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To assess the effect of saphenous-vein bypass grafting on resting ventricular performance, left ventricular volumes and ejection fraction were measured before and after surgery in 40 patients. Symptomatic improvement occurred in 80 per cent (32 of 40), maximal treadmill exercise performance improved in 50 per cent (15 of 30) (p

A new percutaneous femoral method for studying the coronary arteries, left ventricle and saphenous vein bypass grafts using a single catheter has been developed. A #8 French 100 cm polyurethane catheter with wire incorporated and a 45° curved tip has been used in 6,800 patients. This technique combines the speed and simplicity of the percutaneous femoral approach with the safety of the single catheter technique by eliminating multiple catheter and guidewire changes. Manipulation techniques for selective right and left coronary artery and saphenous vein bypass graft injections as well as for left ventriculography are described. In only 10% of the cases has it been necessary to change to a second catheter, and catheterization time has averaged less than 15 minutes. Complications have been infrequent: femoral thrombosis 0.3%, hematoma 0.2%, myocardial infarction 0.04%, cerebrovascular accident 0.03% and death 0.07%. The speed of the technique and the elimination of multiple catheter changes seem to have contributed to the low complication rate.

Experience with 184 patients undergoing internal mammary artery bypass grafting has resulted in a reproducible, simplified, and organized surgical technique. Recatheterization study has been performed in 39 asymptomatic and 3 symptomatic patients at two weeks to one year postoperatively. Two distal stenoses and no closures have been found. The advantages of internal mammary arteries as bypass grafts are that the vessels are comparably sized, there is artery-to-artery anastomosis, only a single distal anastomosis per graft is needed, there is no subintimal hyperplasia, and no leg wound problems occur. Disadvantages are that a more tedious dissection of the relatively more friable internal mammary vessel is necessary, only two grafts are available whereas multiple bypasses are sometimes necessary, and the grafts are limited in length. Complications specific to the procedure are injury to the internal mammary artery during preparation (2 patients) and inadequate graft size (5 patients). Flow rates are adequate to relieve angina. Patients with subclavian bruits or differential blood pressure between the right and left arms are not considered candidates for internal mammary artery bypass grafting. The availability of a special 7-0 Prolene suture on a BV-1 needle and the use of optical magnification are especially important adjuncts to the procedure.

The angiographic findings in 8 patients with surgically produced arteriovenous fistulae performed for lower limb discrepancy are described. The exact site and size of the fistulae were shown in all patients. The arteries below the fistulae are usually of the same size as the normal limb or smaller, suggesting that increased blood flow is not the principal mechanism of the bone growth which may result from fistula formation.Additional information concerning arterial collaterals and enlarged venous tributaries is also obtained.It is suggested that arteriography should be performed immediately before closure of the fistulae.

Anastomotic false aneurysms following femoro-popliteal bypass with autogenous saphenous vein seem to be a very rare complication according to the literature. Three patients with a total of five false aneurysms are presented. The primary operations were performed within 3 weeks. We can give no definite explanation of the occurrence. Infection in association with silk sutures or inferior quality of the silk are possible aetiological factors. With manifest false aneurysm, re-operation is always indicated. The arteries will have to be ligated above and below the aneurysm, and every effort must be made to restore distal arterial circulation. A second vein should be inserted, bypassing the possible infected area of the false aneurysm. In the groin, this can easily be accomplished with the vein placed in the femoral canal.The incidence of anastomotic false aneurysms following femoropopliteal bypass procedures is reported to be higher than 10% with Teflon and Dacron graft in one series (Sawyers et al., 1967), and...

The experiments dealt with lipid synthesis and cholesterol uptake in human coronary arteries without evidence of atherosclerosis and in human saphenous veins perfused in vitro with pulsatile pressure. The results demonstrate the following: 1.1. Human coronary arteries without evidence of atherosclerosis and atherosclerotic coronary arteries are unable to synthesize cholesterol from acetate. 2.2. Synthesis of cholesterol esters is small in coronary arteries regardless of the presence or absence of atherosclerotic lesions. 3.3. Identical uptakes of cholesterol were found in normal and atherosclerotic coronary arteries. 4.4. Lipid synthesis in human saphenous veins perfused at a pressure of 4535 mm Hg does not differ from that in nonatherosclerotic coronary arteries or saphenous veins perfused at a pressure of 130100 mm Hg. 5.5. Cholesterol uptake in saphenous veins perfused at a pressure of 4535 mm Hg is lower than that in coronary arteries or saphenous veins perfused at arterial pressure (130100 mm Hg.

Selective aortocoronary bypass graft angiography was performed in 30 postoperative subjects. Thirty-one of 39 patent graft injections resulted in cardiac arrhythmias including sinus bradycardia, premature ventricular depolarizations, sinoatrial arrest and atrioventricular (A-V) block. In contrast, only 2 of 39 graft angiograms performed during right atrial pacing produced arrhythmias. We conclude the following: (1) Routine prophylactic right atrial pacing is a valuable method for preventing certain cardiac arrhythmias during aortocoronary graft opacification; and (2) the potential for rapid institution of right ventricular pacing provides safety in the event that angiographically induced A-V block occurs.

Review of records of 48 patients, who had had aortocoronary bypasses and preoperative and postoperative catheterizations, showed that 11 had new Q waves after operation. Seven of these had new infarctions immediately before or during operation as determined by evidence of deterioration on postoperative ventriculograms. Four cases had no deterioration, suggesting an alternative explanation for abnormal Q waves. These four patients with new Q waves, all in the inferior leads, had inferior-wall dysfunction before operation, with an inferior scar at surgery. After operation, anterior-wall function improved, without change inferiorly. These observations are consistent with unmasking of pre-existing infarction, rather than development of new infarction, and suggest that before operation, anterior ischemia electrically canceled inferior infarction. After operation, with relief of anterior ischemia by left-descending-coronary-artery bypass, anterior electrical force was augmented, and pre-existing inferi...

The venous volume of the lower legs was examined plethysmographically in 60 primigravidae, grouped according to duration of pregnancy. The three periods were 9–13 weeks (Group A), 15–22 weeks (Group B) and 36–41 weeks (Group C). In addition to the examination during pregnancy, in Group A examinations were performed 1 day and 2 weeks after abortion, while in Groups B and C the examinations were made 2 weeks after abortion and delivery respectively. The recordings were made at venous occlusion pressures of 40, 60 and 80 mmHg. Contrary to the information given in the literature on gravidae, it has not been possible to detect any difference in the venous volume of the lower legs during primipregnancy.

Aortocoronary bypass, with or without myocardial resection, was used to treat eight patients with refractory life-threatening ventricular tachycardia. All patients had documented evidence of coronary artery disease without recent myocardial infarction and were totally disabled by recurrent ventricular tachycardia while receiving aggressive medical treatment. Angiographic studies showed abnormalities of left ventricular contractions in all patients, including aneurysms in four, localized hypokinetic areas in two and diffusely poor contractility in two. Operative treatment consisted of resection of the aneurysm or localized hypokinetic area in six patients and aortocoronary bypass grafting to at least one major coronary artery in all eight patients. Seven patients are alive an average of 17 months after operation and all are free of major ventricular arrhythmias. We conclude that surgical treatment should be considered in patients with coronary artery disease who have life-threatening ventricular arrhythmias that cannot be prevented or controlled with drug therapy.

Blood flow has been measured in 28 aortocoronary saphenous vein bypass grafts performed for chronic angina pectoris using the electromagnetic flowmeter. Nitroglycerin, 0.4 mg. intravenously or 0.1 mg. into the graft, and papaverine 30 mg. intravenously or 15 mg. into the graft, were studied. Intravenous nitroglycerin increased coronary flow a maximum of 4 per cent for 20 seconds followed by 23 per cent decline as mean arterial pressure fell 23 per cent. Intra-arterial nitroglycerin increased coronary flow 74 per cent in 15 seconds with return to control by 90 seconds. Intravenous papaverine elevated coronary flow 76 per cent at 30 seconds with stabilization of flow 15 to 20 per cent above control. Intra-arterial papaverine achieves a maximum flow of 215 per cent at 45 seconds with return to control at five minutes. Although nitroglycerin produces a small but significant rise in coronary flow it is doubtful whether this increase occurs with oral administration in the presence of coronary disease. Thus, the therapeutic effect of nitroglycerin lies in its systemic effects rather than in its coronary effect.

For many years, arterial reconstructive procedures designed to treat arterial occlusive disease involving the lower extremities were limited to the femoral and popliteal vessels. Arterial bypass procedures involving anastomoses below the knee were thought to be impossible because of the small size of the vessels involved and the limited runoff. However, as technics of vascular surgery have improved and as surgeons have become more familiar with the handling of smaller vessels, successful treatment of more distal arterial occlusions has been possible. Morris et al [I ] in 1959 described the first anastomosis of arterial grafts to the distal popliteal vessel below the knee. Two years later, McCaughan [2] described the first group of patients who had bypass grafts to vessels below the popliteal trifurcation. It soon became apparent that vessels distal to the popliteal artery would support inserted autogenous saphenous vein grafts [3-101. Thereafter, the frequency of arterial bypass grafting to the anterior tibial, posterior tibial, and peroneal arteries in the calf region increased rapidly. More recently, refinements in surgical technics for suturing vessels 2 mm in diameter have resulted in favorable patency rates for arterial anastomoses at the ankle and below [11-141. This report is an analysis of sixteen patients in whom the dorsalis pedis artery was utilized for the distal anastomosis in bypass grafting for arterial occlusive disease.

Our experience with the postoperative study of 50 saphenous-venous by-pass procedures has shown that a number of postoperative complications might affect either the veins or the coronary arteries.It is pointed out that the angiographic study must be tailored to properly diagnose and evaluate these complications. Among them one may find: occlusion of the graft; intimal hyperplasia; formation of false aneurysms; loss of coronary collaterals; occlusion of major coronary arteries; or myocardial infarctions.

In order to evaluate the immediate effects of aortocoronary saphenous vein bypass graft surgery on myocardial contractility, studies were carried out in 24 patients with severe occlusive disease of the right or left coronary arteries or both. Myocardial contractility was expressed by the extrapolated maximal velocity of contractile elements shortening (Vmax) and peak (dP/dt)/KP (Vpm) as calculated from the left ventricular pressure and its rate of pressure rise, dP/dt by employment of a needle connected transducer. Studies were made with the patient in sinus rhythm and a stable circulation and no cardiac action drug administration before and after saphenous vein bypass surgery. The patients were divided into two groups: group 1 (12 patients) were those without LV aneurysm and satisfactory myocardial contractility (Vmax 1.40±0.07 and Vpm 1.08±0.06 muscle lengths per second), and group 2 consisted of 12 patients with poor initial myocardial contractility (Vmax±standard error 0.94±0.05 and Vpm 0.74±0.05 muscle lengths per second) and LV aneurysm. In group 1 patients there was a significant increase in Vmax and Vpm values from preoperative results (Vmax±standard error 1.84±0.09 and Vpm 1.39±0.07 muscle lengths per second (p Table 5 ). These preliminary data indicate that increased blood supply to the myocardium delivered by aortocoronary saphenous vein bypass graft surgery is beneficial and increase myocardial contractility in those patients with good preoperative contractility.

The fibrin slide sandwich technique is a histochemical method for the detection and localization of inhibition of fibrinolysis in tissues. By this technique it was demonstrated that plasmin inhibition is present in the human vascular wall. The great diversity in the pattern and the capacity for inhibition among different parts of the vascular system appeared to be in close association with the localization and number of smooth muscle cells present in this system. The postulated relationship between fibrinolytic inhibition and smooth muscle cells was strongly supported by the demonstration of a similar inhibition of fibrinolysis in other human tissues containing a high number of smooth muscle cells.

A pathologic study was done on 53 patients who had received 86 saphenous vein grafts to bypass obstructive coronary arterial lesions. The periods of study after operation ranged from failure to survive the operation to three and one-half years. Of significance was the high incidence of residual obstructive disease in nongrafted arteries (38 of 53 patients) and in grafted systems (graft and distal artery) (55 of 86 grafts; 64 percent). The residual obstructive disease in the graft systems increased with time after operation. Obstruction was observed in 30 of the 86 grafts, and in 17 of these 30 the distal artery was also obstructed (usually by residual atherosclerosis). The characteristic basis for occlusion of a graft one month or less after operation was thrombosis. In longer range grafts, occlusion was most commonly caused by fibrous intimal proliferation, although in a small number, organized thrombosis alone or with fibrous intimal proliferation was the basis. In 28 of the 43 patients who survived one month or less, acute myocardial infarction was present at operation or afterward; that is, in 65 percent of the patients who died during the period of hospitalization. Of the 29 acute infarctions, after operation 23 were in a zone supplied by a grafted artery, and six were in a zone supplied by an artery not receiving a graft. In six of the 14 cases of acute infarction in the distribution of an obstructed graft system, the artery proximal to the graft was also occluded by a recent thrombus. Thrombosis in an artery proximal to a graft was observed in one or more vessels in 12 patients who survived the first month after operation. In these, there were ten acute myocardial infarcts, seven of which were in the distribution of the occluded artery.

The tunica media of the dog lateral saphenous vein contains 8–12 layers of predominantly circular smooth muscle fibers. Numerous nerve profiles exhibit bright green fluorescence after formaldehyde gas treatment. These profiles occur amongst the muscle cells throughout the whole thickness of the media. Electron microscopy shows such profiles to be surrounded by Schwann cell processes enveloping axons which contain large (43%) and small (57%) dense-core vesicles. Axons are separated from muscle cells by 100–300 nm; in some cases intimate contacts, ≈20 nm wide, were seen between an axon and a muscle cell projection. After incubation of the vein with exogenous radioactive noradrenaline, nerves showed a great accumulation of radioactive material. Extraneuronal tissues (muscle and connective tissue) exhibit a much lower grain density (≈15 times less), which is, however, far above background levels. The dense innervation of the vessel wall and the intimate neuromuscular relationship are considered to form the morphological basis for the speed of nerve-evoked contractile responses in this preparation, as well as for the great extent of transmitter inactivation through neuronal reuptake.

Fifty-five consecutive patients with intermittent resting chest pain persisting more than 24 hours after hospitalization and accompanied by ECG changes representative of ischemia were operated urgently more than one year ago. Recent cases with shorter follow-up are excluded. Twenty-eight patients had single grafts, 23 had double grafts, three had triple grafts, and one a quadruple graft. There were three operative deaths (5%) and one sudden late death (2%). There were six early Mls and three late Mls. Follow-up ranges from 12 to 52 months (mean 24 months) with nine patients followed for four years. Actuarial analysis indicates a projected survival rate of 93% three years postoperative. Twenty-three survivors are Functional Class (FC) I, 19 are FC II, and eight are FC III. Functional class could not be determined in one survivor. Thirty patients had postoperative angiography one week to 32 months postop. 35/51 grafts were patent. Only three patients had no patent grafts. There were no significant differences between mean preoperative and postoperative left ventricular end-diastolic pressures (assessed in 20 patients) or ejection fractions (assessed in ten patients). The extremely low mortality early and late postop (7%), the low incidence of Ml (16%), and the excellent functional results after extended follow-up indicate that emergency saphenous vein bypass grafting is an effective therapy for unstable angina.