We have operated upon 588 patients with Klippel and Trenaunay syndrome. The underlying factor is a congenital malformation of the deep veins: agenesis, atresia or compression by fibrovascular bands of the popliteal, femoral or iliac veins. Of these 588 patients, 6 children between 15 months and 4 years of age had severe rectal bleeding and hematuria. One of these children died from massive bleeding of the rectum with septicemia. Another boy was saved by rectal resection and the last one by subtotal cystectomy. The important venogram shows an absence of the anterior venous pathway (superficial femoral vein) compensated by the abnormal development of 2 venous groups, the vein of the sciatic nerve and large veins along the external aspect of the inferior limb. These 2 venous groups penetrate into the pelvis by the sciatic and gluteal notches and terminate in the internal iliac vein which becomes enormous and has a very high flow. This overflow hinders drainage of the venous collateral from the rectum, the bladder and the vagina. The retro adductor vein, prolongated by the deep femoral vein, represents an anastomosis between the sciatic nerve vein and the common femoral vein. The surgeon must try to widen this pathway.

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Among 32 patients with late prosthetic valve endocarditis selected from two cooperative retrospective studies, ten had valve replacement: six men and four women, mean age being 48 years, ranging from 23 to 65 years old. An emergency reoperation was undertaken for refractory heart failure in seven out of ten cases, with an average delay of 6.6 days after the beginning of antibiotic therapy. In the other three cases, the operation was carried out at the end of 40 days of antibiotic therapy, once for recurrent endocarditis and twice for severe aortic insufficiency. The most common causative micro organism was the staphylococcus (7 out of 10 cases). The infected prosthetic valves were, in 8 out of the 10 cases, in the aortic position. The outcome was poor as the mortality rate was 60% (6 out of the 7 patients operated on in an emergency). Death was attributed to heart failure with conduction disturbances and severe aortic regurgitation (2 cases), cerebral emboli (2 cases), septicopyemia (2 cases). Four patients of the ten, after a mean follow up of 10 months, are cured without prosthetic valve dysfunction. The extreme gravity of prognosis seems related to the microorganism (staphylococcus), to the delay between the beginning of antibiotic therapy and the onset of the fever, and finally to the extension of destructive lesions under the prosthetic valve implantation base; the reimplantation of the prosthesis on frail and abscessed tissue implies a substantial risk of disinsertion. The indications for systematic early reoperation in cases of severe acute heart failure are discussed.

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