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Il trattamento chirurgico dell’ischemia gastrointestinale si basa su una buona conoscenza della fisiopatologia dell’ischemia mesenterica, del trattamento chirurgico in urgenza, della necrosi gastrointestinale e delle tecniche classiche di rivascolarizzazione, trombectomie, endoarteriectomia e bypass, e sull’angioplastica con stenting delle arterie viscerali le cui indicazioni sono divenute piu frequenti. I progressi nella diagnostica per immagini hanno consentito una migliore definizione delle lesioni accessibili a un trattamento eziologico, anche in situazioni di emergenza. Nel frattempo, i progressi nella chirurgia gastrointestinale e il ruolo del gastroenterologo hanno partecipato al miglioramento della strategia terapeutica.

El tratamiento quirurgico de la isquemia digestiva se basa en un conocimiento adecuado de la fisiopatologia de la isquemia mesenterica, del tratamiento quirurgico urgente, de la necrosis digestiva y de las tecnicas clasicas de revascularizacion (trombectomias, endarterectomias y derivaciones), asi como en la angioplastia con colocacion de endoprotesis en las arterias viscerales, cuyas indicaciones son cada vez mas frecuentes. Los progresos de las pruebas de imagen han permitido definir mejor las lesiones accesibles a un tratamiento etiologico, incluso en las situaciones urgentes. De forma paralela, los avances en cirugia digestiva y el papel del gastroenterologo han participado en la mejora de la estrategia terapeutica.

La cirugia hibrida de los aneurismas toracoabdominales (ATA) es una alternativa a la cirugia abierta tradicional y a las endoprotesis ramificadas/fenestradas. Combina la transposicion de las arterias viscerales mediante derivacion con la colocacion de una endoprotesis en la porcion toracoabdominal de la aorta. La transposicion de las arterias viscerales suele realizarse a partir de los ejes iliacos, de la aorta abdominal o, en menos ocasiones, de la aorta ascendente. La etapa endovascular puede realizarse en el mismo tiempo quirurgico o en un segundo tiempo. Ninguna endoprotesis ha demostrado su superioridad en esta indicacion. La cirugia hibrida presenta ciertas ventajas teoricas respecto a la cirugia abierta convencional. No requiere un pinzamiento aortico alto. Ademas, permite prescindir de la circulacion extracorporea y, en ocasiones, reducir la duracion de la isquemia cervical. Se han publicado algunas series retrospectivas monocentricas con resultados alentadores, lo que para algunos equipos justifica utilizar la cirugia hibrida como primera eleccion para el tratamiento de los ATA. Sin embargo, se trata de una intervencion compleja y ningun estudio comparativo ha demostrado con claridad que reduzca significativamente la mortalidad y las complicaciones postoperatorias respecto a la cirugia abierta convencional. En la era endovascular, y dada la ausencia de consenso sobre sus indicaciones, la cirugia hibrida para los ATA es una solucion interesante en los pacientes de alto riesgo, que presenten contraindicaciones anatomicas para la colocacion de una endoprotesis ramificada o fenestrada.

La tecnica endovascolare di trattamento delle stenosi carotidee ha dimostrato la sua fattibilita e l’analisi degli studi clinici che la confrontano con la chirurgia tradizionale permette di precisare le rispettive indicazioni di queste due tecniche, a seconda dei sintomi, dell’anatomia dell’arco aortico e della lesione e dello stato del paziente. La tecnica e ormai ben codificata: la via d’accesso piu spesso utilizzata e quella femorale, dei cateteri guida limitano i rischi e le difficolta di superamento dell’arco aortico e i sistemi di protezione cerebrale e lo stenting limitano il rischio embolico. L’angioplastica carotidea offre gli stessi risultati immediati e tardivi della chirurgia, quando realizzata in pazienti giovani che presentano una stenosi stabile e un’anatomia favorevole e quando eseguita da un operatore esperto. I pazienti piu anziani, con una stenosi sintomatica instabile e un’anatomia complessa, vanno, piuttosto, trattati chirurgicamente.

L’emodialisi richiede un accesso vascolare che permetta delle connessioni ripetute al rene artificiale. La fistola arterovenosa nativa e il migliore accesso vascolare. I bypass arterovenosi protesici, indicati in caso di impossibilita di creare un accesso nativo, sono gravati da stenosi recidivanti dell’anastomosi venosa. I cateteri venosi centrali, insostituibili in caso di urgenza, consentono di attendere la maturazione degli accessi vascolari, ma si complicano con infezioni gravi e stenosi venose centrali che minacciano gli accessi vascolari futuri. Le procedure endovascolari permettono la gestione di un gran numero di complicanze, benche la chirurgia mantenga un ruolo certo nel trattamento delle stenosi juxta-anastomotiche all’avambraccio, degli iperflussi e delle ischemie.

L’emodialisi mira a depurare il sangue e a ridurre l’inflazione idrosodica dei pazienti con insufficienza renale cronica. Essa richiede un accesso vascolare che permetta delle connessioni ripetute al rene artificiale. La fistola arterovenosa nativa, descritta da circa 50 anni, e il migliore accesso vascolare, benche richieda un periodo di maturazione prima dell’utilizzo. I bypass arterovenosi protesici sono gravati da stenosi ricorrenti dell’anastomosi venosa. I cateteri venosi centrali, insostituibili in caso di urgenza, si complicano con infezioni gravi e stenosi venose centrali che minacciano gli accessi vascolari futuri. L’anestesia locoregionale permette la realizzazione degli accessi in chirurgia ambulatoriale nella maggioranza dei casi. La microchirurgia semplifica molto la preparazione delle anastomosi distali nell’adulto e la rende possibile nei bambini. L’eco-Doppler e l’esame di riferimento nella valutazione pre-, intra- e postoperatoria. L’angiografia e le procedure endovascolari permettono la gestione di un gran numero di complicanze, benche la chirurgia conservi un ruolo certo nel trattamento delle stenosi juxta-anastomotiche all’avambraccio, degli iperflussi e delle ischemie.

Le eziologie degli aneurismi toracoaddominali sono dominate dall’ateroma e dalle dissecazioni. Le tecniche chirurgiche devono adattarsi all’estensione dell’aneurisma e ai rischi particolari delle ischemie midollare, renale e viscerale. Delle tecniche specifiche di monitoraggio perioperatorio, in particolare i potenziali evocati motori, il ricorso a un’assistenza circolatoria e/o a una perfusione selettiva e il reimpianto dei rami dell’aorta hanno permesso di ridurre la mortalita, il tasso di paraplegia e la gravita delle complicanze d’organo di questa chirurgia, che rimane, malgrado lo sviluppo delle tecniche endovascolari, il trattamento di riferimento degli aneurismi toracoaddominali nei pazienti a basso rischio chirurgico.

Las rupturas de aneurisma de la aorta abdominal son una urgencia quirurgica cuyo tratamiento sigue teniendo una gran mortalidad. Las modificaciones recientes de la estrategia terapeutica y de los tratamientos deben permitir mejorar estos resultados: la tomografia computarizada (TC) siempre que sea posible permite a algunos equipos aumentar la precision de la decision quirurgica; en anestesia-reanimacion y en reanimacion prehospitalaria se ha adoptado el principio de la hipotension controlada. Desde el punto de vista quirurgico, el pinzamiento rapido mediante cirugia tiende a sustituirse por la oclusion endovascular mediante balon intraaortico y el uso de endoprotesis (EVAR) es cada vez mas frecuente en los pacientes que tengan una anatomia compatible.

L’apporto dei lembi liberi o peduncolati nel trattamento delle perdite di sostanza ischemiche e/o infettive degli arti inferiori e ben codificato. Nell’ambito dell’ischemia critica essi vengono spesso associati a una rivascolarizzazione endovascolare o mediante bypass distale. Sono indirizzati a una categoria selezionata di pazienti, tenendo conto dell’importanza della riabilitazione postoperatoria. Consentono di evitare un’amputazione maggiore in particolare nei diabetici e in traumatologia.

Las indicaciones de la cirugia endovascular en el tramo aortoiliaco han cambiado en pocos anos: disminucion del numero de derivaciones aortofemorales, ayuda en el mantenimiento de la permeabilidad de las revascularizaciones extraanatomicas y, sobre todo, ampliacion de las indicaciones en la que paso a ser de primera eleccion gracias a las endoprotesis. Los resultados a largo plazo de las tecnicas endoluminales llevan a plantear las revascularizaciones endoluminales respecto a la cirugia clasica en la mayor parte de las situaciones clinicas y de las lesiones anatomicas, estenosis y oclusiones. Aunque es indispensable que el cirujano vascular actual tenga un conocimiento adecuado de las modalidades tecnicas (cateteres y guias, balones y endoprotesis, vias de acceso homo y contralaterales), tambien debe conocer las complicaciones y los limites de esta tecnica.

Le tecniche endoluminali di trattamento dell’ateroma si basano ormai su procedure ben codificate e su materiali le cui caratteristiche sono standardizzate. Esse possono essere eseguite sia in sala operatoria, sia in sala radiologica interventistica. Introduttori, guide e cateteri consentono l’accesso a tutti i territori arteriosi. Si devono conoscere bene le caratteristiche dei cateteri da angioplastica transluminale (profilo, compliance). Diverse architetture di endoprotesi si adattano alla sinuosita dei vasi e alla forza radiale richiesta a seconda della lesione da trattare, mentre lo sviluppo di endoprotesi ricoperte ampia il loro campo di applicazione. Il ruolo e l’interesse delle tecniche endovascolari in rapporto al trattamento medico e alla chirurgia, sono oggetto di un «consensus» nella maggioranza delle indicazioni. Il chirurgo deve, quindi, conoscerle bene, tanto piu che puo utilizzarle come complemento di una chirurgia convenzionale o trovarsi di fronte alle loro complicanze immediate o secondarie.

Resume Les traitements thrombolytiques ont ete employes dans le traitement des obliterations arterielles depuis 40 ans par voie systemique et depuis 1971 par voie locale. Plusieurs etudes randomisees, publiees dans les annees 1990 comparant le traitement thrombolytique au traitement chirurgical de reference ont montre l'interet du traitement thrombolytique, en mesurant, neanmoins, les risques et les complications. L'integration du traitement thrombolytique, dans la prise en charge endovasculaire des lesions, par les techniques de recanalisation, de thromboaspiration, d'angioplastie avec ou sans stent a permis de definir des strategies modernes de traitement. Le but de ce travail est de mettre a jour un travail precedent de notre equipe, en precisant les nouveautes therapeutiques observees ces dix dernieres annees, d'exposer le mecanisme d'action des thrombolytiques classiques, streptokinase (SK) et urokinase (UK) utilisees par voies systemique, locale, et en peroperatoire, puis des thrombolytiques modernes, de l'activateur tissulaire du plasminogene (tPA) a la staphylokinase. Une conference europeenne de consensus a permis de preciser les indications, les contre-indications et les complications de l'utilisation du traitement thrombolytique (TASC). La recommandation 59 conclut qu'il n'y a plus aucune indication au traitement systemique des obliterations arterielles aigues, avec les agents thrombolytiques actuellement disponibles. Les contre-indications du traitement thrombolytique, publiees en 1998, sont actuellement universellement reconnues. Les indications actuelles de la thrombolyse arterielle demeurent la thrombolyse par voie locale. La duree de procedure, outre les complications auxquelles elle expose, n'est pas toujours compatible avec l'urgence de la revascularisation que reclament certaines ischemies aigues. Le traitement thrombolytique peroperatoire est licite lors des interventions peripheriques sur les membres, en particulier, dans le traitement des occlusions de pontage. Meme si les donnees de la litterature sont trop parcellaires, l'association chirurgie-thrombolyse permet de reduire la dose de produit employee et le temps de procedure, ce qui peut etre important dans les ischemies aigues graves.

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.

Pendant pres d’un demi-siecle, la mise a plat-greffe a ete le traitement de reference des anevrismes rompus (AR) de l’aorte abdominale avec un taux de mortalite estime aux alentours de 50 % a 1 mois. Depuis 1994, le traitement endovasculaire est apparu dans l’arsenal therapeutique. Dans les registres et les etudes observationnelles, il semble associe a une diminution de la mortalite (divisee par 2) ainsi qu’a une diminution des complications peri-operatoires. Neanmoins, 4 essais randomises n’ont pas confirme de superiorite du traitement endovasculaire sur le traitement chirurgical en termes de diminution de la mortalite. Dans l’essai francais ECAR (endovasculaire ou chirurgie dans les anevrysmes rompus), 107 patients avec une anatomie favorable et une hemodynamique stable et pouvant recevoir l’une ou l’autre technique ont ete inclus. Les taux de mortalite a 1 mois et 1 an ont ete de 17 et 35 % pour le traitement endovasculaire versus 25 et 40 % pour le traitement chirurgical (non significatif). Par contre, le traitement endovasculaire a ete associe a une diminution des transfusions postoperatoires, de la duree en reanimation et des complications. Le traitement endovasculaire a l’aide d’une endoprothese standard est realisable chez environ 50 % des AR satisfaisant a des criteres hemodynamiques et morphologiques. Chez les malades ayant une instabilite hemodynamique severe, un endoclampage aortique a l’aide d’un ballon permet d’envisager ensuite un traitement endovasculaire ou chirurgical. Chez les malades ayant une anatomie defavorable (collet court), une revascularisation des arteres renales par la mise en place de stents concomitants a la mise en place d’une endoprothese standard peut etre effectuee selon la technique de la cheminee. L’ajout du traitement endovasculaire dans l’arsenal therapeutique du chirurgien a une place qui commence a etre bien definie dans les centres experimentes. Il devrait permettre pour la premiere fois depuis un demi-siecle de reduire la mortalite/morbidite postoperatoire des AR et aussi d’economiser les ressources hospitalieres.

Resume Introduction Le textilome pulmonaire ou compresse oubliee est une complication rare qui peut avoir de graves consequences. Son diagnostic est difficile malgre l'apport de la tomodensitometrie et pose toujours un delicat probleme medicolegal. Exegese Nous rapportons le cas d'un homme de 46 ans aux antecedents de tuberculose ganglionnaire mediastinale diagnostiquee par thoracotomie gauche en 1986. Chez ce patient hospitalise pour une hemoptysie, la tomodensitometrie a revele une masse intrapulmonaire. L'aspect clinique, radiologique et fibroscopique etait compatible avec une dilatation des bronches ou un abces. Le patient a beneficie d'une lobectomie inferieure gauche. L'examen anatomopathologique a conduit au diagnostic de textilome. Conclusion Cette observation souligne la difficulte du diagnostic de textilome thoracique, malgre l'emploi de la tomodensitometrie thoracique. Le diagnostic de textilome doit etre evoque devant toute masse pulmonaire atypique chez un patient aux antecedents de thoracotomie.

The endovascular treatment of abdominal aortic aneurysm (EVAR - EndoVascular Aneurism Repair) has become an alternative therapy to conventional open surgery. The objective of Angiovision project was to contribute to the improvement of EVAR procedures in terms of accuracy and customization of the interventional strategy. Our approach was mainly based on the use of patient-specific data, computer-aided endovascular navigation and numerical simulation. We proposed a new FEM-based patient-specific simulation solution to estimate the deformations caused by the introduction of stiff endovascular devices. We developed and implemented an original endovascular navigation system to augment the intraoperative fluoroscopy with the visualization of deformed preoperative aorto-iliac structure, and related information concerning vessel wall (calcifications), as well as stent-graft virtual deployment. The proposed solution, that requires only lightweight computer equipment, can be used in a standard operating room in order to optimize device placement (from a single angle of incidence). Evaluation is currently under way.

From October 1978 to December 1989, 51 patients underwent lower-limb revascularization from the supracoeliac aorta through a transcrural approach. Symptoms were related to lower-limb ischaemia in all patients: 20 had critical ischaemia (three with severe acute ischaemia) and 31 claudication. One patient had renal failure with hypertension and stenosis of the renal arteries associated with an infrarenal aneurysm induced by Takayasu's disease. Indications for exposure of the supracoeliac aorta were Takayasu's disease in two patients and atheroma in 34 (implantation of the graft on the supracoeliac aorta because of the status of the aortic wall (calcification, inflammation) in 25 and because antegrade revascularization of the visceral arteries was required in nine). In 15 patients repeat aortic surgery was performed; four of these had undergone three previous aortic approaches. The postoperative mortality rate at 30 days was 2%. There were four (8%) acute postoperative graft occlusions and four late occlusions, which occurred between 13 months and 6 years. Life-table analysis showed a 5-year primary patency rate(s.d.) of 83(10)% and a 5-year secondary patency rate(s.d.) of 88(8)%. There are few indications for the transcrural approach to the supracoeliac aorta. Nevertheless, this technique can prove useful in selected cases, for example in those with a calcified aorta, for repeat aortic surgery and for aortic thrombosis near the renal arteries. It is also useful when combined revascularization of the lower limb and right renal or hepatic artery is being considered.

L’histoire naturelle des anevrysmes de l’aorte abdominale sous-renale (AAA) est marquee par une augmentation progressive de taille (environ 4 mm par an). Le risque de rupture depend principalement du diametre anevrysmal. Lorsque le diametre est compris entre 5 et 5,9 cm, le risque de rupture est de 11% par an et il s’eleve a plus de 25% au-dela de 6 cm (1). Ainsi, la rupture d’AAA est actuellement responsable de 1 a 2% des deces des hommes âges de plus de 65 ans dans les pays industrialises (2).

La rupture d’un anevrysme de l’aorte abdominale ou de l’artere iliaque (AAIR) est grevee d’un taux de mortalite spontane de plus de 80% (1). La «mise a plat greffe chirurgicale» de l’anevrysme est le traitement de reference des AAIR mais le taux de mortalite de cette intervention rapporte par une meta-analyse sur 171 etudes compilees depuis 1955 est de 48% (2).

Le pontage femoro-poplite-jambier en veine saphene a longtemps ete le gold standard du traitement de la pathologie atheromateuse occlusive femoro-poplitee tibiale ainsi que des anevrismes poplites. Ces interventions necessitent le plus souvent une anesthesie generale ont une morbi/mortalite non nulle et necessitent des incisions etagees des veines saphenes. Les taux de permeabilite peuvent atteindre plus de 70 % a 5 ans. Ces interventions sont depuis les annees 1990 concurrencees par les therapeutiques endovasculaires qui ont les avantages de pouvoir traiter les patients sous anesthesie locale en percutane au prix d’une morbi/mortalite quasi nulle mais avec des taux de permeabilite plus faibles a long terme. Dans les maladies occlusives, les essais controles proposent d’utiliser la veine saphene preferentiellement si celle-ci est de bonne qualite, chez les patients ayant une ischemie critique et une esperance de vie superieure a 2 ans. Le prelevement veineux peut etre effectue sous videoscopie, ce qui pourrait diminuer le traumatisme local lie au prelevement. Dans les anevrismes poplites, la plupart des equipes favorisent l’utilisation de la veine saphene par rapport au stent couvert ou a la prothese ce d’autant que le malade est jeune et la veine de bonne qualite. Le traitement medical par antiagregant plaquettaire doit etre systematiquement debute et poursuivi en association avec le pontage saphene.

Pulmonary textiloma or retained surgical sponge is rare but can have detrimental consequences. Its diagnosis is difficult, even when using computerized tomography (CT) scan and is always a medical and legal problem.We report the case of a 46-year-old man with a history of pulmonary tuberculosis diagnosed by thoracotomy in 1986, who was admitted to hospital for hemoptysis. CT scan showed the existence of a pulmonary lesion. Clinical, radiological and fiberoptic endoscopy features mimicked an abscess or bronchiectasis. The patient underwent left inferior lobectomy. Anatomical findings led to the diagnosis of textiloma.This case shows the difficult in diagnosing pulmonary textiloma, even when using CT scan. Textiloma should be considered when an atypical pulmonary mass is found in a patient with past history of thoracotomy.

Coated stents can be an alternative to open surgery for arterial aneurysms, particularly in patients with high operative risk.A 90-year-old man with advanced stage cardiopathy developed a 52 mm aneurysm of the iliac artery. Perioperative imaging (arteriography with marked catheter, CT-scan and endovascular ultrasonography) provided a precise description. The material used (PTFE coated thermal memory endoprosthesis, balloon in the hypogastric) provided effective exclusion.Endovascular treatment can be a useful alternative to open surgery for arterial aneurysm in the very elderly.

Endovascular surgery can be proposed as an alternative to infrainguinal conventional surgery in critical ischemia. The aim of this study was to report the latest results of our series of 186 patients.One hundred and eighty-six patients (100 women and 86 men; mean age 74.5 +/- 13 years) were treated for pain during rest (31.5%), gangrene (58%), or ischemic ulcer (10.5%). The lesions were unilateral (n = 172) or bilateral (n = 14). Two hundred eighty-seven target lesions were treated: for stenosis (n = 168) or occlusion (n = 119): of superficial femoral artery (31.7%), popliteal artery (40%) or tibial arteries (28.3%).Technical success was achieved in 81% (15% amputations). The in-hospital mortality rate was 6.5%. The cumulative patency rate was 61 +/- 3% at 12 months, and 52 +/- 6% at 48 months. The limb salvage rate was 87 +/- 3% at 12 months and 82 +/- 4% at 48 months. Thirteen potential factors of patency were analyzed: the only predictive factors affecting patency were occlusion versus stenosis, and the use of atherectomy (Log rank test: P0.001 and P0.0001).Despite a risk of technical failure and of mid-term restenosis, endovascular surgery for critical ischemia provides a fair long-term limb salvage rate.

Angioscopy has been used in the superficial femoral artery for many years, as well as in the control of vascular surgery procedures. It is more reliable than angiography, which often misses such features as intimal flaps, residual valves in "in situ" vein bypasses or persisting thrombus after embolectomy. As fluid irrigation allows visualization of the iliac arteries, and as smaller atraumatic fibres allow safe visualization of the tibial arteries, new fields are opened for the use of angioscopy in peripheral vascular disease. This technique has been proved to be useful: (1) as a diagnostic tool, (2) as a control device in new endovascular procedures (percutaneous angioplasty, atherectomy and stents), and (3) as a therapeutic tool (thromboembolectomy, simplification of bypass procedures). In a modern operating room, angioscopy does not replace angiography, but these two imaging techniques are complementary, as they help the surgeon to provide the patients with a less invasive vascular surgery.

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.

Lower limb arterial disease in diabetics resembles that in non diabetics. However, some important differences include the vessels involved and the extent of the involvement. In the diabetic, the arteries most frequently involved are those below the knee. Arterial occlusions are bilateral, multisegmental, and involve unusual vessels such as the internal iliac artery, the deep femoral artery, the small branches and the collateral circulation. Arterial disease in the diabetic appears at a younger age, advances more rapidly, is more diffuse, and is almost as common in women as in men. Interaction of arterial disease, neuropathy and infection produces a wide away of clinical findings, including callus formation, foot ulcers, cellulitis, osteomyelitis and patchy areas of gangrene. Foot abscess and cellulitis require emergency debridement and drainage. Arterial reconstruction, including endovascular procedures, lessen the rate of amputation, allow partial foot amputation, and prevent from recurrent foot ulcer. Soft tissue repair, and especially fasciocutaneous flaps or musculocutaneous flaps, provide the means to heal most of the patients without infection, and avoid below-knee amputation.

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 fraction35%), 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 aneurysm60 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.