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To describe the surgical anatomy of the femoral tripod arteries and their anatomical variants.Patients who underwent vascular surgery by external arciform approach of the Scarpa between May 2022 and July 2022 were selected. The surgical anatomy was assessed by direct observation. The origin and the course of major branches of the femoral artery (FA) were studied. Diameters and the distance of the origin of the femoral profunda artery (FPA) from the midpoint of the inguinal ligament was measured in millimeters and recorded. The observed anatomical variations were photographed and compared to those in the literature.A total of 40 patients (34 men, 85%) were included. The median diameter of the common femoral artery (CFA) was 9mm (IQR: 7-12mm). The Modal bifurcation was noted in 95% of cases. The collateral branches of the CFA were found to be distributed as follows: the superficial circumflex iliac artery (SCIA) in 34 cases (85%), the superficial epigastric artery (SEA) in 22 cases (55%), the deep external pudic artery in 16 cases (40%), and the superficial external pudic artery in 18 cases (45%). The median diameter of the FPA was 5mm (IQR: 4-6mm). The FPA originated from the posterolateral side of the CFA in 90% of cases, from the posterior side in 5% of cases and from the medial side in 5% of cases. The median diameter of the SFA was 6mm (IQR: 4-9mm).The anatomic variants of the femoral tripod arteries are extremely frequent. Therefore, it is important to recognize the anatomy in order to avoid possible diagnostic errors and to minimize the risk of per and post procedural complications.

Funding Acknowledgements Type of funding sources: None. Introduction Directly observed supervision with video recording (DOSVR) is used as a learning method in several countries. This technique has proven itself, but remains little used in Tunisia. On the other hand, the use of DOSVR in surgery is rarely described. The objectives of our work were to describe the development and experimental implementation of DOSVR in surgery and to evaluate the feedback from residents and teachers. Methods This is a prospective, observational and descriptive study concerning the experimentation of DOSVR in five surgical procedures performed by residents of cardiovascular surgery department. These video recordings were followed by a backscatter with self and heteroevaluation. We based ourselves on the methodology of teaching by simulation for the design of the protocol: the Briefing, the scenario and then the debriefing. Results A total of ten took part in this experiment. The average age was 28.5 years [26 -33 years] with a sex ratio F/M of 4. All residents declared that the protocol provided was easy to understand and apply. After obtaining the consent of the patients, five interventions were filmed in whom three were in emergency. Seven residents said that using a smartphone to vdeo recording was not easy and 8 easily got rid of the presence of the camera. All the learners denied having to change their operating techniques because they were being filmed. All the residents agreed that a minimum number of six DOSVR sessions in each residency year is appropriate and praised the technique as a powerful tool for the development of their practical training. Conclusions Our study showed that the application of Directly observed supervision with video recording in vascular surgery is feasible. It is a promising educational tool for the practical learning of residents as well as a tool for the continuous formative evaluation of their progress.

Despite the success of angioplasty of the iliac artery, this technique remains associated with significant amputation rates. The purpose of this study was to identify predictive factors for lower limb amputation after iliac angioplasty in patients with critical ischemia.We reported a retrospective study including patients who successfully underwent angioplasty of the iliac artery between 2014 and 2018. The primary endpoint was limb salvage at 1 month. The variables were studied in univariate and multivariate analysis.Our study included 86 patients. The median age was 57±10 and the sex ratio was 4.7. Cardiovascular risk factors were represented by smoking in 14 cases (16.3%), diabetes in 25 cases (29.1%), arterial hypertension in 2 cases (2.3%) and dyslipidemia in 2 cases (2.3%). Seventy patients (81.3%) were classified as stage 4 according to the Leriche and Fontaine classification and 16 patients (18.7%) were classified as stage 3. The lesions were stenosing in 48 cases (55.8%) and occlusive in 38 cases (44.2%). These lesions were classified according to the TASC classification "Trans-Atlantic-Society-Consensus" in TASC A-B in 61 cases (70.9%) and TASC C-D in 35 cases (29.1%). Distal arteritis was found in 8 cases (9.3%). Balloon angioplasty was performed in 36 cases (41.8%) and angioplasty stenting in 50 cases (58.2%). At 1 month, the amputation rate was 9.3%. Univariate analysis showed that diabetes and smoking were the most important factors associated with amputation (respectively P=0.007, OR=9.31, 95% CI=[1.73-50.07] and P=0.022; OR=6.8; 95% CI=[1.46 to 31.61]). Multivariate analysis showed that diabetes and distal arteritis were the predictive factors for amputation (respectively P=0.034, OR=21.06, 95% CI=[1.25 to 354.46] and P=0.008, OR=11,61, 95% CI=[1.88 to 71.69]).Diabetes and distal arteritis are the predictive factors for lower limb amputation after iliac angioplasty.

The purpose of our study was to review the population at risk of upper limb arterial injury, to determinate the rate of upper limb salvage and the predictive factors of limb loss.This was a retrospective study, involving 128 patients with upper extremity arterial trauma operated between January first, 2006 and June 30, 2017. Exclusion criteria were arterial ligation, primary limb amputation and arterial iatrogenic injuries. End points were immediate technical success, primary patency and limb salvage rate.The average age was 27.7 years with a sex ratio M/F=41, causes of trauma were self-inflicted wounds (51%), assaults (23%), road traffic accidents (10%), work accidents (9%) and domestic accidents (7%). Injured arteries were brachial (66.5%) usually because of self-inflicted injuries; arteries of the forearm (31%) and axillery arteries (2.5%). The techniques of arterial repair were vein graft interposition in 52% of cases, end-to-end anastomosis in 23%, primary arterial repair in 21% and venous patch in 4%. Eight reconstructions occluded during the first week (6.25%). Four patients required secondary amputation and limb salvage rate was 96.8%. After a median follow-up time of 62 days, only 21% were followed at 3 months. Mechanism of injury, soft tissue loss and arterial reconstruction thromboses were selected as factors influencing the rate of limb salvage. One death occurred at day 14 secondary to multi-component poly-trauma.Prompt diagnosis, appropriate multidisciplinary management of the upper extremity arterial trauma and a readiness to revise the vascular repair early in the event of failure will maximize patient survival and upper extremity salvage. Associated soft tissue injury is a poor limb salvage factor.

The aim of this study was to evaluate the results of conservative surgical treatment of the aneurysmal complications of arteriovenous hemodialysis fistulae and to determine the factors predictive of long- and mid-term patency of treated fistulae. The surgical treatment was mainly based on caliber reduction and reconstruction.This was a descriptive retrospective study with a five-year duration, going from January 2013 to December 2018. This study included 40 patients presenting aneurysmal complications of their hemodialysis vascular access who were treated with aneurysmorrhaphy.The mean age of the aneurysmal-complicated hemodialysis vascular access was 42 months. The indications for treatment were puncture-related difficulties in 42.5% of cases, rapid increase of the aneurysmal diameter in 27.5%, skin thinning in 25% and aneurysmal rupture in 5%. The mean aneurysmal course was 6.6 months with an average diameter of 3.25cm at the moment of management. The initial technical success rate was 100%. Twenty patients had complications in the postoperative period. Patency rates at 3, 6, 12 and 24 months were 89.5%, 81.6%, 71% and 63.1%, respectively. Factors predictive of thrombosis were diabetes (P=0.001), peripheral arterial disease (P=0.003), number of punctures per week (P=0.003) and context of emergency presentation (P=0.001).Aneurysmorrhaphy seems to be the best conservative surgical treatment for aneurysmal complications of hemodialysis vascular access fistulae. This surgical approach allows us to conserve the native autologous vascular access and spare the patient's venous network.

Atherosclerosis occurring in the digestive arteries is rare and often asymptomatic. When it becomes symptomatic, surgical care is indicated. Conventional procedures are giving way to improved endovascular techniques applied to the mesenteric arteries. The aim of this single-center study was to evaluate short- and mid-term outcome after endovascular revascularization of the mesenteric arteries.We report a retrospective study about patients who underwent endovascular treatment of chronic mesenteric ischemia between 2013 and 2018.Our population consisted of 10 patients. The average age was 60 years [range 45-78]. Clinical symptomatology associated abdominal pain and weight loss. All patients underwent computed tomographic angiography (CTA). Severe stenosis (70%) involved the superior mesenteric artery (SMA) in ten cases, the celiac trunk in four cases and the inferior mesenteric artery in three. The procedure was performed under local anesthesia in all cases. The superior mesenteric artery was revascularized in all cases and the celiac trunk in two. Transluminal angioplasty was followed by deployment of a stent in all cases. The postoperative course was satisfactory. Outcome was good with all patients being symptom-free at one month. Our average follow-up was three years [range 1-5]. All patients underwent a Duplex ultrasound every six months. Recurrence of symptomatology was reported in two patients at 18 months and 24 months. The first patient underwent CTA that showed superior mesenteric artery and celiac trunk stent stenosis. The patient underwent a second transluminal angioplasty with a drug eluting balloon. The second patient was admitted to the emergency room for acute mesenteric ischemia related to acute thrombosis of the superior mesenteric artery stent. Laparotomy enabled extensive resection of the small bowel and aorto-mesenteric venous antegrade bypass, but the patient died the same day.Endovascular treatment has an important role to play in the management of chronic mesenteric ischemia. It is associated with a high rate of technical success. Patients should be carefully followed-up because of the mid-term risk of recurrent symptoms associated with intra-stent restenosis or thrombosis.

Renal artery stenosis (RAS) may be symptomatic. The treatment of these lesions is primarily medical but may sometimes require surgical or endovascular revascularization. RAS angioplasty is well controlled but its results are discussed. The objective of this work was to report the short- and long-term results of the endovascular treatment of renal arteries in our center.We report a retrospective study between 2013 and 2018, including patients who received endovascular treatment for severe symptomatic RAS (≥75%).Our population consisted of 17 patients. Mean age was 51.1 years [18-76], sex ratio 2.4. RAS was discovered during work-up for severe renovascular hypertension resistant to medical treatment for 16 patients and rapidly progressive renal failure for one patient. The etiology retained was: atherosclerosis (9 cases), fibromuscular dysplasia (6 cases) and Takayasu's disease (2 cases). The average stenosis rate was 85.9% [75-97%]. We performed simple angioplasty in 47% of the cases and stenting in 53%. The technical success rate was 100%. At 1 month, morbidity-mortality rates were zero. Mean follow-up was 12 months [6-36 months]. Patients with renovascular hypertension experienced a decrease in blood pressure, with discontinuation of antihypertensive therapy in 62.5% of cases and reduction of doses in 37.5% of cases. The permeability rate was 100% at 1 year, 94% at 2 years and 94% at 3 years. One patient had asymptomatic stent thrombosis at the 18th month. The restenosis rate was zero.Angioplasty of symptomatic RAS may be indicated as first-line treatment. It is associated with satisfactory results in the short and long terms.

The popliteal artery aneurysm (PAA) is a rare vascular disease, but represents the most common site of peripheral aneurysms. We report in this paper our experience in the surgical management of PAA.The aim of this work was to clarify the indications and the results of the surgical management of PAA.It was a retrospective study, extended over a period of 12years, going from 2007 to 2018, covering 26 patients operated on surgically for popliteal aneurysm.We have operated 26 patients for PAA. All patients were male. The average age was 59years [39-80years]. The aneurysm was symptomatic in 22 cases and asymptomatic in 4 cases. The mean aneurysm diameter was 37mm [26-70mm]. Twenty-two patients have received a planned surgery and we did emergency surgery for 4 patients because of a limb ischemia complication. The surgical treatment consisted in a surgical bypass after the aneurysm removing. The restoration of blood continuity was achieved by a vein graft in 23 cases and prosthetic in 3 cases. Three patients needed major amputation within 30days (11.53%) and no mortality was observed during this period. Mean follow-up was 24months [12-96months]. Two-years mortality, complication rate and limb salvage was respectively 7.69%, 15.38% and 84.62%.The PAA represents a serious disease that can affect the vitality of the lower limb. Surgical treatment is currently the gold standard because of its good results.

Acute upper limb ischemia is a medical and surgical emergency. Studies that have reported revascularization results in acute upper limb ischemia are rare. For this reason, the revascularization delay has remained poorly defined. The purpose of this study was to evaluate surgery results of acute upper limb ischemia related to revascularization delay.We report a retrospective study of patients operated for acute upper limb ischemia between 2008 and 2016. Patients with thrombotic, traumatic or iatrogenic ischemia were excluded from this study. Patients were divided into two groups (those operated before 12hours and those operated after 12hours). A statistical analysis was performed to compare surgery results between the two groups in terms of limb salvage rate and neurological sequelae rate.Our population consisted of 138 patients. The average age was 69 [31,92]. There were 90 women and 48 men. The mean revascularization delay was 20hours [2,240]. Seventy-six patients were operated on before 12hours and 62 patients after 12hours. At one month, the mortality was 1.4% and the morbidity was 5.7%. The overall limb salvage rate was 86.9% and the overall neurologic sequelae rate was 31.8%. Statistical analysis showed that there was no significant difference between patients operated before or after 12hours in terms of limb salvage (86.8% versus 87%, P=0.258). However, there was a statistically significant difference in terms of neurological sequelae in favor of patients operated after 12hours (15.7% versus 51.6%, P=0.012).Revascularization of acute embolic upper limb ischemia is often associated with good results even if performed late. Beyond 12hours of ischemia, amputation rate is not significantly higher, however, the rate of neurological sequelae can be high.

Image intensification exposes the endovascular surgery staff to ionizing radiation. The aim of this study was to determine awareness of ionizing radiation risks among personnel working in the endovascular surgery environment and the availability of radiation protection clothes and to propose appropriate corrective measures.This descriptive study was performed in the endovascular operating theatre equipped with a mobile image intensifier unit in La Rabta vascular department in September 2017. We visited the endovascular theatre to identify the availability of radiation protection clothes. We used a questionnaire to identify personnel knowledge about ionizing radiation. We established a global score of knowledge to classify our population.We identified 85 professionals exposed to ionizing radiation. Sixty-four of them (75%) responded to our questionnaire; 65% were male; median age was 34 years (range: 25-61). Endovascular theatre personnel were surgeons (35%), nurses (34%), qualified technicians (18%) and other department employees (13%). The mean global score of knowledge was 8.15/20 (2-18). This score increased significantly with grade and seniority (Kruskal-Wallis test).In the present study, the results indicate insufficiency knowledge about radiation exposure among the endovascular staff and in radioprotection tools availability. In order to minimize all unnecessary radiation, attempts should be made to increase vascular theatre staff knowledge about radiation protection. Safety culture is a referral method to reduce radiation exposure as low as possible.

Introduction La formation d’anevrysmes et de faux anevrysmes (FA) sont les complications les plus redoutees des fistules arterio-veineuses (FAV). L’anevrysmorraphie represente une technique simple et efficace permettant de conserver un abord fonctionnel. L’objectif de ce travail est d’etudier les resultats du traitement chirurgical conservateur des anevrysmes sur FAV. Methodes Traitement chirurgical conservateur des anevrismes sur FAV par anevrysmoraphie avec calibrage de la veine. Nous avons mene une etude descriptive retrospective sur une duree de 5 ans, englobant 40 patients presentant des complications anevrysmales de leurs FAV et traites par anevrysmorraphie afin d’evaluer les resultats de cette technique. Resultats obtenus ou attendus Les fistules etaient humero-cephaliques avec un taux de 42,5 %, suivies par les fistules radio-cephaliques et humero-basiliques avec un âge moyen de 42 mois. L’indication operatoire a ete posee devant une difficulte de ponction (42,5 %), une augmentation rapide du diametre (27,5 %), une souffrance cutanee (25 %) ou une rupture (5 %). La duree moyenne vers l’evolution a la complication anevrysmale etait de 6,6 mois avec un diametre moyen au moment de la prise en charge de 3,25 cm. Les anevrismes etaient localise sur la partie moyenne de la veine de drainage dans 55 % des cas et la ponction inadequate etait l’etiologie principale (70 %). Le succes technique initial etait de 100 %. La duree moyenne d’hospitalisation etait de 2,35 jours. La permeabilite a 3 mois, 6 mois, 12 mois et 24 mois etait respectivement de 89,5 %, 81,6 %, 71 % et 63,1 %. Les facteurs predictifs de thrombose de la FAV apres anevrysmoraphie etaient le diabete (p = 0,001), l’arteriopathie (p = 0,003), le nombre de seances de dialyses par semaine (p = 0,003) et le contexte d’urgence (p = 0,001). Conclusion L’anevrysmorraphie est une technique simple et efficace, elle permet non seulement de conserver le caractere natif de l’abord d’hemodialyse ; d’eviter l’evolution vers la rupture mais aussi de preserver le capital veineux du patient.

Percutaneous endovascular therapy is becoming a primary option for managing femoropopliteal occlusive disease. The purpose of this study was to evaluate the mid-term results of endovascular treatment of femoropopliteal arterial disease.Femoropopliteal percutaneous transluminal angioplasty was performed on 162 consecutive limbs (160 patients) from January 2006 to January 2016.In our study, 87.6% of patients had critical limb ischemia. Lesions were classified as Trans-Atlantic Inter-Society Consensus (TASC) A (43%), B (43%), C (7%), and D (7%). Femoropopliteal interventions included angioplasty only in 70 cases (43.2%), and the remaining 92 (56.8%) received at least one stent. Technical success was achieved in 98.7% of patients, with three deaths and a major morbidity rate of 15%. The actuarial primary patency at 12 and 36 month was 65.4% and 40.2%, respectively, 33 peripheral reinterventions were performed after femoropopliteal axis occlusion, resulting in an actuarial primary limb preservation rate of 94.4 at 12 months. Comparison between angioplasty only and the use of stent show no difference in primary patency (P=0.832) and limb salvage (P=0.67). Negative predictors of primary patency determined by univariate analysis included popliteal location (P0.001) and TASC D (P0.001). However, diabetes mellitus (P=0.001) and poor run off (P0.001) were the principal predictive factors of limb loss.Femoropopliteal angioplasty can be performed with a low morbidity and mortality. Intermediate primary patency is directly related to TASC classification and popliteal localization.

Coarctation of the descending thoracic aorta is uncommon, with controversial etiology. Usually, severe hypertension is the main symptom; lower extremity claudication is less often found. Surgical management remains the standard for long coarctation and provides good results.We report three cases of coarctation of the descending aorta operated at our department of cardiovascular surgery of Hospital La Rabta between January 2012 and December 2013.The median age was 19 years and the median follow-up was 16 months. Hypertension was the most common clinical manifestation. The diagnosis was made by computed tomography angiography. Two cases were treated by an aorto-aortic bypass and one by subclavian-descending aorta bypass. Recovery was excellent, with a decrease in antihypertensive medications (four to two) and restoration of all distal pulses.Middle aortic coarctation is a rare entity. Etiologies include congenital, acquired, inflammatory and infectious causes. The condition is considered a life-threatening emergency as a result of the complications associated with severe hypertension. Depending on technical considerations, open surgical bypass remains the standard repair for mid-aortic syndrome.

Migration of an aortic stent is one of the most serious complications that can occur during follow-up after endovascular repair of an abdominal aortic aneurysm. We report the case of a 75-year-old man who underwent endovascular treatment for an infra-renal aortic aneurysm using an aorto-mono-iliac stent associated to a femoro-femoral bypass. The angiography performed at the end of procedure showed complete exclusion of the aneurysm. The postoperative course was uneventful. CT scans at 1, 6 and 12 months were normal. The CT scan at the 18th month showed a proximal migration of the stent, which was complicated by a type 1 endoleak and a stent disjunction with a type 3 endoleak. Revision surgery was indicated but the patient died from aneurismal rupture pending treatment. The migration of an aortic stent is a rare but serious complication of endovascular aneurysmal repair. Prevention requires a precise anatomical selection and adequate deployment of the stent graft.

The aim of this study was to review our experience in the management of traumatic rupture of the aortic isthmus, to evaluate the results of surgery and endovascular exclusion and to develop an adequate therapeutic strategy based on the existence and severity of associated injuries.A series of 37 patients presenting posttraumatic aortic rupture associated with other severe lesions was collected from 2000 to 2012. There were 33 males and four females, mean age 38 years. In this series, 25 patients underwent surgical treatment and 12 endovascular exclusion.Six patients died during or after surgery. Overall mortality was 16% (24% in the surgery group). The postoperative period was uneventful in all patients treated with the endovascular procedure. Postoperative computed tomography controls at one week, 1 month and 12 months showed good positioning of the stent without endoleakage.Traumatic aortic rupture is often the result of a severe high-energy chest trauma. Other serious injuries are often associated. Results of immediate surgical repair are associated with high morbidity and mortality. The advent of endovascular treatment has revolutionized the treatment of traumatic aortic rupture, especially in patients with a high surgical risk.

Aneurysm of the extracranial carotid artery is rare. The embolic risk mandates prompt intervention once diagnosed. The aim of this study was to determine therapeutic techniques, their indications and outcomes.We report a series of ten patients who underwent surgery for extracranial carotid artery aneurysm in the cardiovascular surgery department of La Rabta hospital.There were six men and four women, mean age 43 years. All patients were symptomatic (swelling and pulsatile cervical mass). Two patients had dysphonia and one patient underwent an emergency procedure because of aneurismal rupture. Aneurismal excision was performed in most patients. The arterial reconstruction was performed by end-to-end anastomosis in four cases, interposition of an autologous venous graft in four, interposition of a prosthetic graft in one and suture of a small rent in the artery in one. There was no postoperative mortality. Early postoperative morbidity included one recurrent laryngeal nerve injury, one hypoglossal nerve injury, one stroke and one infection with thrombosis of a prosthetic graft. The follow-up was uneventful.Surgical treatment of extracranial carotid aneurysms is required, in most cases with good results. Endovascular treatment may be an effective therapy in selected cases.

Ischemic heart disease is the most common etiology of aneurysms of the left ventricle. The latter can also result from trauma. We report a case of a patient operated for false aneurysm of the left ventricle revealed by dyspnea and occurring six years after a nonpenetrating chest trauma. Follow-up after surgery was good with no complication occurring. In conclusion, this lesion must be considered in case of chest trauma and can be easily detected by echocardiography or CT scan.

Cardiac myxoma is the commune cardiac tumors. Their clinical status depends in the anatomic type. The aim of this study is to evaluate our results and to compare them for literature.From January 1990 to June 2004, 20 patients (8 males and 12 females) with mean age of 49 years underwent surgical treatment of cardiac myxoma. The tumors were in left atrium in 14 cases, in right atrium in 4 cases and biatrial in 2 cases. Surgical treatment consisted in complete resection of the tumor in all cases associated with partial atrial septal resection in 9 cases.There is not death in the postoperative outcome. The mean follow up is 50 months. The late mortality rate was 10%. All patients are asymptomatic and the echocardiography control showed no tumor recurrence.Cardiac myxoma is the communist primary tumor of the heart. Diagnosis is based upon echocardiography. Surgical management has well out come with low morbidity and mortality. Late results are satisfactory but regular screening is recommended although risk of recurrence is low.

The goal of this retrospective study is to review indications and results of cross over bypasses.between January 1990 and December 2000, 60 patients (all males with mean age = 60 years) underwent cross over bypass for unilateral iliac occlusive disease: femoro-femoral in 48%, ilio-femoral in 44% and ilio-popliteal in 8%.mortality was 5% while complications occurred in 13.3%. Early limb salvage rate was 92%. During follow-up (mean: 32 months) we noticed 13 late thrombosis. The actuarial patency rate being at 83.5%, 74% and 67% at 1 year, 3 years and 5 years respectively.cross over bypasses are technically simple with low morbidity and acceptable results. In addition to widely accepted indications (general or local unfavourable conditions to approach abdominal aorta), cross over bypasses may be considered as satisfactory challenge even in young patients with how operative risk.

Between 1988 and 2001, five patients with mycotic aneurysm of the abdominal aorta underwent surgery. Extra-anatomical reconstruction with axillo-bifemoral bypass grafting was performed in all patients. The hospital mortality rate was 20%. During the follow-up period two patients presented thrombosis of the axillo-bifemoral bypass, descending aorto-bifemoral bypass was performed in one. Extra-anatomic revascularization is a satisfactory procedure in the treatment of mycotic abdominal aortic aneurysm. The results are acceptable and the prognosis is mainly related to the underlying pathology and the severity of the infection.

Subaortic stenosis is a rare congenital heart disease defined as a left ventricular outflow tract obstruction. We reviewed our surgical experience in this cardiac disease with particularly attention to the different anatomical types of the obstruction.From January 1987 to December 1998, 56 patients with a mean age of 12.4 years underwent surgical treatment of subaortic stenosis in our Institution. The diagnosis included: subaortic membrane in 44 cases, fibromuscular process in seven and tunnel like hypertrophy in five.There were two hospital deaths (2/56 = 3.5%) and three patients presented postoperative heart block. The first postoperative echocardiographic control showed a mean fall in left ventricleaorta gradient of 78%. In a mean follow-up of 36 months, there were no deaths. All patients periodically controlled, showed an echocardiographic progression of the gradient and it was not related to the different anatomical types of the obstruction. There were no signs of aortic insufficiency progression.We can affirm that the surgical treatment of the subaortic obstruction is simple and safe. The medium and long-term progression toward the recurrence is independent to the anatomical type and justify the need of serial echocardiographic control.

The extra anatomical bypasses are those which do not follow the usual arterial pathway. The aim of this study is to define the indication of extra anatomical bypasses and to compare them with other revascularisation procedures. In this paper we report a retrospective study carried between January 1988 and December 1999 involving 80 patients (78 men and 2 women) who underwent extra anatomical bypasses for revascularisation of their lower limbs (83 bypasses). The mean age of the patients was 62 years. The indication for revascularisation was chronic arteritis of the lower limbs in 72 patients (90%), infected aneurysms in 6 cases (7.5%) and acute aortic dissection in 2 cases (2.5%). We performed an axillo-unifemoral bypass in 23 cases, an axillo-bifemoral in 17, a crossover ilio-femoral or femoro-femoral bypass in 41 cases, and 2 transobturator ilio popliteal bypass right and left in 1 case. Hospital mortality rate was 10%. Hospital morbidity was about 65%. Limb salvage was 78%. Sixty patients were regularly followed during a mean follow-up of 31 months. Late mortality was 10%. In the end of our study global limb salvage rate was 74%.extra-anatomical revascularization allows acceptable limb salvage rate along with lower operative risk even in poor state patients.

150 patients had mitral valve repair for mitral valve incompetence. There were 57 males and 93 females with a mean age of 22 years. 60% of the patients were in Class II NYHA and 40% in Class III and IV. Type I was present in 18 patients, type II in 98 and type III in 34 cases. Mitral repair included correction of valve prolapse, valvular enlargement with pericardial patch and annuloplasty with semi-rigid ring in 128 cases and PTFE patch along the posterior leaflet in 12 cases. The perioperative mortality rate was 2.6%. All patients had early post-operative echocardiography. According to this, mitral regurgitation was absent or tiny in 135 patients, grade II in 10 cases and grade III in 2 cases. It was moderate or important in twelve patients. In the late post-operative period. All the others patients were reoperated upon for mitral dysfunction in a mean time of 37 months. The reason for reoperation was in the majority of the cases the recurrence of mitral regurgitation related to increase of valvular and sub valvular disease. The late mortality rate is 7%. Out of 126 reviewed survivors on the long run, 71 patients are asymptomatic in class I, 53 patients in class II and 2 patients in class III NYHA. The estimated mitral regurgitation by echography in those patients is absent or trivial in 96 cases. grade II in 29 cases and grade III in one case. Mitral valvuloplasty is the preferred procedure in mitral insufficiency surgical management. It is associated to a low early mortality and morbidity rate. Despite the need for reoperation in about 10% of the cases in the long follow-up, mitral repair offers a good quality of life without anticoagulant treatment.

In this retrospective study we report 15 cases of peripheral infected aneurysms. The sex ratio was 13/2 and the mean age was 23 years. Patients presented with infection syndrome in 9 cases, vascular mass in 11 cases and limb ischemia in 2 instances. Arterial lesion was documented and confirmed by echography, tomodensitometry and angiography. The infection was recognised by different criteria the main one being micro-organism isolation. In 10 cases aneurysm was secondary to bacterial endocarditis, in 4 it was primary and in one case it was related to arterial catheter procedure. Treatment is based on antibiotics and surgical management by removing of infected aneurysm and arterial restoration whenever possible. Arterial flowerest re-establishment was done in 10 patients among whom 6 by anatomic procedures 4 by extra-anatomic ones. Hospital mortality rate was 13% (2/15), all deaths occurred after cardiac surgery for endocarditis. Two patients were readmitted for adjacent spine infection, one month and one and a half respectively after surgery. One young patient required late surgery (aorto-bifémoral bypass) 24 months after initial treatment and one patient died by intra-duodenal rupture of recurrent false aneurysm. Analysis of our results and literature review allow discussion of clinical, physiopathological and specially therapeutic aspects of infected aneurysm.