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La enfermedad venosa cronica (EVC) es una patologia muy frecuente. La insuficiencia venosa superficial cronica de los miembros inferiores representa la forma mas avanzada. Las varices se definen como venas subcutaneas palpables y dilatadas de un diametro por lo general mayor de 4 mm. El factor hereditario es predominante. Las venas superficiales drenan la sangre procedente de los tejidos supraaponeuroticos y la conducen hacia las venas profundas a traves de dos ejes venosos principales: la vena safena mayor (VSMa) y la vena safena menor (VSMe). El paciente consulta en la mayoria de los casos por trastornos funcionales. La exploracion fisica permite precisar el estadio de la enfermedad y apreciar su importancia y su repercusion. Las complicaciones agudas son la trombosis venosa superficial, la trombosis venosa profunda (TVP) y la ruptura varicosa. Las complicaciones tardias son las pigmentaciones, la atrofia blanca, las hipodermitis, las calcificaciones subcutaneas y las ulceras de la pierna, que son las mas preocupantes. La ecografia Doppler de los miembros inferiores es la exploracion de referencia para el diagnostico, las particularidades anatomicas y hemodinamicas de la insuficiencia venosa superficial y para determinar el tratamiento mas apropiado. El tratamiento de la insuficiencia venosa cronica se dirige a disminuir los sintomas y a prevenir las complicaciones. La compresion es un tratamiento obligatorio. Los venotonicos estan indicados en las manifestaciones funcionales de la insuficiencia venosa cronica no grave. La aparicion de los tratamientos endovenosos (ecoescleroterapia con espuma, laser, radiofrecuencia) ha provocado una reduccion evidente de las indicaciones quirurgicas en el tratamiento de la insuficiencia venosa superficial.

Resume Introduction L’occlusion de la veine femorale commune (OVFC) d’origine iatrogene, secondaire a la pose de catheters femoraux ou a des interventions au niveau du Scarpa, est une cause rare mais tres symptomatique d’insuffisance veineuse chronique. Ces patients, insuffisamment soulages par la compression veineuse elastique, sont des candidats pertinents a une procedure endovasculaire de recanalisation veineuse. Methodes Nous rapportons une serie de trois cas d’OVFC developpee a la suite d’interventions au niveau du Scarpa, leur procedure de recanalisation, le controle par echo-Doppler et le suivi a court terme. Resultats Dans chacun des cas, la recanalisation endovasculaire a necessite du materiel rigide (guide rigide ou aiguille de Colapinto) afin de traverser les adherences fibreuses avant de realiser une angioplastie avec pose de stent. Ces procedures complexes ont permis une recanalisation efficace immediate, sans complication majeure. Le controle par echo-Doppler confirmait la permeabilite de la veine femorale commune. Lors de la consultation de controle, les patients ont constate une amelioration rapide et significative de leurs symptomes. Conclusion Chez les patients souffrant d’insuffisance veineuse chronique severe par OVFC d’origine iatrogene, une recanalisation endovasculaire peut etre proposee. Bien qu’il s’agisse de procedures complexes en raison de la fibrose etendue au niveau du Scarpa et necessitant du materiel specialise, aucune complication majeure n’a ete constatee.

Background The cornerstone of therapy in thromboangiitis obliterans (TAO) is complete abstinence from tobacco. In addition to discontinuation of cigarette smoking, very few pharmacological and surgical options of controversial efficacy are available to date. TAO is associated with a high amputation rate because of tobacco continuation, medical therapy failure, and desert foot with no revascularisation option. Endovascular or bypass revascularisation patency and efficacy are poorly described in the literature. Objectives To describe the results of the French National Reference Centre on TAO on revascularisation modalities, their patency and efficacy. Methods Among the 198 patients followed in our centre, we retrieved data from 19 patients for who a revascularisation procedure has been attempted. Patency was assessed on angioCT scan and Duplex ultrasounds performed during follow-up. Efficacy was assessed according to clinicians in charge of the patient, and if an amputation had been performed or not despite a primary successful procedure. Results In this cohort of 19 patients, 16 were male (84%), all were tobacco active users, and 21% cannabis users. Median follow-up was 19.9 months [11.0–36.9]. Iloprost infusion had been tested for 84.2% of the patients before revascularisation, and 63.2% had a dihydropiridine, 73.3% a statin and 100% at least aspirin. Endovascular procedure was exclusive for 14 patients, and bypass surgery for 1 patient. Four patients had combined procedures. Globally, 44 procedures including 7 bypasses (15.9%) and 37 endovascular surgeries (84.1%), due to multiple procedures for some patients. Primary patency of endovascular procedures was 89.4% and their patency duration was 221±173 days. For bypass surgery, the patency duration was higher 827±408 days (p=0.273). Looking at the territory, aorto-iliac revascularizations gave better results on long term 1830 days followed by upper limb 751±402 days, femoro-popliteal procedures 347±196 days and finally infra-popliteal ones with 178±134 days. Stability or improvement was observed after 52.3% of the revascularizations. Among the failures, 21.2% were associated with a minor amputation, and 11.3% with a major amputation. No predicting factors of failure could have been determined. Conclusions We report the largest series of revascuarization in TAO. As expected, proximal artery revascularisation of lower limbs were associated with a higher and a longer patency rate than femoro-popliteal procedures and even more than infra-popliteal revascularisations. Suprinsingly, upper limb revascularisation had a better outcome than for lower limbs. Efficacy of revascularizations are difficult to assess because such procedures are often proposed as a salvage option. However, it is worth to note that more than 50% of the patients had a benefit from the revascularisation. Disclosure of Interest T. Mirault Grant/research support from: GENZYME (2010) M. Delahaye: None declared, A. Galloula: None declared, M. Guillet: None declared, S. Zarka: None declared, M.-C. Courtois: None declared, M. Sapoval: None declared, G. Goudot: None declared, E. Messas: None declared

Common femoral vein occlusion (CFVO) is frequently found in patients with chronic venous insufficiency. The iatrogenic form, secondary to either central catheter or surgery, is very rare but highly symptomatic. Classical compression therapy barely improves the clinical status of these patients, making them suitable candidates for an interventional procedure for venous recanalization.We report here three consecutive cases of iatrogenic CFVO referred to our outpatient clinic because the disease had an impact on daily life activities. We detail the recanalization procedure, the Doppler control and the short-term outcome.In each case, endovascular recanalization required rigid material (rigid guide or Colapinto needle) to cross the fibrous adhesions before angioplasty could be performed with stenting. The procedure required two attempts in each case, underlining its complexity, but eventually enabled effective recanalization. No major complication occurred per- or post-procedure. One month later, a duplex Doppler control confirmed the permeability of the common femoral vein. The patients had experienced rapid and significant symptom improvement.Patients suffering from severe chronic venous insufficiency caused by iatrogenic CFVO can benefit from endovascular recanalization. Although these procedures may be complex due to the extensive fibrosis at the Scarpa and require specialized equipment, no major complications were observed. Patency of the recanalization persisted at least one month after the procedure. Symptom relief was good.

Diabetes mellitus is an independent risk factor for peripheral artery disease. Life expectancy is 41 months for diabetic patients with an ischemic ulcer. The characteristics of diabetic arteriopathy make its treatment more difficult than in non-diabetic patients. Few data are available about the surgical treatment of arteriopathy in diabetic patients (including angioplasty or bypass), especially in case of distal arteriopathy. The choice of the procedure depends on multiple factors such as the disease localization, its extent, distal blood flow and vascular disease-related surgical risk. The principal aim of revascularisation is to restore direct flow to the foot in order to ensure wound healing and limb salvage. With percutaneous endoluminal angioplasty, limb salvage can be achieved in more than 80% of patients at 1-3 years. The percutaneous procedure is less invasive than open surgery, there are fewer complications, and morbidity and mortality rates are reduced; moreover, a second procedure remains possible in the future. With bypass surgery, the rate of limb salvage exceeds 80% at five years. Nevertheless, peri-operative mortality reaches 3% and arterial anatomy, patient-related risks factors or venous graft availability may be limitations. New endovascular techniques especially designed for the distal arteries of the lower limbs enable very distal revascularization with morbidity and mortality rates lower than with surgery.

Diabetes mellitus is an independent risk factor for peripheral artery disease. Life expectancy is 41 months for diabetic patients with an ischemic ulcer. The characteristics of diabetic arteriopathy make its treatment more difficult than in non-diabetic patients. Few data are available about the surgical treatment of arteriopathy in diabetic patients (including angioplasty or bypass), especially in case of distal arteriopathy. The choice of the procedure depends on multiple factors such as the disease localization, its extent, distal blood flow and vascular disease-related surgical risk. The principal aim of revascularisation is to restore direct flow to the foot in order to ensure wound healing and limb salvage. With percutaneous endoluminal angioplasty, limb salvage can be achieved in more than 80% of patients at 1-3 years. The percutaneous procedure is less invasive than open surgery, there are fewer complications, and morbidity and mortality rates are reduced; moreover, a second procedure remains possible in the future. With bypass surgery, the rate of limb salvage exceeds 80% at five years. Nevertheless, peri-operative mortality reaches 3% and arterial anatomy, patient-related risks factors or venous graft availability may be limitations. New endovascular techniques especially designed for the distal arteries of the lower limbs enable very distal revascularization with morbidity and mortality rates lower than with surgery.