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A 54 year old woman with isolated stenosis of the left coronary ostium died following cardiac catheterisation and emergency coronary artery bypass surgery. Histological examination showed the ostial narrowing to be a local and discrete plaque of atherosclerosis. Like most reported cases this patient was a young woman whose disease pursued an aggressive course.
In addition to its diagnostic value, endoscopic catheterisation of the papilla may be used for the therapeutic purpose of diathermy incision of the papilla and of the intraduodenal portion of the common bile duct. Endoscopic sphincterotomy of this type has been essentially used in choletithiasis and in particular for residual lithiasis. These indications may be widened to include benign stenosis of the sphincter of Oddi, tumours of the ampulla of Vater or even acute pancreatitis. In a total of 362 cases, sphincterotomy was successful in 347 patients, it being possible to remove the calculi present in 279 of the 309 patients treated with success for lithiasis of the common bile duct. Complications occur in approximately 10% of cases, being fatal in 1.4% of cases. These are essentially related to bleeding. Retrospective comparison of mortality after surgical operation and after endoscopic sphincterotomy is in favour of the latter, provided the technique employed is perfect and the indication clearly defined. Performed without general anaesthesia, endoscopic sphincterotomy is above all indicated in the elderly and/or those with other major pathology who can be successfully treated with reduced risk in 93% of cases, as shown by the 140 personal cases of the authors cured between 6 and 36 months ago.
Atherectomy is a new therapeutic intervention for the treatment of peripheral arterial disease, and permits the controlled excision and retrieval of portions of stenosing lesions. The gross and light microscopic features of 218 peripheral arterial stenoses resected from 100 patients by atherectomy were studied. One hundred seventy of these lesions were primary stenoses and 48 were restenoses subsequent to prior angioplasty or atherectomy. Microscopically, primary stenoses were composed of atherosclerotic plaque (150 lesions), fibrous intimal thickening (15 lesions) or thrombus alone (5 lesions). Atherosclerotic plaques had a variable morphology and, in one-third of cases, were accompanied by abundant surface thrombus that probably added to the severity of stenosis. Most patients with fibrous intimal thickening or thrombus alone had typical atherosclerotic plaque removed elsewhere from within the same artery. Intimal hyperplasia, with or without underlying residual plaque, was found at 36 sites of restenosis, the remaining 12 consisting of plaque only. Intimal hyperplasia had a distinctive histologic appearance and was due to smooth muscle cell proliferation within a loosely fibrous stroma. Superimposed thrombus may have contributed to arterial narrowing in 25% of hyperplastic and 8% of atherosclerotic restenoses (p = 0.41). Pathologic examination of tissues recovered by peripheral atherectomy is an important adjunct that may provide insight into the efficacy of vascular interventions and the phenomenon of postintervention restenosis.
A comprehensive review of 188 spinal computed tomography (CT) scans done over a 9-month period was performed to establish both the shortcomings and applications of the technique. The value of intrathecal enhancement was reviewed in an attempt to establish indications for its use. The data base comprised 51 abnormal scans including cases of spinal trauma, dysraphism, intra- and extraspinal neoplasm, and spinal stenosis. Results indicate that: (1) the introduction of intrathecal contrast media greatly extends the morphologic capabilities of spinal CT in practically all cases where altered anatomy of the spinal canal and its contents is suspected; (2) conventional screening procedures such as plain films of the spine and myelography should be obtained prior to spinal CT in most cases because of their value in defining the location and longitudinal extent of the pathologic process; (3) spinal CT examinations tailored to specific areas of interest result in better characterization of traumatic, dysraphic, and stenotic conditions conceivably leading to better surgical management and more accurate prognosis. At present, spinal CT has its greatest diagnostic usefulness in the evaluation of trauma and its sequela.
Correlated pathological and myelographic observations suggest that the combined types of lumbar spinal stenosis appear to be the most common. The posterior articular processes play the greatest part in producing narrowing--the inferior facet narrowing the central canal and the superior facet narrowing the nerve root canal.
Fluid filled oculoplethysmography (OPG) is a widely used method of assessing carotid stenosis but it has limitations in the detection of bilateral internal carotid artery lesions and of external carotid artery stenoses. In this study, 157 consecutive patients having carotid angiography and fluid filled OPG were assessed to determine the accuracy of the technique and define the sources of error. Haemodynamically significant stenosis (HDS) was defined as at least 50% stenosis of the internal carotid artery (ICA). Only the most severely stenosed side of the 35 bilateral HDS lesions was detected owing to the poor reliability of ear pulse delays. Eye/eye delays alone detected the most severely stenosed side in 82 of 98 patients with an HDS stenosis of one or both ICAs for a sensitivity of 84% a specificity of 71% (41/59) and accuracy of 79% (81/157). The measurement of ear/ear pulse delays for external carotid artery (ECA) stenosis had a sensitivity of only 15% (5/34). Ear/eye pulse delays detected none of the 35 patients with bilateral HDS ICA stenosis. Bilateral equal HDS ICA stenoses were a significant source of error. Stenotic disease was present in the aortic arch and branches (five patients) or the carotid siphon (eight patients) and in seven cases it resulted in an incorrect localization on OPG. There was no diagnostic relationship between the severity of delay and the presence of total occlusion. Chronic local eye pathology was present in 13 patients and did not affect the results of the OPG. We have ceased to use ear pulse measurements for routine assessment but continue to use the eye/eye delays in conjunction with a carotid doppler imaging system.
Extracranial vertebrobasilar artery thrombo-occlusive disease may cause repetitive transient ischemic episodes and, less frequently, brain-stem or cerebellar infarction. This report describes 40 patients who experienced repetitive vertebrobasilar ischemic symptoms despite maximal medical therapy. The natural history, pathogenesis, and treatment options for each causative lesion are reviewed. The operative approaches to symptomatic disease of the proximal vertebral arteries, arterial compression by cervical osteophytes, traumatic lesions of the vertebral arteries, and thrombo-occlusive pathology of the distal extracranial vertebral arteries are outlined. Specific anesthetic and surgical techniques that have proved successful while achieving zero operative mortality and low perioperative morbidity rates are reported.
This study was carried out on 49 patients who underwent an ultrasound study by continuous Doppler and echotomography B real-time, an angiography of supra-aortic arteries, and a carotid endarterectomy. Thirteen had had transient ischemic attacks and 20 a stroke. A quantification of the carotid stenosis in 4 stages was established for each method. For detection of lesion an excellent correlation was observed between the results of echotomography and pathology. For the quantification of lesion the correlation between echotomography and pathology was excellent also in 79,7 p. 100 of the cases, discordant in 20,3 p. 100. It was similar to the correlation between arteriography and pathology (excellent in 83 p. 100 of the cases). The correlation with pathology enabled to distinguish for stages of atherosclerotic lesions, to clarify their type of complications, and to evaluate their functional significance, particularly those with a high risk of embolism.
Morphometrical examinations of 265 normally formed hearts collected at autopsies of infants under 2 years of age were used as a control of the heart weight and size of the pulmonary trunk and aorta. The time of anatomical closing of the arterial duct and oval window were established. Comparisons of the results of morphometry of normal and 173 malformed hearts with the tabulated data were used to develop objective criteria for pathological diagnosis of congenital heart diseases: open arterial duct and centrally located defect of the interatrial septum in infants dying within the first two months of life. The criteria for the detection of marginal forms of stenosis of the pulmonary trunk ostium and isolated coarctation of the aortal isthmus were established.
In this study, the author reports on the pathological aspect in seven cases of "entrapped" popliteal artery. Alterations observed were similar to arteriosclerotic changes. The pathologic aspect is not specific. The physiopathogenic mechanism of this arteriopathy is similar to that of the chronic vascular compression syndrome due to pre-existing anatomic abnormalities, such as the thoraco-brachial outlet syndrome of the subclavian artery. Chronic compression of the popliteal artery is considered as a localized microtrauma of the arterial wall.
A complex examination of 76 patients subjected to choledochoduodenostomy has shown that unsatisfactory results of the operation were due to various pathological alterations of anatomical structures and the created anastomosis. The state of distal parts of the cholangiopancreatic system should be necessarily studied by means of endoscopic pancreaticocholangiography when investigating the reasons of unsatisfactory results of choledochoduodenostomy.
After cholecystectomy reoperations are required in 7%. A reoperation in indicated by pathologic alterations overlooked at the first operation, not working biliodigestive anastomoses and injuries to the common bile duct. 138 reoperations of the bile duct wer performed within 4 years which were aimed at reconstructing the normal bile duct anatomy. Mortality rate 8,7%.
The aim of the study was to evaluate the clinical usefulness of transesophageal echocardiography in the imaging of the left main coronary artery. The group tested--consisted of 26 patients with angina pectoris and 8 controls. The identification and adequate images of the left main coronary artery were obtained in 33 of 34 (97%) patients. In 5 of 26 patients with angina pectoris we observed stenosis of the left main coronary artery. The diameter stenosis of the lesion was judged to be greater than 50%. In addition, we tried to asses Doppler-derived parameters of blood flow. We have demonstrated that the pulsed Doppler study of the left main coronary artery is feasible. Comparison of patients with angina pectoris with the control group showed lower systolic flow velocities (35 +/- 10 cm/s vs. 55 +/- 15 cm/s) and slightly higher diastolic flow velocities (75 +/- 20 cm/s vs. 70 +/- 10 cm/s). This transesophageal examination holds promise for detecting pathologic vascular status. Although the sensitivity and specificity of this findings cannot be determined by our study, we believe that transesophageal echocardiography can provide a reference for the evaluation of patients with known or suspected ischemic heart disease. Further studies including larger groups of patients are recommended.
The popliteal fossa is a relatively small, muscle-bound strategic anatomical area where is found, on the posterior aspect of the knee, a vasculonervous pedicle and where both vascular and pseudovascular disease may develop, the latter originating from wall-constituting parts. Among non-typical popliteal diseases, the authors have singled out four rare syndromes. The popliteal vein may be trapped due to fibrous strangulation or, more often, to compression by the hypertrophied gastrocnemius muscle. This requires proper diagnosis and surgical management prior to thrombosis onset. Synovial cysts raise no diagnostic problems, unless they mimic an episode of phlebitis; echotomography has now become essential for diagnosis. Desmoid tumors for which predominant extra-abdominal occurrence sites are the popliteal fossa, the leg and thigh, are difficult to excise completely, especially at the popliteal level, and are a major technical challenge because of the inclusion of the vasculonervous pedicle. Lastly, in sports pathology, one must be able to recognize the painful fabella syndrome (osteochondritis of sesamoid fibrocartilage in lateral head of gastrocnemius), so as not to mistakenly implicate vascular disease. New developments in imaging (namely, real time CT-echography) are of major help to clinicists, who should, nonetheless, remain chiefly responsible for detecting these diseases.
This report describes a rare case of bronchial mucosal injury caused by aspiration of a delayed-iron tablet. A 44-year-old woman had been taking delayed-iron tablets (Feto-Gradumet) regularly because of iron deficiency anemia, and accidentally aspirated a tablet into her bronchus. After this accident, she had complained of wheezing and shortness of breath. On bronchoscopy, the bronchial mucosa of left lower lobe initially showed remarkable swelling and redness, and became corroded and narrowed gradually by iron toxicity over several months, although we tried to remove some fragments of tablet as completely as possible. While we had examined her bronchi repeatedly by bronchoscopy, the bronchial mucosa gradually normalized during 15 months, but moderate stenosis of the left basal bronchus remained. The pathological findings showed infiltration of inflammatory cells, edema and granuloma formation in the submucosal region. This report suggests that the bronchial injury was due to the toxicity of persistent ferrous sulfate eluted from the iron tablet which had adhered firmly to the wet bronchial wall for a long time.
In two patients in whom most of the bile and the pancreatic juice were mixed, one within the pancreatic duct because of a presumed injury to the ampulla of Vater and the other within the bile duct secondary to a tumor of the ampulla of Vater, there was no pathologic evidence of acute pancreatitis within the pancreas. This was true even though there was chemical evidence that trypsin in its active form passed through the pancreas. On explanation for this is that trypsin inhibitors contained in human bile and pancreatic juice may bind trypsin.
The chest roentgenograms of 691 normal, arteriosclerotic and hypertensive patients have been reviewed for measurements of the aortic knob. There is a significant correlation between the width of the aorta and age, but no such correlation was found with the degree of hypertension. The comparison between average widths of the aorta in the 3 categories of subjects has shown its increase in arteriosclerotic and hypertensive patients.
The enteric coated KCl tablet formulation generates complications that affect selectively the small intestine. A novel 1 g KCl tablet preparation proved to be accountable for the development of a specific type of intestinal disease. 11 cases of stenotic ulcers of the proximal ileum have been treated at the Clinique chirurgicale "C" (CHRU, Nancy) since January 1986, 9 of them presenting with perforations. These 11 patients required potassium replacement, which was being supplied by the same tablet formula. A study of these 11 cases focusing on the patients history and clinical characteristics was carried out, that included both macroscopic and microscopic examinations of the lesions. Arterial and venous networks were visualized by X-ray in two surgical tissue specimens, respectively, following injection of contrast material. The authors were thus able to bring forth evidence of the clinical uniqueness (prodromal pain reminiscent of König's syndrome and peritonitis characterized by asthenia); to identify the main risk factor (i.e., reduced bowel movement); as well as describe the basic lesion (pylorus-like stenosis), and propound a novel theory concerning the etiology and the pathology of this condition. The observation of the aforementioned cases initiated a nation-wide, post-marketing pharmacological survey, which resulted, as did a similar investigation which had been carried out in the States, in the discontinuation of any treatment by this type of galenic form of the product.