Frédéric Gigou

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.

Arterial complications of the thoracic outlet syndrome: Fifty-five operative cases

Between January 1, 1969, and December 31, 1984, 55 operative procedures were carried out in 47 patients to correct subclavian-axillary artery lesions resulting from compression at the thoracic outlet. The most common causes of compression were a long cervical rib (27) and an anomalous first rib (15). Presenting features included claudication, vasomotor phenomena, digital gangrene, and acute limb-threatening ischemia. A combined supraclavicular and infraclavicular approach was preferred. Decompression was best achieved by excision of the cervical rib and the first rib and division of all soft tissue elements. The most common methods of arterial repair were resection-anastomosis (23) and replacement of vein graft (11). Embolic occlusions were frequently present (35). Axillary emboli were amenable to direct revascularization at the time of subclavian artery repair. If possible, more-distal embolic occlusions were managed without recourse to embolectomy catheter manipulations. The mean follow-up was 5 years 8 months (range 4 months to 16 years). Patients were assessed clinically, and the arterial repair was monitored by Doppler ultrasonography, B-mode scanning, and digital subtraction angiography. Of the 39 patients available for follow-up, 35 had no symptoms and four had residual claudication. There were no amputations. In the remaining cases the subclavian-axillary artery segment showed no hemodynamic or anatomic abnormality.

Atherosclerotic Occlusive Disease of the Superior Mesenteric Artery: Late Results of Reconstructive Surgery

Between 1975 and 1988, 103 patients underwent reconstruction of the superior mesenteric artery for atherosclerotic occlusive disease. Patients undergoing revascularization with associated mesenteric infarction were excluded. There were 89 men and 14 women whose mean age was 57.2 years. Six patients were operated on emergently for impending mesenteric infarction; six patients underwent revascularization after intestinal resection for ischemic lesions; 20 patients had typical abdominal angina; 39 patients had nonspecific abdominal symptoms, and 32 patients underwent revascularization of their superior mesenteric artery for asymptomatic lesions. Revascularization of the celiac axis and inferior mesenteric artery was associated in 36 and four cases, respectively. Four patients (4%) died postoperatively. Four early occlusions (4%) were observed. During the follow-up period (mean=69 months), 18 patients died; five patients had recurrent intestinal ischemic symptoms, four of whom died. All surviving patients underwent follow-up duplex scanning, examination, and arterial or venous digitalized angiograms in selected cases. Nine patients (9%) had anatomical abnormalities: two stenoses and seven occlusions. Failure of revascularization of the superior mesenteric artery was observed in patients with severe initial intestinal ischemia. Late complications were not statistically significantly related to the different techniques of revascularization used.

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.

Low-Molecular-Weight Heparin vs. Unfractionated Heparin in Femorodistal Reconstructive Surgery: A Multicenter Open Randomized Study

: Several clinical trials have been conducted to study the role of low-molecular-weight heparin (LMWH) in the prevention and treatment of venous thrombosis. In contrast, there have been few studies investigating LMWH in the prophylaxis in arterial thrombosis. After informed consent and institutional approval were obtained, 201 consecutive patients scheduled for femorodistal reconstructive surgery under general anesthesia were enrolled in an open randomized multicenter (n = 14) study (from November 1990 to November 1992). Immediately before arterial cross-clamping, patients were given an intravenous bolus of either enoxaparin (ENX), 75 anti-Xa IU/kg (n = 100), or unfractionated heparin (UFH), 50 IU kg (n = 101). Meanwhile the saphenous vein or a prosthetic graft was flushed with ENX (25,000 anti-Xa IU) or UFH (25,000 IU) in 250 ml of saline solution. Subsequent treatment consisted of subcutaneous administration of ENX, 75 anti-Xa IU/kg, or UFH, 150 IU kg, beginning 8 hours after the intravenous injection and then every 12 hours thereafter for 10 days. The primary end point was graft patency on day 10 +/- 2 after surgery as assessed clinically and/or by arteriography on day 10 +/- 2 and/or during reintervention or autopsy. Analysis of patients on an intention-to-treat basis (patients who received at least on injection of ENX or UFH and who had at least one end-point evaluation) showed that graft thrombosis occurred in 30 of 199 cases: eight (8%) in the ENX group and 22 (22%) in the UFH group (p = 0.009). Among the 131 patients who were evaluated by arteriography before day 12, twelve (9.1%) had graft thrombosis: four (6%) in the ENX group and eight (12.5%) in the UFH group (NS). There were no significant differences between the two groups in terms of safety--that is, there were 12 major hemorrhages in each group, and during the follow-up period five patients in the ENX group died compared to nine in the UFH group (NS). These results indicate that ENX is as safe as but more effective than UFH when used for the prevention of early graft thrombosis in patients undergoing femorodistal reconstructive surgery.

Acute Colorectal Ischemia after Aortic Surgery: Pathophysiology and Prognostic Criteria

Acute colorectal ischemia is a rare though potentially lethal complication of aortic surgery. We reviewed our recent experience with 16 cases in order to analyze its causative and prognostic factors. The incidence was 2.8%, and the inferior mesenteric artery was occluded in all cases. All patients also had severe occlusive disease of at least two of the hypogastric or deep femoral arteries. Hypoperfusion due to arterial ligation, prosthetic occlusion or embolism was responsible in half the cases. Ischemia and perfusion due to aortic cross-clamping or perioperative hemorrhage were involved in the rest of the cases. Postoperative mortality was 31%. The mortality was lower for partial, nontransmural necrosis, and for elective operations. Recurrent intestinal ischemia, transmural necrosis, surgery for ruptured aneurysm, intestinal hemorrhage and pulmonary edema were associated with a higher mortality rate. All patients with anuria or extrarenal epuration and hepatic cytolysis died. Although reconstruction of the inferior mesenteric artery might lessen the incidence of postoperative colonic ischemia due to hypoperfusion, the role of oxygen free radicals should be investigated in humans, in order to afford colonic protection against the consequences of ischemia-reperfusion.

Polytetrafluoroethylene Bypass for Revascularization of the Atherosclerotic Internal Carotid Artery: Late Results

Between 1979 and 1986, 60 patients underwent a total of 62 revascularizations of the internal carotid artery with an expanded polytetrafluoroethylene (ePTFE) bypass. In 54 cases, the indication for surgery was the presence of extensive lesions in both the internal and common carotid arteries and, in 8 cases, a late complication of a previous surgical procedure. There were no early postoperative deaths (within 30 days). Three patients (5%) experienced postoperative neurologic complications. Two complications resolved completely whereas one left minimal residua. The bypasses remained patent in all three cases. All patients had early postoperative Doppler B-mode ultrasonography. Two early occlusions (3.2%) were disclosed but the patients remained symptom-free. Four neurologic complications were observed over long-term (average 23 months) follow-up. None were related to the operated carotid artery. There were no cases of infection or late occlusion. No hemodynamic or morphologic anomalies were observed on late follow-up ultrasound studies. These favorable results support the use of ePTFE as a reliable substitute when adequate autologous saphenous vein is not available for carotid bypass. Routine utilization might be indicated in cases of long bypasses, especially when it is necessary to implant the bypass on the ascending aorta, or when the proximal site of implantation is made on a thickened arterial wall.

Pelvic arteriovenous fistulas: Therapeutic strategy in five cases

Pelvic arteriovenous fistulas are rare. They may be defined as arteriovenous communications developing in the pelvis from the internal iliac artery, the origin of its posterior trunk or branches of its anterior trunk. Congenital arteriovenous malformations, more common in women, and posttraumatic arteriovenous fistulas are the two main etiological forms. Diagnostic problems include appreciation of visceral extension in arteriovenous malformations and precise localization of fistulas especially when they affect the internal iliac artery itself. Therapy is aimed at complete closure of arteriovenous communications using interventional radiologic methods or surgery. Although indications are difficult to assess, complete, one-stage therapy is preferable due to surgical difficulties following failed or incomplete radiological or surgical attempts.

Renal Artery Revascularization with Polytetrafluoroethylene Bypass Graft

Between January 1979 and December 1986, a total of 74 renal revascularizations were performed in 68 patients using the reinforced expanded polytetrafluoroethylene prosthetic graft. These 74 revascularizations represent 29% of 251 surgical renal revascularizations performed during the same period of time. Eight patients had a total of nine revascularizations in the emergency setting (group I) for ruptured suprarenal aneurysm or acute thrombosis of the renal arteries. Only one patient survived and six years later, his anatomic and functional results are satisfactory. Sixty-five revascularizations were performed electively in 60 patients (group II). This group consisted of 19 renal revascularizations alone, and 46 combined aortic and renal revascularizations. One patient died of respiratory complications two months after operation after his thoracoabdominal aneurysm was cured. Early repeat postoperative arteriography showed that six reconstructions had occluded (three major renal arteries, three polar arteries). One patient was lost to follow-up. The remaining patients were followed for a mean of 41 months. Follow-up arteriograms obtained during 1987 showed that there were two late occlusions and two distal anastomotic stenoses. Actuarial patency was 85 +/- 10% at 72 months. Polytetrafluoroethylene prosthetic grafts constitute a reliable material for renal revascularization and combined aortic and renal reconstruction in certain anatomic conditions.

Curative Treatment of Pelvic Arteriovenous Malformation – An Alternative Strategy: Transvenous Intra-operative Embolisation

OBJECTIVES Pelvic arteriovenous malformations (AVMs) are difficult to treat. Arterial embolisation is the most common strategy but often has poor results. We report an alternative surgical approach of controlled intra-operative transvenous embolisation with long-term results in seven cases. MATERIALS AND METHODS Between 1980 and 2008, we treated seven patients (four men, three women, mean age 50 years). Indications were rectal bleeding (one case), urinary tract problems (four cases), oedema of lower limb (one case) and high-output cardiac failure (one case). Four of them had previous operations and three had previous attempts for embolisation. Embolisation of the malformation was performed through the internal iliac vein. This was done after clamping of all the feeding and draining vessels. The agent used was cyanocrylate (one case), Ethibloc (one case) and bone wax (five cases). RESULTS Mortality was 0%. Complications occurred in two patients (28,5%), one pulmonary embolism and one regressive femoral paresis. Three patients were re-operated for various reasons. The mean follow-up period was 6 years (1-12 years). Symptoms resolved in all patients, while control by computed tomography (CT) angioscan revealed one residual shunt. CONCLUSION Complete surgical excision of pelvic AVMs is not always possible. Embolisation does not offer a permanent cure. Intra-operative transvenous embolisation of persisting complex AVMs appears to be an alternative approach with good immediate and long-term results. Ethylene glycol appears to be the most suitable agent.