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J M Fichelle

Publications and source records attributed to J M Fichelle.

At least 19 recordsLinked to original sources
PubMed2001

[Post-irradiation axillo-subclavian arteriopathy: surgical revascularization].

Post-irradiation axillo-subclavian arteriopathy can develop 6 months to 20 years after radiotherapy. Incidence estimated from duplex scan screening is about 30%, half of the cases having no hemodynamic significance. In our experience, asymptomatic lesions are the most common. Nevertheless, we have observed since 1978, 38 symptomatic patients including 23 with either acute ischemia (8 patients), or chronic ischemia (15 patients) requiring revascularization. We used an endovascular approach in 8 and open surgery in 15. A bypass graft was performed in 13 patients, using a vein (8 patients) rather than a prosthesis (5 patients), implanted in healthy territory, proximally or in the common carotid (11 patients) or the proximal subclavian (2 patients), and distally in the axillary artery (5 patients) or the brachial artery (8 patients). One venous bypass became occluded postoperatively. The other bypasses remained patent during follow-up of over 10 years. There of the five prosthetic bypassess gradually failed without recurrence of critical ischemia. Other revascularization procedures included endarterectomy and thrombectomy. In the long term, functional prognosis mainly depended on the frequently associated involvement of the plexus in the post-irradiation changes, which, together with the revascularization procedure, also required neurolysis in 11 patients, two omental covers and a free musculocutaneous transfer in 9 patients.

Adult↗
PubMed2000

Endovascular treatment of iliac aneurysms with covered stents.

The purpose of this retrospective, single-institution study was to analyze the results of endovascular treatment of iliac aneurysm using covered stents. Since January 1, 1996, a total of 34 iliac aneurysms have been treated with covered endovascular stents. The series included 9 isolated aneurysms, 29 aneurysms following repair of aortic aneurysm, and 3 false anastomotic aneurysms. The mean diameter of aneurysm was 42 mm (range, 21 to 120 mm). The aneurysm was either symptomatic or complicated in 11 cases. Three procedures were carried out under emergency conditions after acute rupture. Stent deployment was successful in 33 cases (technical success rate, 97.6%). Exclusion of the aneurysm was obtained in all cases with one (n = 26) or two overlapping (n = 7) covered stents. Mean procedure duration was 45 min (range, 25 to 75 min). The internal iliac artery was patent in 28 cases, but patency was preserved in only 4 cases. In the remaining 24 cases the internal iliac artery was excluded either preoperatively by embolization using Gianturco coils (n = 15) or intraoperatively by placement of the stent (n = 9). Endovascular treatment of iliac aneurysm with covered stents achieves good short- and middle-term results but usually requires exclusion of the internal iliac artery.

Aged↗
PubMed1999

[Arterial complications of neurofibromatosis].

Type 1 neurofibromatosis (NF1) is the most frequently observed phacomatosis, but involvement of arterial trunks is uncommon. Expression depends on the localization and is not easily related to the causal condition. Seven patients with type 1 neurofibromatosis developed vascular manifestations (table I) disclosed by hypertension (n = 2) digestive angina (n = 1), arterial rupture (n = 1) and aneurysm of the subrenal aorta (n = 1). The diagnosis of NF1 was clear in 5 cases; in 2 cases, the diagnosis could only be established on the basis of pathology findings demonstrating dysplasia of the media with voluminous periadventitial hypertrophic nerves (table II). All the large arteries can be involved in NF1. A complete vascular work-up is needed to identify multiple arterial localizations as found in two of our cases. Thoraco-abdominal stenosis was observed in 5 cases leading, in 2 cases, to coarctation with a hemodynamic and functional impact requiring aortic revascularization. The most frequently observed localization involves the renal arteries: 3 of our patient had occlusive lesions of the renal arteries and in 2, aneurysms were observed. Three of our patients (including 2 of the preceding), had major occlusion of digestive arteries. Three other cases revealed an aneurysm of inflammatory subrenal aorta, a rupture of the iliac into the inferior vena cava and a rupture covered by a subclavian aneurysm. The indication for surgery depends on the arterial signs of associated complications (5 of our cases). In one case surgery was indicated to prevent rupture of a splenic artery aneurysm and an aneurysm of the subrenal abdominal aorta. Two cases were treated by exclusion (ilio-cava fistula) or excision (splenic aneurysm); renal or digestive revascularization was performed with arterial or venous autografts in young patients (3 cases). One extensive abdominal coarctation was repaired with a PTFE graft as were the subclavian and subrenal aorta aneurysms. One patient with an ilio-cava fistula died from collapsus. Long-term results of the revascularizations are satisfactory with good control of the hypertension and total regression of the digestive angina. Fibrodysplasia of the renal or digestive media occurring alone or thoraco-abdominal coarctation should suggest NF1 and lead to a complete work-up to identify other arterial localizations. Patients should be followed regularly to prevent complications which in case of rupture can be life-threatening.

Adult↗
PubMed1998

[Long-term outcome of infra-inguinal endovascular surgery for critical ischemia].

STUDY AIM: 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. MATERIALS AND METHODS: 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%). RESULTS: 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: P < 0.001 and P < 0.0001). CONCLUSION: Despite a risk of technical failure and of mid-term restenosis, endovascular surgery for critical ischemia provides a fair long-term limb salvage rate.

Aged↗
PubMed1998

[Abdominal aortic aneurysms associated with visceral artery stenoses].

During a 6-year period six patients had combined revascularizations for an abdominal aortic aneurysm and a high-grade (> 80%) stenosis of either the superior mesenteric artery (N = 14) and/or a renal artery (N = 60 including 6 bilateral revascularizations). Revascularizations of a visceral artery were done more often with a bypass graft (N = 61) than by endarterectomy (N = 6), reimplantation (N = 4) or endovascular technique (N = 3). Fifty patients had concomitant repair of the aorta and of the visceral artery, and ten had a staged repair, favored in-high risk patients and in cases of multiple visceral artery revascularizations. Four patients (7.5%) died (2 myocardial infarctions and 2 multisystem organ failure) and twelve (20%) had a non-fatal complication in the postoperative period. Survival was 91% at one year and 81% at 5 years. Our experience emphasizes the option of a staged approach in these high-risk patients, with the availability of extra-anatomic reconstruction, and the limited value of endovascular revascularization of the visceral arteries.

Adult↗
PubMed1997

Infected false hepatic artery aneurysm after orthotopic liver transplantation treated by resection and reno-hepatic vein graft.

Vascular complications after liver transplantation are relatively rare. Thrombosis of the host-transplant arterial anastomosis is the most frequently encountered vascular complication whereas only a few observations of infected anastomotic aneurysms, often leading to death by massive bleeding or loss of the transplant, have been reported. We report herein the case of a patient with an infected false anastomotic aneurysm of the hepatic artery associated with dissection of the celiac artery following orthotopic liver transplantation in a 35-year-old man who had received a liver transplantation for end-stage liver disease secondary to posthepatitis cirrhosis in March 1989. Starting at day 30, he had signs of infection associated with hemocultures positive for Staphylococcus aureus. A subhepatic collection was found on sonography and CT scan and also cultured positive for the same germ. Arteriograms demonstrated a celiac artery dissection associated with a false anastomotic aneurysm of the hepatic artery. Surgical treatment consisted of arterial reconstruction using a saphenous vein graft between the right renal artery and the hepatic artery of the transplant, followed by resection of the hepatic artery aneurysm and the celiac artery. Hepatic ischemia was 12 min. The immediate postoperative course was uneventful and postoperative angiograms showed that the reconstruction was patent at 5 years.

Adult↗
PubMed1996

Colonic ischemia reveals thromboangiitis obliterans (Buerger's disease).

Two years before the appearance of distal peripheral manifestations of thromboangiitis obliterans (Buerger's disease), a young man had acute peritonitis attributable to an ischemic perforation of the sigmoid colon. Only the histological examination of excised tissue was able to differentially diagnose this entity unambiguously.

Adult↗
PubMed1996

[Emboligenic aortopathies. Cholesterol embolisms: surgical treatment].

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.

Aortic Diseases↗
PubMed1996

[Diabetic arteriopathy of the lower limbs].

Diabetic arteriopathy is a specific entity as it associates macro-angiopathy ischemia factor and micro-angiopathy leading to peripheral neuropathy. This association leads to specific clinical manifestations dues to interplay of ischemic and infectious phenomena. Diffuse occlusive lesions predominate distally with mediacalcosis. Wider surgical indications for revascularization of distal vessels of the leg, the ankle and the foot have reduced the number and extent of amputation. Long-term permeability after salvage surgery is identical to that in non-diabetic patients as shown by our series of 695 distal revascularizations. Endovascular techniques with or without stents or recanalization are alternatives which may be indicated in case of short occlusions or trophic disorders contraindicating surgery. Associating stents with conventional surgery may also be indicated in diabetic patients. One final progress in reducing the number of amputations has been provided by free-transfer micro-surgery techniques which allow both vascular supply and coverage of distal tissue loss.

Aged↗
PubMed1995

[Arterial disease of the lower limbs in diabetic patients].

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.

Arterial Occlusive Diseases↗
PubMed1995

Infrapopliteal polytetrafluoroethylene and composite bypass: factors influencing patency.

Between January 1, 1979, and December 31, 1988, 149 infrapopliteal polytetrafluoroethylene (PTFE) bypasses were performed in 145 patients with chronic, critical, limb-threatening ischemia. These operations represented 27.9% of 534 infrapopliteal bypasses performed during the same period. There were 92 males and 53 females. Mean age was 71.8 +/- 12.3 years. Signs and symptoms of critical ischemia were gangrene, ulceration, and isolated rest pain in 101 (69%), 23 (15.3%), and 25 (16.7%) cases, respectively. A composite (PTFE-saphenous vein) graft was used in 53 (35%) cases. In 96 prosthetic bypasses the distal anastomosis was performed using vein patch angioplasty in 65 (44%) cases and directly in 31 (21%). The in-hospital mortality rate was 3.3%. Patency, limb salvage, and patient survival rates were plotted according to the actuarial method and the curves obtained were compared using the log-rank test. Actuarial survival rates were 68% +/- 5% and 57% +/- 7% at 3 and 5 years, respectively. Primary patency and lower limb salvage rates were 41% +/- 5% and 68% +/- 6% at 3 years and 35% +/- 9% and 65% +/- 10% at 5 years, respectively. There was no statistically significant difference noted in primary patency rates at 3 years according to the type of bypass (composite or all-prosthetic: 36% vs. 44%), the type of distal anastomosis (direct or vein patch angioplasty: 43% vs. 45%), the site of distal anastomosis (upper or lower half of the leg: 38% vs. 46%), lateral or medial placement of the bypass (39% vs. 43%), or according to whether or not it was a repeat operation (40% vs. 44%). In conclusion, patency rates using infrapopliteal PTFE bypasses are low. Certain technical approaches, although they do not seem to improve patency, definitely increase the feasibility of bypass and in our opinion decrease the risk of early failure in unfavorable anatomic settings. The limb salvage rates following infrapopliteal PTFE and composite bypass are encouraging and justify the use of routine distal revascularization, even in the absence of autogenous vein graft.

Adult↗
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

[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

[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↗
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↗