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Biomedical subjects

J M Fichelle

Publications and source records attributed to J M Fichelle.

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

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

[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↗
PubMed1993

[Fifty-three atherosclerotic carotid stenoses in an irradiated environment].

Fifty-three atheromatous carotid stenosis in a previously irradiated zone were operated upon between January 1983 and December 1991. A case control (retrospective) study confirmed the reality, even within the context of multiple artery atheromatous localizations, of an atypical profile suggestive of incrimination of the radiation: extension of the atheromatous lesions distally in the common carotid, proximally beyond the bulb. An isolated atheromatous lesion in the common carotid is very suggestive of postradiation atheroma, which also presents specific histologic features: peri-adventitial inflammation, adventitial and medial sclerosis. These changes are not accompanied by any particular neurologic clinical manifestations, but require frequent changes in surgical strategy: bypass rather than endarterectomy; the extent of the lesions decides whether the proximal implantation of the bypass is in the lower part of the common carotid or the subclavian. Radiotherapy adds to the difficulty of dissection and provokes a slight increase in morbidity, but the long term prognosis is analogous to that of usual atheromatous lesions with, however, the risk of atherosclerotic changes proximally.

Adult↗
PubMed1993

[Foot equipment of diabetic arteriopathy].

Surgical appliances have a place of choice in the care of the foot with trophic lesions in diabetics, after partial amputation and as a preventive measure when it is free from trophic disorders. The type of appliance will depend on the footwear and the possibility of wearing orthopedic soles, whatever the stage of the affection. For the foot free from trophic disorders the shoes should be wide fitting, in soft leather and of the seamless type. Made to measure shoes should be reserved for badly deformed feet. The soles should be molded in silicone or polyurethane to distribute weight bearing and to avoid it over zones at risk. Appliances for the foot with trophic lesions should allow the resumption of walking. If the lesions are too extensive an orthosis is performed or a specific type of slipper with molded soles is worn to avoid pressure on the wounds. After amputation of toes a silicone orthoplasty is used to fill the interdigital space to avoid deformity of the other toes. If a front of foot has been amputated a corrected silicone molded sole with false extremity is applied. For a back of foot amputation an orthoprosthesis is made, preferentially in silicone introductible in a regular high sided shoe. In order to fulfil its preventive or temporary role, the appliance should evolve with time and be followed up regularly with close collaboration between the diabetic specialist the podologist and the orthotist.

Amputation, Surgical↗
PubMed1992

[Femoro-distal revascularization for "critical" chronic atheromatous ischemia. 695 cases].

The results of the revascularizations carried out over a 10-year period for "critical" chronic ischaemia, using the femoropopliteal bypass technique, have been retrospectively analyzed. In all, 600 patients underwent femoro-distal revascularization in 644 limbs, and 695 bypasses were performed. The hospital mortality rate was 4.3 percent. Among these 695 bypasses, postoperative occlusion occurred in 16.5 percent of the cases, and major amputations were necessary in 9.8 percent. The probability of 5-year survival was 47 percent. The probabilities of bypass patency and limb salvage were 50 and 76 percent respectively. The failure of revascularization ending in amputation did not significantly increase the postoperative mortality rate (4.1 percent versus 4.6 percent), but the life expectancy of patients who were amputated was significantly lower than that of patients who were not (55 +/- 5 percent versus 63 +/- 3 percent at 3 years; P = 0.03). The factors predictive of successful bypass were examined; they included age, clinical stage, diabetes, bypass material, site of distal implantation, revascularization procedure and reoperation. Femoro-distal revascularization makes it possible to cope with the challenge of limb salvage, even when the receiving vessel is an artery of the foot.

Aged↗
PubMed1992

Renal revascularization in high-risk patients: the role of iliac renal bypass.

Between 1984 and 1989, 29 iliac renal artery bypasses were performed in 29 patients (mean age 67.8 years) with severe renovascular disease due to atheroma. The indication for renal artery reconstruction was hypertension in all patients, which was associated with kidney failure in 16 cases. In six cases, reconstruction was performed after failure or complications of percutaneous transluminal angioplasty. The bypass was constructed with polytetrafluoroethylene in 24 cases (83%) and vein graft in five cases (17%). There was no postoperative mortality. All bypasses were found to be patent on duplex scanning or digital subtraction arteriograms. One patient was lost to follow-up. Mean follow-up was 23.2 months. One patient died of acute kidney failure, probably related to occlusion of the bypass. Hypertension improved in 22 cases (79%), was cured in two cases (7%), and remained unchanged in four (14%). Renal function remained unchanged in six cases (40%) and improved in nine (60%). Iliac-to-renal artery bypass seems to be the surgical renal revascularization modality best adapted to high-risk patients or those who have severe atheroma. Additionally, this technique enables rapid treatment of failures or complications of percutaneous transluminal angioplasty of the renal artery.

Aged↗
PubMed1992

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.

Acute Disease↗
PubMed1992

[Erythroderma induced by teicoplanin].

We report the case of a 38-year old man who developed erythroderma during treatment with teicoplanin for staphylococcal septicaemia. The clinical symptoms, which included high fever, shock and erythroderma, were suggestive of staphylococcal toxic shock. After teicoplanin was withdrawn and replaced by vancomycin the disease followed a favourable course. The reintroduction test was positive. This case illustrates the problems associated with the diagnosis of erythroderma in intensive care patients and confirms that it is possible to prescribe vancomycin in cases with allergic reaction to teicoplanin.

Adult↗
PubMed1992

[Results of ambulatory and hemodynamic treatment of venous insufficiency (CHIVA cure)].

From January 1987 to December 1988, 100 conservative and hemodynamic treatments of superficial venous insufficiency in great saphenous vein territory, have been done on 86 patients. They were 32 men, whose mean age was 53.7 years, and 54 women, whose mean age was 44.5 years. Indication for surgery was mainly functional in 28 cases, esthetic in 26 cases, both in 25 cases and trophic problems in 21 cases. Ligation of the sapheno-femoral junction has been done in 91 cases (62 clips, 9 clips and ligations, 11 ligations, 9 sutures). Distal interruption has been done above knee in 24 cases, below knee in 50 cases, and both in 16 cases. Early postoperative complications have been one septic collection of the groin, one hematoma of the groin, one durable contusion of the saphenous nerve, and 21 superficial venous thrombosis. There were six thrombosis of excluded branches, seven subtotal thrombosis of the saphenous and height partial thrombosis of the saphenous vein. Subtotal thrombosis of the saphenous vein were due either to a mistake in position of distal ligation in three cases, either to a too large saphenous vein in four cases. Five out of height partial thrombosis occurred on saphenous veins larger than ten millimeters. Follow up was obtained, in 1990, so that all patients had at least one year of follow-up. Seven patients have been lost for follow-up. Three patients had recurrence because of failure of the clip. An additional procedure was necessary in 30 patients. Functional results were correct in 89% of patients, and esthetical results in 68% of patients.

Adult↗
PubMed1991

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.

Adult↗
PubMed1990

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.

Adult↗