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The experience in the use of 37 Bovine heterografts for the treatment of arterial insufficiency and of 37 Bovine heterografts for construction of arterio-venous fistulas for hemodialysis is described. The Bovine heterograft was found unsuitable for use in the femoro-popliteal position, as contrasted to satisfactory follow-up in the aorto-iliac-femoral area. On the other hand, it was found to be an acceptable substitute to the autogenous saphenous vein in the construction of an arterio-venous fistula for chronic dialysis.

Six free deltopectoral skin flaps have been successfully transplanted. This free flap provides a large amount of good quality hairless skin for reconstruction of the face. It has many advantages over conventional pedicle flaps; for example shorter hospitalisation, no fixation of the operated area and emergency cover of a defect.

Two cases of clinical success of distant transfer of free skin flap in head and face regions by microsurgical anastomoses are reported. Case 1 is a 31 year old male with cicatricial, alopecia of the scalp and treated by a free hairy scalp transfer. Case 2 is a 20 year old male with burn contracture of the chin and cheeks with ectropion of the lower lip and treated by a free deltopectral skin flap transfer.

The distant transfer of the free skin flap by microvascular anastomosis opens a new era in reconstructive plastic surgery and herein the author's personal experiences regarding to the microvascular surgery are described in details in the following subjects; introduction, concept of microsurgery, microvascular instruments, fundamental techniques of microvascular anastomosis, experimental study in dogs, one staged transfer of free skin flap in clinical cases, and advantages and disadvantages of microvascular transfer of skin flap.

Animal experiments were done to learn the degree of coronary narrowing required to produce the larger intercoronary collateral channels, their speed of development, and the degree of protection afforded the myocardium. Twelve or more days of 75 per cent narrowing were required to produce sufficiently rich anastomotic communications to protect the myocardium from damage, and to permit survival after superimposed acute complete occlusion. The physiologic and pathologic significance of the intercoronary collateral communications and the clinical implications in coronary artery disease are discussed.

In repairing damaged blood vessels, lifesaving measures take precedence over limb-saving procedures; at exploration, proximal and distal arterial control must be established before repair is attempted; vascular reconstruction is preferable to ligation; and the best evidence of good repair is restoration of the distal pulses. These principles are based on experience with 125 peripheral vascular injuries in Vietnam.

The various tests of venous function are discussed, with particular reference to their interpretation in the light of modern venous physiology; certain common fallacies are mentioned. Simple high ligation combined with simultaneous and/or subsequent injection of a sclerosing solution appears to be sufficient to cure the majority of cases requiring operation. A table of results is included. The only cases where such operative treatment failed were two in which there were a large number of incompetent communicating veins. Further investigation of the postoperative function of the communicating veins is proposed.

THE appreciation of renal-artery lesions as a cause of systemic hypertension began with the work of Goldblatt et al.1 in 1934. This experimental finding was immediately implicated in human hypertension with overenthusiasm and eventual disillusionment by many workers in the field. Although many nephrectomies were performed for presumably unilateral renal-artery disease only an occasional cure of systemic hypertension was reported. It now appears that the primary reason for the high failure rate of nephrectomy in these early reports was the inability to make an accurate diagnosis of renal-artery disease. The development of aortography described originally by dos Santos and his . . .

IN the course of chronic liver disease the development of portal hypertension and the subsequent formation of portal collateral circulation may permit certain nitrogen-containing substances in the portal blood to bypass the extraction mechanism of the hepatic parenchyma. A cerebral intoxication, which Sherlock and her co-workers1 have termed portal–systemic encephalopathy, has been observed in some of these cases. This phenomenon has been known since 1893, when Hahn et al.2 described the "meat-intoxication" syndrome — that is, stupor, ataxia, convulsions and coma — in animals with an Eck fistula that were fed high-protein diets. Recently, there have been a few patients . . .

The prime principles in the management of vascular trauma are control of hemorrhage, restoration of major arterial pathways, adequate debridement of wounds, control of venous bleeding, recognition of inadequate arterial circulation secondary to compression or contusion, relief of arterial spasm, and prevention of closed-compartment compression. While the majority of arterial injuries are immediately evidenced by serious hemorrhage, delayed arterial rupture is a more insidious problem and should always be considered as a possible sequela of serious trauma.

IN the first publication of this series of papers attention was called to the need of a method for the direct delivery of venous blood into the pulmonary arterial circulation.1 The congenital anomalies of the heart that might be remedied from this operation are characterized by malfunction of the right atrium or right ventricle or both. More specifically, the cardiac conditions that would benefit from circulatory bypass of the right side of the heart include stenosis or atresia of the tricuspid and pulmonary outflow tracts, Ebstein's anomaly, single ventricle, bilocular heart and transposition of the great vessels with an associated . . .

Summary There has been, until recently, little experimental evidence to support the widely used method of delayed transfer (delay). The effects of four methods and three durations of delay on the surviving length of experimental flaps have been investigated in the pig. A maximum increase of 60 per cent. was observed, and the optimal timing for transfer was about two weeks after delay. The initial raising of bipedicled flaps was most effective, and incision of the margins least effective, suggesting that the best form of delay is the one which divides most vessels short of causing necrosis.

Eight patients with systemic arteriovenous fistulas have been studied with special emphasis on systemic arterial and multiple right heart indicator-dilution curves with indocyanine green. Seven patients were studied preoperatively; 4 subjects were restudied after surgical intervention. One patient was catheterized only after surgical correction of the fistula. Five subjects were investigated before and during acute occlusion of the fistula. Cardiac output was determined by indocyanine green in all patients; the Fick principle was also employed in 4 patients to determine cardiac output. The cardiac index was elevated before surgery; occlusion of the fistula resulted in a decreased cardiac index. Surgical correction of the fistula also led to a fall in cardiac index. The indocyanine indicator-dilution curves were utilized to demonstrate and localize the left to right extracardiac shunts. After surgical correction, physiologic evidence of the shunt was no longer evident.

Summary 1. Six cases of subclavian artery aneurysms associated with cervical ribs are reported. 2. The natural history of progression from a fusiform dilatation to a grossly abnormal vessel liable to massive or mural thrombosis with embolization is described. 3. For those cases with thrombosis and significant ischaemia, aneurysmal formation of great size or fragility, containing mural thrombosis with embolization, it is recommended that the segment should be resected and a graft inserted. 4. A method of graft insertion without resection of the clavicle is described.

RECONSTRUCTION of a missing thumb by pollicisation of a finger (Littler, 1953) produces the most satisfactory functional result, even though this entails transposing an adjacent digit on an already compromised hand. Local tissue may be preserved by the multiple stage construction and transfer of distant tubes and pedicles containing bone grafts (Reid, 196o). McGregor has overcome many of the disadvantages of this procedure with a composite bone skin flap incorporating a neurovascular tactile island at the time of transfer (McGregor and Simonetta, 1964). The transplantation of the toe to the hand first described by Nicoladoni in 1897 has held a somewhat controversial place in hand reconstruction. This interesting history has been reviewed recently by Davis (I964), who has improved and modified the technique. The objectives of this experiment were to transplant immediately the hallux of a Rhesus monkey's foot to the thumb position, re-establishing circulation by the F~G. ~ primary anastomoses of small critical blood Right hand (above) and foot (below) of a Rhesus vessels. monkey. The thumb is small, the hallux is large and strong. Mater ia l . -The Rhesus monkey was used as the experimental animal. Being arboreal the animal uses its fingers as hooks to swing from limb to limb. The thumb consequently is small and poorly developed (Fig. I). The hallux, however, is large and capable of strong opposition, paralleling the human thumb from a functional standpoint (Bunnell and Boyes, 1965) (Fig. 2 D, ~). The principal arterial supply to the dorsum of the animal's foot comes via the superficial dorsalis pedis to the hallux and first web space and the deep dorsalis pedis to the remainder of the dorsum. These are terminal branches of the saphenous artery not present in man. Blood is drained from the dorsum of the foot through the medial malleolar and lateral malleolar veins into the posterior saphenous system, since the anterior great saphenous system is absent in the Rhesus monkey (Lopel et al., I961). These vessels on the foot's dorsum in an 8 to 12 lb. Rhesus monkey measure from 0"8 to I "3 mm. in external diameter.

Prompt recognition and immediate surgical repair is recommended in the management of acute arterial injuries to the upper extremity. This therapeutic concept is most urgent in injuries involving the larger proximal vessels where hemorrhage frequently threatens survival. Well established incisions and current vascular surgical technics preclude equivocation in the management of injuries in this location. Damage to peripheral arteries of the arm and forearm should also be repaired immediately in order to restore optimal circulation unless such emergency repair jeopardizes survival of the patient. Ligation can be performed in injuries in this location with minimal risk of amputation. Arteriography is helpful in establishing the diagnosis of arterial injury in equivocal cases and will reduce the number of negative explorations. Careful attention must be paid to the total problem of trauma in patients with acute arterial injury of the upper extremity since associated damage to nerves and tendons is the determining factor in restoration of function and rehabilitation of the patient.

1. 1. Carotid body tumors may invade, may metastasize, and may cause symptoms by increase in size. 2. 2. They should probably be left alone in the older patient. Surgical excision is the procedure of choice in the younger patient. 3. 3. Normal blood pressure must be maintained if the carotid artery is ligated. Arterial replacement should be done if possible. Elevated systemic pressures should be produced by means of drugs if arterial replacement is impossible.

ASTOMOSIS by suturing, patching, and shunt ing of small arteries and veins 4 ram. or less in external diameter car ry a high incidence of failure because of constrict ion and thrombosis, as compared to vessels of larger d iameter (5-6 ram. and larger). I t is true t ha t Seidenberg et al. 12 repor ted excellent results by meticulous direct anastomosis of small arteries with sutures, using 7-0 braided silk. 13 However, application of this technique to surgery of intracranial vessels presents additional difficulties, such as: (1) difference in structure of cerebral arteries ~ as compared to extraeerebral vessels, with less adventit ia, reduced media, absent external elastic membrane , ~ and minimal suppor t by surrounding tissues; (~) the presence of perforat ing branches precluding rota t ion; (3) l imitation of t ime of vascular occlusion (even with the use of hypothermia) ; and (4) lack of maneuverabi l ity. With a few exceptions, u,15 patency of the a r te ry has been lost, or could not be reestablished, following such a t t empts in m a n . 8-11,14,15