immediate or short-term mortality. Detecting such associated lesions is thus of major importance to adapt patient management and treatment strategy. We assessed the following parameters associated with increased risk of peri-operative death in a series of 418 patients who underwent elective surgery for aneurysms of the abdominal aorta between 1986 and 1994: chronic renal failure (with or without dialysis), clinically apparent coronary artery disease, age over 75 years, defective left ventricular function. The effect of the characteristics of the aneurysm on immediate survival was also assessed. Aneurysm larger than 6 cm extending to the hypogastric artery had a higher operative risk. Post-operative survival was 96.5% at one month, 90% at one year and 87% and 69% at 2 and 5 years respectively. The predominant causes of death late in the post-operative period were vascular disease (coronary or neurologic) and cancer. Complications related to the operation were rare (1.5%). In conclusion, detection of operative risks allows 1) better patient selection for surgery, 2) adopting appropriate measures when the indication for surgery is retained, 3) establishing a follow-up and a screening protocol for detecting factors causing late deaths.

Local complications of femoral artery catheterization are less frequent than those occurring after puncture of other sites. Nevertheless, their prevalence is estimated to be 0.5 to 1%. Some of them are health-threatening. Fifty-one arterial obstructions, 18 hematomas, 38 pseudoaneurysms and 11 arteriovenous fistulas have been operated on during a 25 years period. They were responsible for 4 death and 1 above-knee amputation. During the same period, several arteriovenous fistulas and pseudoaneurysms were treated conservatively. Our study and the literature show that Duplex-scan allow a management of these complications more eclectic than previously. Arterial obstructions should be operated on rapidly in case of acute ischemia with neurologic deficit. When the ischemia is less severe, heparin therapy may help the lysis of the clot. If not, simple thrombectomy is sufficient when the arteries are normal while more complete revascularizations after angiographic evaluations are necessary in case of atherosclerotic arteries. Hematomas should be avoided by local compression during a period which should be longer when the hole is large or when anticoagulation is used. An implantable bio-absorbable device has been used with good results in another study. Increasing hematomas and hematomas responsible for neurologic symptoms should be operated on. Blood restoration should be rigorous in patients with cardiac disease. Pseudoaneurysms may be easily diagnosed and controlled with Duplex-scan. Ultrasound-guided compression during 10 to 20 minutes periods should be used before deciding surgical repair.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal aneurysmectomy in kidney transplant recipients can be successfully performed without adjunctive protective measures if the period of renal ischaemia is short. A technique that attains this goal is described here. An aortic aneurysm (5 cm) was removed 2 years after kidney transplantation to the left external iliac vessel. The right common iliac artery was divided first and anastomosed to the right branch of the bifurcated graft. Aortic anastomosis was then performed; the period of renal ischaemia was only 20 min. Arterial flow was re-established in the right common iliac artery, providing profuse collateral flow to the transplanted kidney through the internal iliac arteries during the time necessary to complete the left common iliac artery anastomosis. This procedure is feasible unless the internal iliac artery is severely stenosed, occluded or terminally anastomosed to the transplanted renal artery. In all other cases, this technique may be the optimal procedure to protect the kidney during elective abdominal aorta aneurysmectomy in renal transplant recipients by reducing the period of ischaemia to that of one anastomosis only.

Symptomatic subclavian artery damage, following radiation for breast or head and neck cancer, is very rare. We report three new cases in which arterial insufficiency of the upper limb developed respectively 3, 36, and 27 years after irradiation for breast cancer in two cases and tumor of the clavicle in one case. Patients were treated by saphenous vein by-pass using a new extra-anatomic route from the carotid to the brachial artery. They were two main differences from the classical carotido-brachial by-pass. The brachial artery was approached by a lateral mid-arm incision between the biceps and the humeral bone, and the grafts were tunnelled, subcutaneously, laterally on the medial head of the deltoid muscle avoiding the hump of the clavicle, and then between the biceps and the humeral bone. The postoperative courses were uneventful with good healing of the wounds. All grafts remained long-term patent and no compression was detected by ultrasound and arteriogram. This new technique of extra-anatomic carotido-brachial by-pass is a safe and efficient alternative to treat radiation induced injury of the subclavian artery.

Cerebrovascular accidents (CVAs) are the third commonest cause of death in France. Approximately 15% of them are due to stenosis of the extracranial internal carotid. The fact that a third of CVAs are followed by death and another third by major handicaps leads to the need for careful prevention. This has three aspects: 1) Correction of risk factors: hypertension, smoking, hyperglycemia, hyperlipidemia, obesity, alcohol abuse, hematological abnormalities and oral contraception; 2) the prescription of one of two platelet anti-aggregants, the efficacy of which has been proved: acetylsalicylic acid or ticlopidine; 3) surgical elimination of tight carotid stenoses. The following require surgery: 1) more than 70% stenosis following cerebral or ocular TIA or minor CVA; 2) more than 75% stenosis in asymptomatic patients or with episodes of VBI as well as 70% in case of thrombosis of the contralateral internal carotid; 3) following a CVA leaving serious sequelae: tight stenosis when it is reasonable to assume that a further CVA could lead to clinical worsening or to a loss of independence; 4) symptomatic and/or more than 80% restenosis. The decision should be made only after confirmation of the diagnosis and of the degree of stenosis and verification of the absence of any local or systemic contra-indication. The surgical team must have a low cumulative mortality and perioperative CVA rate. These patients require ongoing medical monitoring, particularly from a cardiological standpoint.

Venous leiomyosarcoma are rare malignant tumours that are usually revealed by an oedema of the lower limb, a sign of deep phlebitis. As the development is not linked with radiotherapy and chemotherapy, the prognosis depends mainly on a early diagnosis, which brings the best opportunities of complete surgical exeresis before the apparition of metastasis. The case reported below as well as ten other cases taken in the literature show the necessity to mention this diagnosis when confronted to any phlebitis appeared in the absence of usual precipitating factors. It is all the more necessary when mass is found by palpation, a small tumour is revealed by echography or when phlebography shows a lateral or circumferencial stricture that is different from usual pictures of phlebitis.

This retrospective study was undertaken to evaluate the prognosis of and to determine optimal therapy for thyroid carcinoma adhering to or invading the trachea or esophagus. In our series of 412 operated thyroid cancers, there were 45 patients including 20 with adherences to the trachea or esophagus that were dissected free by sharp dissection (group 1), six patients with invasion of the trachea or esophagus who underwent total resection followed by radioiodine and external-beam irradiation (group 2), and 19 patients with invasion of the trachea or esophagus that had been incompletely resected (group 3). There were no major complications. Survival or disease-free unrelated deaths were recorded in 80%, 100%, and 16% of patients in groups 1, 2, and 3, respectively. The three patients with anaplastic carcinoma in group 1 are free of disease 3, 6, and 7 years after operation, respectively. Combined with those in the literature, our data indicate that (1) adherences to the trachea or esophagus are not necessarily associated with poor prognosis and should be treated with aggressive surgery even in anaplastic carcinoma, (2) invasion of the trachea or esophagus must be treated whenever possible by total resection followed by radioiodine and external-beam irradiation, (3) a two-stage operation should be considered when optimal conditions are not available initially, and (4) cure may be obtained with complementary radioiodine and external-beam irradiation after incomplete resection of papillary carcinoma.

This retrospective study was conducted to evaluate the long-term results obtained after treating anastomotic false aneurysm occurring after implantations of aorto-iliac or aorto-femoral prostheses in order to identify optimal treatment. During a 20-year period, 66 anastomotic aneurysms were discovered and treated in 48 patients. The mean delay after initial surgery was 6.3 years. Locations observed were femoral (n = 58) aortic (n = 6) and iliac (n = 2). Five aneurysms were revealed by an acute ischaemia, three others by bleeding and one by abdominal pain. The 57 others were diagnosed in an equal proportion either during physical examination or periodic imaging. Aortic and iliac aneurysms were treated by complete or partial replacement of the prosthesis. There were two urinary fistulas, one being fatal and one recurrent haemorrhage followed by death. Femoral aneurysms were treated in 4 out of 5 cases by interpositioning a prosthesis and in 1 out of 5 cases by simple resuturing. There was one fatal cerebral haemorrhage, 4 cases of early thrombosis and 6 cases, of recurrent anastomotic aneurysm (10%). The clinical course required amputation in 3 patients. In this series, the overall outcome was satisfactory. For aneurysms of aortic or iliac anastomoses, one must avoid dissecting the prosthesis-ureter crossover and blind extraction of a branch which can lead to urinary fistulas. For femoral anastomoses, the following recommendations are important: conservation of the collaterals, suturing deeply into healthy tissue and interposition of a new prosthesis in case of tension. Cases of recurrent aneurysm are rare and should be treated with the same careful procedures.

The object of this retrospective (case-control) study of 513 carotid artery operations in 471 patients was to evaluate whether the presence of coronary artery disease at the time the decision to operate was taken, influence the prognosis of patients operated upon for stenosis of a carotid artery. Three groups were constituted and compared; no coronary artery disease (NC), stable coronary artery disease (CS) and unstable coronary artery disease (CI). Operative mortality was 1% (NC), 5% (CS) and 9% (CI) respectively (p0.001). The rate of neurologic deficits was 1.3% (NC), 2.4% (CS) and 3.1% (CI), and the 5 year actuarial survival rate 83% (NC), 78% (CS) and 63% (CI) (p = 0.040 by the Log-Rank test). Premature deaths were due to cardiac and neurologic causes. In the patients with coronary disease, local and regional anesthesia was followed by 0% mortality whereas the rate was 3% (CS) and 13% (CI) (p0.001) after general anesthesia. The cause of delayed death was determined accurately in 50% of cases; it was cardiac in 25% (NC) and 70% in patients with coronary disease. Results of the present study confirm that the presence of coronary disease has an adverse effect on the immediate and long term prognosis for patients undergoing coronary artery surgery, and demonstrate that the operative risk can be significantly reduced by the use of local and regional anesthesia. Long term close cardiology surveillance is justified, particularly if signs of coronary disease are noted perioperatively.