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Biomedical subjects

J M Cormier

Publications and source records attributed to J M Cormier.

At least 37 records · Page 2Linked to original sources
PubMed1995

Outcome of infrainguinal endovascular revascularization procedures for limb-threatening ischemia.

This report describes the results of 96 infrainguinal endovascular revascularization procedures performed in 86 patients with limb-threatening ischemia over a 3-year period. There were 41 women and 45 men (mean age 72.9 +/- 11.9 years) including 47 patients (51.1%) with diabetes and 13 (15.1%) with renal insufficiency. All patients had severe ischemia characterized by rest pain (18.8%), ulceration (12.5%), or gangrene (68.8%). Twelve procedures were carried out in association with conventional surgical reconstruction and in eight patients with mixed ulcers a venous procedure was performed during the same session. A total of 143 arterial lesions were treated including 61 occlusions (mean length 5.9 +/- 3.5 cm) and 82 stenoses (mean length 4.6 +/- 3 cm). The following techniques were used: transluminal angioplasty in 99 cases, laser in five cases, Rotablator in 24 cases, and aspiration thrombectomy in 15 cases. Nine patients (10.5%) died in the hospital. Initial failure was observed in 32 patients, of whom 18 underwent subsequent surgical revascularization and 14 required amputation of the extremity within 2 months. Analysis of variance was used to assess the following 12 risk factors for initial failure of endovascular revascularization: sex, age, diabetes, renal insufficiency, associated surgery, treatment of multiple lesions, artery treated, type of lesion, length of lesion, quality of runoff, use of an atherotome, and stent placement. Results showed a significant correlation between initial failure and both quality of runoff (12.9% in patients with two or more patent leg arteries vs. 36.5% in patients with one or fewer patent leg arteries; p < 0.05) and type of lesion (14.5% for stenosis vs. 45.9% for occlusion). Mean follow-up was 9.98 +/- 9.9 months and 4.7% of patients were lost. Restenosis was observed during follow-up of 16 of the 74 initially successful procedures. ANOVA was used to assess the same 12 risk factors for restenosis. Results showed a significant correlation between restenosis and both sex (10.8% in women vs. 32.4% in men; p < 0.05) and age (8% for patients > 80 years of age vs. 28.6% for patients < 80 years; p < 0.05). Primary patency, secondary patency and limb salvage rates calculated according to the actuarial method were 65%, 75%, and 84%, respectively, at 6 months and 47%, 67%, and 81%, respectively, at 1 year. Limb salvage rates for the endoluminal techniques used in this study were satisfactory, especially in elderly patients with either segmental lesions or contraindications for distal bypass.

Adult↗
PubMed1995

[Disabling calf pain in the context of venous angiodysplasia: Contribution of dynamic exploration].

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.

Adult↗
PubMed1995

[Is it permissible to operate on an asymptomatic aneurysm of the abdominal aorta after the age of 80?].

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

Aged↗
PubMed1994

Vertebral arteriovenous fistulas: a study of 49 cases and review of the literature.

The experience is reported with 50 vertebral fistulas treated by the authors in a joint radiological and surgical team. Of the 28 fistulas that were traumatic, 18 occurred after incidental iatrogenic puncture, and 22 were spontaneous, of which four presented in patients displaying angiographic features of fibromuscular dysplasia. Eleven patients were operated on and 33 had endovascular treatment. In nine patients who were either symptom-free or in poor health, no treatment was advised. The fistula was occluded in 38 (93%) of the treated patients, and the vertebral artery patency was preserved in 32 (78%). A total of 224 published cases were reviewed: 152 were traumatic, most after a penetrating injury; 72 were spontaneous, with three age peaks (at 7, 26 and 52 years). Treatment has evolved considerably and endovascular occlusion is now the treatment of choice, surgery being reserved for specific indications.

Adolescent↗
PubMed1994

[Distal arteritis of the legs: endovascular treatment].

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.

Aged↗
PubMed1994

[Internal carotid artery surgery using a venous graft].

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

Carotid Artery, Internal↗
PubMed1993

[Arterial aneurysms in Behçet's disease. 4 cases].

Four cases of Behçet's disease with aortic and peripheral lower limb lesions illustrated the characteristics of the disease: multifocal lesions, false aneurysms suggesting infectious perforation and iterative false aneurysm in 1 case. The symptoms of Behçet's disease must be looked for stubbornly. In the presence of any arterial abnormality of this type, this cause must be seriously considered.

Adult↗
PubMed1993

[Surgery of aneurysm of the subrenal abdominal aorta in patients over 80 years of age].

In patients aged over 80 years infrarenal aortic aneurysmectomy is controversial because of reduced life expectancy and multiple risk factors and associated vascular or non-vascular lesions. Our personal experience of 984 operations performed for unruptured abdominal aortic aneurysms over a 6-year period showed a significantly higher perioperative mortality in patients aged more than 80 years (15.4 versus 2 percent). In contrast, for ruptured aneurysms, the difference of perioperative mortality was not significant (71 percent in the over 80 group versus 37 percent in other groups), but the number of patients (17 and 52 respectively, to a total of 69) was too small. In patients over 80, it seems reasonable to restrict elective surgery to aneurysms that are symptomatic or complicated, or to those which carry higher risks of rupture in view of their diameter and gradual enlargement. The best treatment, in fact, is early diagnosis and surgery before the age of 80, when perioperative mortality is much lower, less than 2 percent. Less aggressive treatments, including endoluminal aortic graft placement, are very promising but still experimental.

Age Factors↗
PubMed1993

Long-term follow-up of positive cultures in 500 abdominal aortic aneurysms.

Routine aneurysm culture is frequently performed as it is thought that a positive culture could be a risk factor for secondary graft infection. Five hundred aneurysms, in a series of 796 patients, had microbiologic examination of the thrombus and/or aneurysm wall. Cultures were positive in 185 cases (37%), mostly due to normal skin flora microorganisms (80%), whereas 16 patients (3.2%) had infectious aortitis. Gram-stained smears were positive in nine of these 16 patients compared with two of the other 169. Of the 185 patients with positive culture, after a mean length of follow-up of 35 months, only one had a graft infection that occurred 6 years later and was not due to the same microorganism. Graft sepsis was diagnosed in six of the 296 patients who did not have a positive culture, and was related to clinically obvious locoregional or systemic foci. In this series, positive cultures from aneurysm without rupture or signs of infection were not a risk factor for secondary graft sepsis. Therefore, in cases of asymptomatic unruptured aneurysm, routine culturing is not necessary as a positive result has no pathogenic significance or therapeutic implication.

Aged↗
PubMed1993

High levels of portal TNF-alpha during abdominal aortic surgery in man.

During shock or multiple organ dysfunction syndrome, translocation of bacteria and/or lipopolysaccharide (LPS) from the ischaemic gut might occur and could explain the excess of cytokine production detectable in plasma. To test this hypothesis, we studied a model of mild gut ischaemia due to bowel manipulation and aortic clamping in patients undergoing abdominal aortic surgery (n = 14). Per-operative levels of LPS and cytokines were measured before clamping and after reperfusion, and compared in systemic and portal blood. Systemic levels of LPS and cytokines were measured in a control group of patients undergoing internal carotid surgery (n = 7). Portal LPS was detectable (i.e., > 12 pg/ml) in 36% of the patients undergoing aortic surgery after bowel manipulation, and in 71% after clamp release. Similar levels of LPS were observed in portal and systemic blood after clamp release. Circulating tumour necrosis factor alpha (TNF-alpha) was observed in all patients undergoing aortic surgery. Levels of portal TNF-alpha were higher than those in systemic blood after bowel manipulation as well as after reperfusion (P = 0.02 and 0.007, respectively). LPS was never detected in control patients and TNF-alpha was detectable in only two out of seven patients. Mean levels of IL-6 were similar in the two groups, with a peak on the day following surgery, confirming that circulating IL-6 is associated with any surgical procedures. Our data indicate that bowel manipulation, aortic clamping and reperfusion lead to similar levels of portal and systemic circulating LPS.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1993

A randomised controlled trial of a low-molecular-weight heparin (Enoxaparin) to prevent deep-vein thrombosis in patients undergoing vascular surgery.

The incidence of postoperative deep vein thrombosis (PDVT) after aortic surgery and lower limb revascularisation has not been assessed by a large prospective study. In a prospective randomised trial the effect of a low-molecular-weight heparin fragment, Enoxaparin (ENX) 4200 anti factor Xa IU once daily was compared to that of unfractionated heparin (UFH) 7500 IU twice daily. Two hundred and thirty-three consecutive patients were classified into three groups, aortic or aortoiliac and aneurysmectomy (n = 75), aorto-femoral bypass for atherosclerotic disease (n = 71), and femoropopliteal or femorodistal bypass (n = 87). Patients were analysed for development of deep vein thrombosis by Duplex scanning and, if positive, by venography between the seventh and tenth postoperative day. PDVT was present in 10 patients in the ENX group and in four patients in the UFH group (8.2 and 3.6% respectively, NS). The incidence of PDVT was 8% after aortic or aortoiliac aneurysmectomy, 7% after aortofemoral revascularisation, and 3.4% after femoropopliteal or femorodistal bypass. The overall incidence of PDVT after aortic surgery was 7.5% (95% CI 5.4-9.7). There was no pulmonary embolism. Intra-operative blood loss and postoperative bleeding events did not differ significantly between the ENX and UFH groups. After 1 month follow-up, no clinical event or death could be related to PDVT or pulmonary embolism. In conclusion, in vascular surgery ENX is as safe and effective in the prevention of PDVT as is UFH.

Aged↗
PubMed1993

Infected infrarenal aortic aneurysms: when is in situ reconstruction safe?

Twenty-five infected infrarenal aortic aneurysms operated on between 1968 and 1989 were reviewed. They were classified into post-embolic (mycotic) aneurysms (group I), infective aortitis (group II), and infected atherosclerotic aneurysms (group III). Aortoduodenal fistulas were found in eight patients and aortocaval in two. Five patients were operated on in a state of shock, and 12 had preoperative positive blood cultures. Surgical procedures included in situ reconstruction of the aorta (n = 21) and extra-anatomic bypass associated with aneurysmal resection (n = 4). In 19 patients, prostheses were covered with omental flaps, and antibiotics were continued for more than 6 weeks in all patients. In patients who underwent in situ reconstruction, three deaths were related to the initial surgery. All surviving patients were regularly followed up, and none showed any sign of late septic recurrence. In patients who underwent extra-anatomic bypass, two died in the postoperative period, one underwent reoperation 2 years after the initial surgery, and the last patient is doing well. Positive postoperative blood cultures (n = 4) revealed persistent sepsis: two cholecystitis, one spondylitis, and one aortic infection. An exhaustive review of the literature was performed; clinical, bacteriologic, and operative features and results were analyzed; prognostic factors were evaluated; and a practical therapeutic approach was suggested. The importance of preoperative diagnosis, complete resection, debridement of infected tissues, omental flap coverage, and long-term antibiotic therapy with regular computerized tomographic scanning follow-up is stressed.

Adult↗
PubMed1993

Lower-limb revascularization from the supracoeliac aorta through a transcrural approach.

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.

Adult↗
PubMed1993

Arterial thrombosis: a rare complication of the nephrotic syndrome.

Arterial thrombosis is a rare complication of the nephrotic syndrome, occurring mainly in men. Two cases of arterial thrombosis are described, the first affecting a 54-year-old man in whom aortic thrombosis initiated the nephrotic syndrome and who relapsed 1 year later resulting in graft thrombosis, the second affecting a 15-year-old male patient with extensive popliteal and distal arterial thrombosis, followed by recurrent venous bypass thrombosis. A review of the literature shows that arterial thrombosis occurs primarily in the femoropopliteal, renal and coronary arteries. The genesis of arterial thrombosis in patients with nephrotic syndrome involves increased blood viscosity, platelet adhesion and aggregation, high levels of fibrinogen, low levels of serum antithrombin III, diuretic agents and steroid therapy. For high-risk patients with low levels of plasma albumin or those receiving steroids, anticoagulation therapy should be introduced to prevent thrombosis. Urine protein should be evaluated in patients with arterial thrombosis of unknown origin.

Adolescent↗
PubMed1993

[New trends in limb salvage. Endovascular techniques applied to leg arteries].

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

Aged↗
PubMed1993

[New trends in limb salvage. Vascularized flaps].

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

Aged↗