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A new incision for retroperitoneal approach to the abdominal aorta is described. The incision extends from alongside the rectus abdominis muscle across the costal arch over the 7-8th intercostal space. In the upper part only the skin and muscles are divided, allowing wide opening of the incision. The approach is muscle-sparing, since fibers of the transverse abdominal muscle are incised only in the upper part. It permits a good approach even for high aortic reconstruction.

Lower-limb amputation was performed on 261 patients from a catchment population of 232,500 in 1984-1986, and 253 of the amputees were retrospectively followed up. In 241 cases amputation was performed because of threatening or manifest gangrene, 95 of them without preceding consultation with vascular surgeons. In 19 cases amputation followed thromboembolectomy. Of the 127 patients seen by vascular surgeons, 66 were judged to be unsuitable for reconstructive surgery, 22 because of poor general health and 44 because of contraindicating vascular status. In the 61 patients with vascular reconstruction prior to amputation, the level of amputation did not differ from that in patients without such antecedent surgery. The proportion of cases rejected for vascular surgery rose from 18% in 1984 to 33% in 1986. The need for amputation could probably be reduced by earlier detection and vascular surgical evaluation of arterial insufficiency.

Pulmonary microembolization was induced by infusion of thrombin during inhibition of the fibrinolytic system. After embolization cardiac output decreased, pulmonary vascular resistance and pulmonary arterial pressure increased. There was a transient decrease in PaO2. Immediately after embolization there was an increased permeability indicated by tremendous increase in lymph flow with a constant lymph/plasma protein ratio. The lymph/plasma ratio for hemoglobin and for FITC-Dextran (mw 150 000) also increased indicating leakage of large molecules. The increased permeability was accompanied by a significant increase in extra-vascular lung-water as measured both with the thermal conductivity and the dry/wet weight method.

Based on animal data it has been hypothesised that lungs may regulate systemic fibrinolysis. To test this hypothesis 12 patients undergoing infrarenal aortic reconstruction due to arteriosclerotic disease were evaluated for influence of the respiratory pattern on release of tissue plasminogen activator (t-PA) and its inhibitor (PAI) in systemic and pulmonary arterial blood. Blood samples were drawn simultaneously from the pulmonary artery and a radial artery at defined times before and during surgery. Samples were also collected during application of positive end expiratory pressure (PEEP) of 5, 10 and 15 cmH2O. The blood samples were analysed for euglobulin clot lysis time (ECLT), t-PA activity, t-PA antigen and PAI. ECLT was not altered during surgery and t-PA activity was below the detectable limit. Before surgery t-PA antigen was 14.5 +/- 1.3 ng/ml and PAI 15.1 +/- 2.8 U/ml (mean +/- SEM). PAI was significantly elevated at end of surgery. There were no differences between samples from systemic and pulmonary arteries. Following application of 5, 10 and 15 cmH2O PEEP the fibrinolytic parameters were unchanged. Thus, in the present study on arteriosclerotic patients undergoing abdominal aortic reconstructions no influence from the respiratory pattern on systemic fibrinolysis could be demonstrated.

The records of 82 patients with vascular trauma, treated at the Departments of General Surgery of the Sahlgren's Hospital, Göteborg, between 1969-1978 were revised. Nine patients were female and 73 male. The most common type of trauma was stab wounds. The overall mortality was 10.9%, all being patients with major vascular trauma and/or multiple injuries. Fourteen cases were due to iatrogenic lesions. Of the remaining 68 patients, minor vessels were traumatized in 40 cases, and treated with ligation. In 28 patients some kind of reconstructive procedure was attempted, 23 of these patients survived. All reconstructive procedures in surviving patients were successful. In comparison with international experience, vascular trauma in Sweden seems to be very uncommon.

Spontaneous ischemic colitis is an often dramatic but common condition. Following resections of abdominal aneurysms it is not an unusual complication. Most cases will have mild symptoms. In patients with multiple arteriosclerotic disease there is an increased risk for rectal necrosis when the flow from the internal iliac arteries is impaired. We report a patient with multiple arteriosclerotic disease who developed necrosis of the left colon and rectum following occlusion of the inferior mesenteric artery.

Surgical preparation of a lung lymph fistula in sheep was previously shown to induce temporary permeability disturbance of pulmonary microvessels. Flow and composition of lung lymph were compared in 19 sheep with acute, and 16 with chronic lymph fistula. Lymph and plasma were analyzed regarding activities of prothrombin, antithrombin III, prekallikrein, kallikrein, functional kallikrein inhibitors and 11 acid hydrolases of lysosomal origin. Levels of prothrombin and antithrombin III fell postoperatively in plasma and reached even lower values in lymph, indicating systemic activation of the coagulation system as well as local activation in the lung. The studied components of the plasma-kallikrein system were unchanged. Lysosomal enzymes were released in lung lymph, reflecting cell injury in the lung. Local activation of proteolytic enzyme systems thus occurs in the lung after trauma. Analysis of organ-specific lymph (= interstitial fluid) may contribute to better understanding of the pathophysiology of trauma.

A reliable predictive test as a guide in selection for arterial reconstruction vs. primary amputation would be of great value. An ideal test should also be simple and noninvasive. We evaluated prediction based on preoperative and early postoperative (repeatedly in the first week) measurements of ankle and toe pressure in relation to patency 6 months after reconstructive peripheral vascular surgery in 39 patients. Occlusion occurred within 6 months in ten patients. In eight of them the preoperative ankle-brachial pressure index (ABI) was less than 0.4, but seven other patients with ABI less than 0.4 had maintained patency. In six of the ten with occlusion the toe-brachial pressure index (TBI) was less than 0.1, but in three others with TBI less than 0.1 the grafts were patent. During the first postoperative week there was progressive rise in pressure indices, reaching statistical significance on day 6, though with greatest rise on day 1. Although preoperative ABI less than 0.4 and TBI less than 0.1 were associated with high occlusion risk, the specificity of these indices was too low for predictive value. The repeated measurements during postoperative week 1 added no useful information to that obtained on day 1.

A review of the symptoms and signs as well as preoperative investigations was made in 12 patients with proved colovesical fistulas. The symptoms were predominantly those of the lower urinary tract. The value of barium enema, cystogram, cystoscopy and sigmoidoscopy was pointed out. Treatment consisted of a combined treatment with colostomy and indwelling bladder catheter, primary closure of the fistula only and various staged procedures with bowel resection. We emphasize the value of the one-stage procedure in the uncomplicated case.

A new, sleeve-shaped interpositional anastomosis of the small intestine was tested in rats. It was compared with a conventional two-layer anastomosis as regards healing, bursting strength, collagen content and complications. Each type of anastomosis was constructed in a separate group of 38 rats. The complications rate did not differ between the two groups. At 2 and 4 days postoperatively the bursting pressure was significantly higher in the sleeve anastomosis than in the conventional anastomosis. Hydroxyproline content did not differ between the two types of anastomosis. The study demonstrated superior breaking strength of sleeve anastomosis in the early postoperative period compared with conventional two-layer anastomosis. This finding merits further investigation.

Surgical procedures in veins such as thrombectomy are followed by a high complication rate. Re-occlusion is not uncommon in spite of primarily successful thrombectomy. The venous endothelium is damaged by the thrombotic process and the mechanical trauma from the balloon will be additive. The endothelial cells are the source of fibrinolytic activators. The present study compared changes in fibrinolytic activity in the vessel walls from the caval veins in rats to ultrastructural changes as seen in the scanning electron microscope. The balloon caused an almost complete denudation of the intima and the lesions were fully covered with platelets 1 hour after trauma. After 3 days reendothelialization had started. The fibrinolytic activity was significantly decreased at 1 and 24 hours following trauma. Reendothelialization was accompanied by return to normal fibrinolytic activity.

The effects of application of a vascular clamp for 30 sec were studied on the femoral vessels in rats. Control and injured vessel segments were studied with scanning electron microscopy and with a histochemical method to estimate the fibrinolytic activity in the vessel walls. Endothelial injury with loss of endothelial cells was induced by application of the clamp. This was correlated to a reduction of the fibrinolytic activity in the vessel wall. In arteries re-endothelialization was seen three weeks after induction of the trauma, and it was completed after eight weeks. Venous lesions healed earlier. The re-endothelialization was followed by a return to normal fibrinolytic activity.

The cardio-pulmonary effects of a rapid infusion of a crystalloid (Ringer's lactate) and a colloid solution (Dextran 40) were compared in healthy dogs. The colloid solution produced a long lasting volume expansion and hemodilution. The improved circulation in this group was reflected in an increased cardiac output and arterial blood pressure. The ventilation/perfusion ratios were reduced and the pulmonary vascular resistance was significantly lower in the colloid group in comparison both to the crystalloid group as well as to the control animals. The total oxygen consumption increased slightly in the colloid group but decreased in the crystalloid group. The postmortem extravascular lung water content did not differ in the groups.

For study of the progression and resolution of endothelial damage following mechanical vascular trauma in rats, the effects of a clamp with hydrostatically controlled occlusion pressure were compared with those of a standard mechanical clamp. The endothelial morphology was investigated with scanning electron microscopy and its function with histochemical analysis of plasminogen activator activity. Arterial or venous compression with hydrostatic pressure 1.5 kPa (11 mmHg) for 5 or 20 min produced de-endothelialized areas in veins, but only slight endothelial elevation in arteries. Hydrostatic occlusion of arteries with 12 kPa (90 mmHg) for 30 sec did not affect endothelial morphology and fibrinolytic activity, but after occlusion for 5 or 20 min the endothelium in both arteries and veins was severely damaged. The effects of hydrostatic (12 kPa) clamping on endothelial morphology and function after 5 or 20 min did not differ from those of mechanical (48 kPa = 360 mmHg) clamping. Apposition of vascular walls, except for the shortest time (30 sec) thus injured the endothelium, but minimizing occlusion pressure may reduce structural damage in the vessel wall.

The records of 57 patients with abdominal stab wounds, treated at the Surgical Departments of the Sahlgrenska Hospital, Göteborg, between 1969-1974, were revised. Fifty-five patients were males and 2 females. The wounds were situated in the upper abdomen in 72% of the patients. Forty-nine patients were treated with an explorative laparotomy and the findings were considered to be negative in 31% of these patients. Liver injuries were found in 45% of the operated patients. No complications occurred in the patients with negative laparotomy findings. One patient with multiple intra-abdominal lesions succumbed from an irreversible septic shock.

A patient who 5 years previously had an aortoiliac reconstruction with a dacron graft developed intestinal bleeding. At laparotomy this was found to be due to a fistula between a pseudoaneurysm at the right iliac artery anastomosis and the appendix. Resection of the aneurysm and adjacent parts of artery and graft with additional appendectomy prevented further intestinal bleeding. A search of the literature produced only one previously reported case similar to this.