J Mal Vascul
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Case Reports
[A case of type I aortic dissection presenting as bilateral lower limb ischemia. Discussion of surgical strategy].
The authors report about one case of type I aortic dissection disclosed as bilateral lower limb ischemia. The rarity of this way of expression of dissections may result in a delay in diagnosis that can be highly pejorative in such diseases where mortality is high without surgical treatment. The timing and tactics of the surgery to be implemented between the cure of dissection and the removal of ischemia is discussed. Lastly the choice of the mode of arterial cannulation in a patient who had had an axillo-bifemoral bypass ten days earlier also makes this case interesting.
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Plasma measurement of D-dimers (DD) with the Elisa technique is very useful in the diagnostic approach of venous thromboembolic diseases: a low level of plasma D-dimers (500 micrograms/l when using the Elisa from Stago) allows to exclude the diagnosis of deep venous thrombosis or pulmonary embolism with predictive values of 94% and 98%, respectively. Such a diagnostic potential is particularly useful in the group of patients with inconclusive perfusion-ventilation scintigraphy (low or indeterminate probability of pulmonary embolism) which represent more than 50% of the patients with suspected pulmonary embolism. Presence of pulmonary embolism is suggested by levels above 4.000 micrograms/l in the collective of outpatients who are urgently referred because of clinical suspicion of embolism.
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Despite 25 years of clinical practice, concerning chronic epidural spinal cord stimulation (SCS) for pain control, the mechanisms underlying the beneficial effects are still poorly understood. The main indications for SCS are intractable chronic pain secondary to neurogenic origin (essentially neuropathies by lesion of peripheral nerve or roots) or to ischemic origin. ⋯ In peripheral vascular disease, the analgesic effect appears as the consequence of the vasodilatory effect of SCS. The actual experimental data indicate that SCS produce its influence on peripheral microcirculation via a transitory suppression of the sympathetic vasoconstrictor control.
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Review Case Reports
[Chylothorax and chylous ascites following surgery of an inflammatory aortic aneurysm. Case report with review of the literature].
Chylous ascites complicating surgery on the abdominal aorta is infrequent: we report one case associated with right chylothorax, secondary to the surgical cure of an inflammatory aortic aneurysm. Surgery for aneurysms causes 81% of all chylous ascites caused by injuries to the intestinal lymphatics or to their recipients, the left latero-aortic lymph nodes or the cisterna chyli. Upper or extensive dissections of the retroperitoneal space and difficult dissection of ruptured or inflammatory aneurysms are the cisterna chyli. ⋯ An early diagnosis must be established with paracentesis before any compressive, metabolic, immunological or septic complications occur. Continuous parenteral feeding and selective paracenteses dry out 80% of the postoperative chylous ascites. If the ascites persists after 4 to 6 week's conservative treatment, a peritoneojugular derivation or a direct lymphostasis may be contemplated, according to the patient's condition.
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Between 1973 and 1988, 200 patients underwent repair of unruptured aortic aneurysm located distal to the renal arteries. There were 181 men (90%) and the mean age was 68.8 years. The most serious associated disease was arteriosclerotic heart disease which was present in 102 patients (51%): 48 patients had angina pectoris; 59 patients had previous myocardial infarct; 8 patients had ischemic myocardiopathy. Associated cerebrovascular disease was found in 29 patients (15%). Of these 200 patients, 36% had no symptoms relating to the aneurysm. The aneurysm was associated with iliac aneurysm (19%), iliac occlusion (14%), distant femoral occlusion (14%). In patients with history of coronary arteries disease (102), 39 (18%) had a coronary angiography prior the elective resection, 18 (9%) coronary artery bypass surgery underwent elective myocardial revascularisation prior to elective resection of their aneurysm. The treatment was by graft replacement and exclusively by graft inclusion. ⋯ Young (15) and associates reported an operative mortality rate of 6.3% for elective aneurysm resection but found that 20% of the patients with pre-operative evidence of coronary artery disease had post-operative myocardial infarct of which 58% were fatal. Hertzer and colleagues (6), using routine coronary angiography prior to elective aortic reconstruction, have documented a 59% incidence of significant anatomic coronary artery disease. This incidence increased to 95% in patients with abdominal aortic aneurysm and suspected coronary artery disease. Only one patient of the 68 patients with an abdominal aortic aneurysm had normal coronary arteries in their series. Thus, considering the omnious implications of coronary artery disease in patients with abdominal aortic aneurysms, routine preoperative coronary angiography has been recommended. For Brown and coll. (1), it would appear that the risk of prophylactic coronary artery revascularisation may be greater than that for elective abdominal aortic aneurysm resection alone in the older age group. For the authors, only patients which instable angina pectoris or angina pectoris with a myocardial infarct had a coronary angiography. The coronary artery bypass is recommended for left maintrunk obstruction or diffuse multivessel coronary artery disease.