In our experience the incidence of anastomotic aneurysms (AA) after prosthetic bypass varied from 0.3 to 0.7% depending on location; it was 5 times higher at aortobifemoral anastomoses (77/3146; 2.44%) than aortic anastomosis (8/2173; 0.37%) (p less than 0.005). In the inguinal region the incidence of femoral AA (FAA) is the same as elsewhere when the prosthesis is placed in front of the inguinal ligament (axillo-femoral anastomoses, 1/200; 0.5%; femoro-femoral anastomoses 1/270; 0.37%). However when the prosthesis is placed behind the ligament, the incidence of FAA rises to 2.44% (77/3746). In our opinion, this difference is due to adherence between the prosthesis and the ligament during hip movement. When the hip is in extension, tension is placed on the prosthesis and the adjacent arterial junction causing the wall of the artery to tear. The sutures almost always remain intact. In an effort to avoid this problem, we have developed a technique that consists of enlarging the passage of the prosthesis by partial section of the inguinal ligament and then wrapping the prosthesis with a free non pedunculated segment of omentum from above the femoral anastomosis down to the healthy segment of the femoral artery which, being elastic, can stretch. The omentum acts as sheath that reinforces the anastomosis. To evaluate this technique we assessed our patients operated upon for aortobifemoral (or aortofemoroiliac) bypass into two groups. Group A included 115 patients operated on by the same surgeon using the new technique (October 1981 and December 1984). There were 111 men and 4 women (mean age: 59.7 years). Mean follow-up was 7.36 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Anastomosis, Surgical↗

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Single staged carotid and coronary arteries surgery. Indications and results.

The frequency of associated carotid and coronary stenosis is estimated to be 40% of cases including asymptomatic patients. The risk of death by myocardial infarction during carotid surgery is in the neighborhood of 1%. With Doppler and ultrasonic imaging, it is now possible to recognize carotid stenosis in 11% of these cases. Depending on the extent of the clinical manifestations caused by one or the other of these lesions, there are several therapeutic options: surgery of the carotid with special protection of the myocardium during and after surgery or simultaneous carotid and coronary surgery in high risk cases. Between 1979 and 1986, simultaneous surgery was performed in 18 cases in our department. During the same period, 1194 carotid endarterectomies and 505 coronary bypasses were performed. These 18 cases included 13 males and 5 females with a mean age of 62 years (range: 43 to 78 years). The procedure performed in these cases were 17 carotid endarterectomies, one bypass of the innominate artery and an average of 2 aorto-coronary bypasses per patient. One death from myocardial infarction occurred in the immediate postoperative period and another patient died suddenly 8 months later. The evolution of arterial disease was evaluated in the other patients. Simultaneous carotid and coronary artery surgery is indicated in high risk carotid and coronary patients. Perusal of the results in the literature allows a better appreciation of the indications and risks of this type of surgery. Our series indicates the necessity for a careful preoperative workup in these patients and the need for more accurate screening to obtain better results.

Adult↗

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Carotid surgery under cervical block anesthesia. A simple method of heart and brain protection in high risk patients.

Between January 1, 1985, and December 15, 1987, 60 patients underwent surgery for carotid lesions under local cervical block anesthesia. Sixty-seven reconstruction procedures were performed including 64 endarterectomies and 3 vein bypasses. During the same 3 year period, 938 other reconstruction procedures were carried out under general anesthesia for a total of 1005 procedures. These 60 patients, who accounted for 6.7% of our indications, were selected for surgery under local anesthesia because they were at high risk for cardiac and neurologic complications. As far as staging is concerned, this subgroup of patients included: 14 asymptomatic cases (stage 0), i.e., 21%; 44 transient ischemic attacks (stage I), i.e., 66%; 2 progressive stroke (stage II), i.e., 3%; 7 patients with neurologic sequels (stage III), i.e., 10%. In all 79% of the patients were symptomatic. The asymptomatic patients all presented bilateral tight stenosis sometimes with thrombosis of the contralateral carotid. The technique of local anesthesia and endarterectomy were classic: closing with a bougie to calibrate the lumen, systematic intraoperative arteriography and immediate correction of technical failures (2 times); no death occurred among the patients in stages 0, 1 and II; 1 early asymptomatic occlusion that was not corrected was noted; in one case, a ligation of the carotid was necessary after technical failure, without consequences; one death occurred in stage III after intracerebral hemorrhage. On the basis of our experience local cervical block anesthesia appears to be a simple and reliable method of ensuring intraoperative diagnosis of cerebral ischemia. It eliminates all intraoperative cerebral complications secondary to ischemia and allows a better understanding of the physiopathologic mechanisms underlying perioperative neurologic complications. The absence of neurologic and cardiac complications in this series of very high risk patients enables us to extend eligibility for surgery to include patients with unstable cardiac and cerebral disease.

Aged↗

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Carotid restenosis: should they all be reoperated on?

Restenosis of carotid arteries after endarterectomy is a rare complication; in our series 1.2% (19 patients - 20 recurrences out of 1658 operations - Dec. 1985). It usually occurs early, i.e. in the first months (12 cases) with features of myointimal hyperplasia. Peroperative angiography should be routinely performed to rule out technical errors that might be mistaken for restenosis. At the time of reoperation, 12 patients were symptomatic. The operation consisted of 6 second endarterectomies, 13 saphenous vein grafts and 1 PTFE graft. The postoperative period was uneventful in 14 cases, but in the remaining patients there were 2 transient ischemic attacks, 2 monoplegias and 1 dysphasia (with immediate thrombosis of the bypass in 3 cases). Five patients were lost at follow-up. In the remaining 14 patients, the follow-up period varied between 3 and 84 months (mean: 20 months). Presently 11 carotid arteries are patent. In one case involving a venous patch, the artery is dilated. All 12 of these patients are asymptomatic. One thrombosed bypass is also asymptomatic. The two monoplegias occurred in patients whose bypasses occluded immediately. The recurrence rate varied according to the imaging technique. i.e. pulsed Doppler, B-mode scanning or angiography, used to detect restenosis. Restenosis usually remains asymptomatic even in patients with hemodynamically significant lesions. Restenosis due to myointimal hyperplasia does not carry the risk of embolism and atheromatous stenosis does not have the same prognosis. In our experience immediate and long term results of red are not as good the first endarterectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

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Cervical artery exploration: choice and need for a non-invasive technique.

The different non-invasive exploratory techniques for cervical arteries are compared and classified as hemodynamic exploration methods (continuous and pulsed Doppler testing, frequency profile analysis, oculoplethysmography), and imaging methods (ultrasonic and real-time echotomography imaging). We believe that the best results can be obtained by associating frequency profile analysis with real-time echotomography or Doppler testing with real-time echotomography. The choice between these combined modalities is determined by the clinical context and particularly whether the patient is symptomatic or not. Angiography and therapeutic strategy may be indicated either immediately after a Doppler test or after more extensive examination.

Blood Flow Velocity↗

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Influence of the haemodynamic parameters on the repartition of the flow between an artery and its graft.

The aim of this study was to investigate the repartition of the flow between an artery and its graft for several values of the geometric and dynamic parameters (length and severity of the stenosis, Reynolds number and frequency pulse value). The model, fabricated in silicone, was included in an hydrodynamic test bench, allowing to reproduce physiological conditions. Our study showed that the severity of the stenosis was the most influent parameter on the repartition of the flow; in particular, a 75% severity was necessary to obtain a repartition 70-30% between the graft and the artery.

Arterial Occlusive Diseases↗

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[Indications of intraluminal shunt. In carotid surgery].

The essential clamping during carotid artery surgery requires different procedures for cerebral protection. Most surgeons prefer the use of an intra-luminal shunt allowing conservation of a part of the proximal carotid artery. A study was conducted to compare two statistically similar series of 50 patients (with a residual pressure of less than 50 mmHg) treated or not by intra-luminal shunts. Results showed a significant difference with respect to early postoperative neurologic accidents between the groups operated without (8% accidents) and with (0%) shunts. Precise indications for the use of this procedure are discussed in relation to pre- and peri-operative findings, with the aim of reducing the incidence of postoperative neurologic complications.

Aged↗

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Carotid stenosis. Surgery after 75 years.

Is it reasonable and useful to perform surgery on carotid lesions after 75 years? ("old man" according to the W.H.O. classification). To answer this question, we re-examined 66 patients aged 75 to 87 years, who underwent 76 carotid thromboendarteriectomies with one post-operative death. The results study showed that morbidity and general complications were not more important than in younger patients. Late results from 2 to 94 months showed a very low percentage of secondary neurologic complications even if patients had a vascular or general surgical intervention in a second period: 13 cases. There were only 2 re-stenoses. Indications were defined, but it was above all the asymptomatic patients or patients who had a TIA who could benefit from them.

Age Factors↗

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[The subclavio-subclavian bypass].

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Aged↗

PubMedDate not supplied

[Hypoplasia of the abdominal aorta. Apropos of 4 surgical cases].

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Adult↗

PubMedDate not supplied

Evaluation of effectiveness of lumbar sympathectomy by non invasive diagnostic techniques.

Out of a total of more than 1,200 patients in whom lumbar sympathectomy was carried out, two groups of 96 and 50 consecutive and non selected patients were evaluated before and after the operation by non invasive physiologic tests (digital plethysmography, post-occlusive reactive hyperemia, segmental blood pressure at rest and after exercise, Strandness test). Results were compared with angiography and clinical data. The statistical study of results corroborates the following points. 1. Lumbar sympathectomy is essentially effective in atherosclerotic arterial disease, but much less so in diabetic patients and in cases of widespread disease. 2. Patients with obstructive disease of the femoral artery had more improvement (t = 4.25) than patients with obstruction of peripheral arteries (t = 2.4). 3. Walking time was significantly improved after sympathectomy (p = 0.02). 4. Only one parameter, rheographic quotient Rq was statistically improved (p = 0.01). 5. The post occlusive reactive hyperemia test is a good method to predict the results of lumbar sympathectomy (correlation r = 0.22). We feel that this operation is indicated in cases of: isolated obstruction of the femoral artery with claudication superior to 200 meters, reconstruction with an associated obstruction of the superficial femoral artery.

Aged↗

PubMedDate not supplied

Surgical treatment of bilateral carotid artery lesions.

Sixty-eight patients (7.1% of all cases) underwent bilateral carotid thrombo-endarterectomy, with one peroperative death due to permanent vascular cerebral ischemia. Two patients were re-operated (saphenous vein) for a thrombosis which had given rise to a totally regressive transient ischemia. The usual surgical technique was not modified for bilateral lesions, and the follow-up was similar. The evolutive risk of bilateral lesions was higher than that for isolated lesions as the risk of an accident after unilateral surgery in bilateral cases remained higher. As regards the surgical technique, we did not observe significant differences between the stump pressures according to the side operated. A one-week interval between the two surgical stages seems necessary and sufficient. Operative indications are studied except in cases of bilateral lesions which are asymptomatic or with former TIA, where surgery is considered mandatory.

Aged↗