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Objective To compare cancer detection rate (CDR), patient recall, and interpretation time of a full protocol MRI (fpMRI) to an abbreviated MRI protocol (abMRI) in high-risk women. Methods This retrospective study was approved by the IRB. All sequential high-risk screening MRI examinations performed between January 1, 2013, and December 31, 2016, were included. Breast radiologists reviewed patient history, prior images, and abMRI images and recorded their interpretation. Time for interpretation reflected review of the MRI study but not dictation or report generation. Following a minimum 30-day washout period, radiologists interpreted the fpMRI, with interpretation and timing recorded. Data collected included CDR, interpretation time, and patient recall rate. Statistical analyses utilized were Cohen’s kappa coefficient, Student’s t-test, and McNemar’s test. Results Included were 334 MRI examinations of 286 women. Interpretation time was 60.7 seconds for the abMRI compared to 99.4 seconds for the fpMRI, with an average difference of 38.7 ± 5.4 seconds per patient (P < 0.0001). Recall rates were comparable: the abMRI recall rate was 82/334 (24.6%) and the fpMRI 81/334 (24.3%). All five cancers included were detected by both protocols with equal recall rate. However, there were more recommendations for biopsy with the fpMRI, although this difference was not statistically significant. Conclusion The abMRI demonstrated comparable CDR to fpMRI, with shortened interpretation time and similar recall rates. Implementing an abMRI to screen high-risk women reduces imaging and interpretation time, thereby improving cost-effectiveness and the patient experience without reduction in cancer detection.

Aim To describe the impact of extracorporeal membrane oxygenation (ECMO) assisted CPR (E-CPR) on cerebral oxygen delivery during in-hospital cardiac arrest (IHCA). Methods Retrospective case series from a tertiary academic medical center. Regional cerebral oxygen saturation (rSO2) was measured continuously using cerebral oximetry in six patients who experienced IHCA. During CPR, the time of E-CPR initiation was recorded, and rSO2 values were subsequently analyzed for a period beginning 5 min before and ending 2.5 min after the initiation of E-CPR. Results The average rSO2 value in the 2.5 min period following E-CPR initiation increased by 20.8% as compared to the 5-min period before E-CPR initiation. Conclusions ECMO can be employed in parallel with cerebral rSO2 monitoring during CPR for adult IHCA patients. E-CPR is associated with rapid and significant increases in brain oxygen delivery.

Objective: In March of 2020, at the outset of the SARS-CoV-2 pandemic in New York City (NYC) the Maternal Fetal Medicine (MFM) clinic at a federally qualified health clinic (FQHC), transitioned to the use of telehealth in order to implement social-distancing. We aimed to determine the impact of telehealth availability on patient access and adherence to MFM care at a FQHC during and after the SARS-CoV-2 pandemic. Study Design: This is a retrospective, quality improvement project comparing non-adherence to scheduled visits over 3 timeframes: 1. "Pre-COVID" (11/1/2019-2/28/2020) 2. "COVID" (4/1-7/31/2020) - virtual telehealth fully implemented 3. "Post-COVID" (8/1-9/15/2020) - after NYC surge of SARS-Cov-2 with conversion back to in-person visits. All scheduled encounters in the MFM FQHC clinic were included. Non-adherence was defined as encounters cancelled prior to appointment time or a "no-show." Chi-square and logistic regression (SAS v9.4;Carey, NC) were used to compare differences between groups with p

The history of medicine is filled with stories of tireless researchers who failed to get credit for their hard work. Examples of this include Rosalind Franklin, who helped to elucidate the structure of DNA; Frederick Banting, who helped to discover insulin; and Jay McLean, who discovered heparin. The founding of the field of vascular surgery provides one of the most vivid examples of uncredited work. Even though Alexis Carrel was an unpaid, untitled assistant in Charles Guthrie's laboratory, it was Carrel alone who received a Nobel Prize for their work. In an attempt to give credit where due, the reasons for this injustice are described.

Objective: Ischemia-reperfusion injury is a pathologic event characterized by tissue damage. It is mediated by tumor necrosis factor (TNF) and other cytokines that activate complement and proteases and stimulate fibrinolysis, degranulation of white blood cells, and free radical production. We recently reported that vagus nerve stimulation (VNS) suppresses endotoxin-induced cytokine synthesis through α bungarotoxin-sensitive cholinergic receptors. VNS protects against endotoxin-induced shock by inhibiting hepatic and cardiac synthesis of TNF. Here, the effects of VNS on suppression of ischemia-reperfusion injury and cytokine release were studied in a rat model of aortic occlusion. Methods: Adult male Lewis rats were subjected to laparotomy and suprarenal aortic clamping for 15 minutes followed by reperfusion. Blood pressure, heart rate, and respiratory rate were recorded every 3 minutes for 90 minutes. Exposed cervical vagus nerves in the experimental group were stimulated for 5 minutes before and after aortic occlusion, with constant voltage (1 V, 2 ms, 5 Hz); sham-operated animals received no stimulation. TNF levels in serum and organs were measured with enzyme-linked immunosorbent assay ELISA (BioSource International, Camarillo, Calif). Data analysis was performed with the Student t test. Results: Control animals had shock develop (mean, 59% decrease in blood pressure) whereas blood pressure in the stimulated animals did not decrease (control versus stimulated animals, P < .05). VNS significantly inhibited TNF levels in serum (7 ± 1 ng/mL versus 45 ± 6 ng/mL; P = .0008), heart (21 ± 11 ng/g protein versus 85 ± 15 ng/g protein; P = .01), and liver (16 ± 2 ng/g protein versus 42 ± 12 ng/g protein; P = .02). Conclusion: VNS significantly attenuates TNF synthesis and shock during reperfusion injury in a standard model of aortic occlusion. Clinical evaluation of VNS for this condition may be warranted. (J Vasc Surg 2002;36:1231-6.)

Background a retrospective chart review of 94 patients with asymptomatic high-grade carotid stenosis undergoing coronary bypass (and valve replacement in some cases) was performed to determine whether significant carotid lesions can be safely ignored in patients undergoing cardiac surgical procedures. These operations were performed during a 2-year period. Patients and methods there were 55 men and 39 women, with an age range of 37–89 years. Seventy-one patients had unilateral high-grade carotid stenosis, 17 patients had bilateral high-grade lesions, and six patients had unilateral high-grade stenosis and contralateral occlusion. Associated medical problems were recorded and short-term follow-up was obtained. Results there was one perioperative stroke and no deaths in this group of patients. Conclusions although these data indicate that high-grade carotid stenoses may be safely ignored during cardiac surgical procedures, a multicentre prospective randomised trial is needed to determine the appropriate treatment of the patient with coexisting carotid and coronary artery disease.

BACKGROUND: Advanced glycation endproducts (AGEs) are implicated in the pathogenesis of atherosclerotic vascular disease of diabetic and nondiabetic etiology. Recent research suggests that advanced glycation of ApoB contributes to the development of hyperlipidemia. AGE-specific receptors, expressed on vascular endothelium and mononuclear cells, may be involved in both the clearance of, and the inflammatory responses to AGEs. The aim of this study was to examine whether there is a relationship between serum AGE-ApoB and AGEs in arterial tissue of older normolipidemic nondiabetic patients with occlusive atherosclerotic disease, compared with age-matched and younger asymptomatic persons. MATERIALS AND METHODS: Serum AGE-ApoB was measured by ELISA in 21 cardiac bypass patients. Furthermore, an AGE-specific monoclonal antibody, and polyclonal antibodies against anti-AGE-receptor (anti-AGE-R) 1 and 2 were used to explore the localization and distribution of AGEs and AGE-R immunoreactivity (IR) in arterial segments excised from these patients. RESULTS: Serum AGE-ApoB levels were significantly elevated in the asymptomatic, older population, compared with those in young healthy persons (259 +/- 24 versus 180 +/- 21 AGE U/mg of ApoB, p < 0.01). Higher AGE-ApoB levels were observed in those patients with atherosclerosis (329 +/- 23 versus 259 +/- 24 AGE U/mg ApoB, p < 0.05). Comparisons of tissue AGE-collagen with serum AGE-ApoB levels showed a significant correlation (r = 0.707, p < 0.01). In early lesions, AGE-IR occurred mostly extracellularly. In fatty streaks and dense, cellular atheromatous lesions, AGE-IR was visible within lipid-containing smooth muscle cells and macrophages, while in late-stage, acellular plaques, AGE-IR occurred mostly extracellularly. AGE-R1 and -R2 were observed on vascular endothelial and smooth-muscle cells and on infiltrating mononuclear cells in the early-stage lesions, whereas in dense, late-stage plaques, they colocalized mostly with lipid-laden macrophages. On tissue sections, scoring of AGE-immunofluorescence correlated with tissue AGE and plasma AGE-ApoB. CONCLUSIONS: (1) The correlation between arterial tissue AGEs and circulating AGE-ApoB suggests a causal link between AGE modification of lipoproteins and atherosclerosis. AGE-specific receptors may contribute to this process. (2) Serum AGE-ApoB may serve to predict atherosclerosis in asymptomatic patients.

Exposed or infected peripheral vascular grafts pose a significant challenge to the vascular surgeon. Although graft removal and extraanatomic bypass is feasible in selected circumstances, this procedure is generally not applicable for bypass to the pedal vessels. Preservation of patent grafts is almost always required for limb salvage. We present a case report of an exposed vein graft to the dorsalis pedis artery. We conclude that a local fasciocutaneous flap is an excellent treatment option, and describe the procedure in detail.

This review outlines the mechanisms underlying the interaction between the nervous and immune systems of the host in response to an immune challenge. The main focus is the cholinergic anti-inflammatory pathway, which we recently described as a novel function of the efferent vagus nerve. This pathway plays a critical role in controlling the inflammatory response through interaction with peripheral α7 subunit-containing nicotinic acetylcholine receptors expressed on macrophages. We describe the modulation of systemic and local inflammation by the cholinergic anti-inflammatory pathway and its function as an interface between the brain and the immune system. The clinical implications of this novel mechanism also are discussed.

Hypothesis Ultrasound-guided injection of thrombin is the treatment of choice for femoral pseudoaneurysms. Design A prospective study of patients undergoing a single form of treatment for femoral pseudoaneurysms. Setting Patients were treated at 2 tertiary care, university-affiliated hospitals. Patients Forty consecutive patients with femoral pseudoaneurysms resulting from diagnostic and therapeutic catheterizations for peripheral arterial, coronary arterial, and cerebrovascular diseases were evaluated. Intervention Thrombin was injected directly into the pseudoaneurysms under ultrasonographic guidance. Main Outcome Measure Thrombosis of the pseudoaneurysm following thrombin injection was the goal of treatment. Results All 40 patients had initial complete thrombosis of their femoral pseudoaneurysms. In each case, except for one, the aneurysm was noted to have thrombosed on follow-up duplex ultrasongram. There was one complication. Conclusion Ultrasound-guided thrombin injection is the treatment of choice for femoral pseudoaneurysms.

Efferent activity in the vagus nerve can prevent endotoxin-induced shock by attenuating tumor necrosis factor (TNF) synthesis. Termed the “cholinergic antiinflammatory pathway,” inhibition of TNF synthesis is dependent on nicotinic α-bungarotoxin-sensitive acetylcholine receptors on macrophages. Vagus nerve firing is also stimulated by CNI-1493, a tetravalent guanylhydrazone molecule that inhibits systemic inflammation. Here, we studied the effects of pharmacological and electrical stimulation of the intact vagus nerve in adult male Lewis rats subjected to endotoxin-induced shock to determine whether intact vagus nerve signaling is required for the antiinflammatory action of CNI-1493. CNI-1493 administered via the intracerebroventricular route was 100,000-fold more effective in suppressing endotoxin-induced TNF release and shock as compared with intravenous dosing. Surgical or chemical vagotomy rendered animals sensitive to TNF release and shock, despite treatment with CNI-1493, indicating that an intact cholinergic antiinflammatory pathway is required for antiinflammatory efficacy in vivo. Electrical stimulation of either the right or left intact vagus nerve conferred significant protection against endotoxin-induced shock, and specifically attenuated serum and myocardial TNF, but not pulmonary TNF synthesis, as compared with sham-operated animals. Together, these results indicate that stimulation of the cholinergic antiinflammatory pathway by either pharmacological or electrical methods can attenuate the systemic inflammatory response to endotoxin-induced shock.

Objective: The incidence of postoperative hypertension (HTN) after eversion carotid endarterectomy (e-CEA) was compared with that after standard carotid endarterectomy (s-CEA). Methods: In a retrospective analysis from January 1998 to January 2000, 217 patients underwent 219 CEAs for symptomatic (68) or asymptomatic (151) high-grade (>80%) carotid artery stenosis by either standard (137) or eversion (82) techniques. The eversion technique involves an oblique transection of the internal carotid artery at the carotid bulb and a subsequent endarterectomy by everting the internal carotid artery over the atheromatous plaque. All procedures were done under general anesthesia, and somatosensory-evoked potentials were used for cerebral monitoring. Patients with s-CEA were compared with those with e-CEA for postoperative hemodynamic instability, carotid sinus nerve block, requirement for intravenous vasodilators or vasopressors, stroke, and death. Results: Patients who underwent e-CEA had a significantly (P

Activation of the innate immune system, even by relatively innocuous stimuli, stimulates the release of cytokines (e.g. TNF) that can injure or kill the host. To maintain homeostasis, mammals have evolved a counter-regulatory response that suppresses the development of excessively robust inflammation. Fetuin, a 66-kD negative acute phase glycoprotein, was first identified in 1944. We recently discovered an anti-inflammatory role for fetuin, because it suppressed the release of TNF from lipopolysaccharide- (LPS) stimulated macrophages. Here the anti-inflammatory effects of fetuin were studied in vivo in an LPS-independent model of acute inflammation caused by administration of carrageenan. Administration of fetuin (5-500 mg/kg intraperitoneally) dose-dependently attenuated the development of paw edema as compared to either asialofetuin (500 mg/kg) or bovine albumin (500 mg/kg). TNF production in the carrageenan-injected paws was significantly inhibited by administration of fetuin (586+/-98 pg TNF/paw) as compared to either asialofetuin (1018+/-186 pg TNF/paw) or saline (1,005+/-172 pg TNF/paw). When specific anti-fetuin IgG was administered into the paw prior to the application of carrageenan, the development of edema formation was significantly increased as compared to irrelevant IgG, indicating that endogenous fetuin normally attenuates the inflammatory response. These results now reveal a previously unrecognized anti-inflammatory role of fetuin in counter-regulating the innate immune response, and suggest that it may be possible to use fetuin as an experimental anti-inflammatory agent.

Objective: In this retrospective multicenter study, the results of a minimally invasive method of endovascular-assisted in situ bypass grafting (EISB) versus “open” conventional in situ bypass grafting (CISB) were evaluated with a comparison of primary and secondary patency, limb salvage, and cost. Methods: Enrolled in this study were 273 patients: 117 underwent CISB (42 femoropopliteal, 75 femorocrural) and 156 underwent EISB (41 femoropopliteal, 115 femorocrural). EISB was performed with an angioscopic Side Branch Occlusion system and an angioscopically guided valvulotome. All the patients underwent follow-up examination with serial color-flow ultrasound scanning. Results: Both groups had similar comorbid risk factors for diabetes mellitus, coronary artery heart disease, hypertension, and cigarette smoking. The primary patency rates (CISB, 78.2% ± 5% [SE]; EISB, 70.5% ± 5%; P = .156), the secondary patency rates (CISB, 84.1% ± 4%; EISB, 82.9% ± 5%; P = .26), and the limb salvage rates (CISB, 85.8%; EISB, 88.4%; P = .127) were statistically similar, with a follow-up period that extended to 39 months (mean, 16.6 months; range, 1 to 40 months). In veins that were less than 2.5 to 3.0 mm in diameter, the EISB grafts fared poorly, with an increased incidence of early (12-month) graft thromboses (CISB, 10 grafts, 8.5%; EISB, 24 grafts, 15.3%). However, wound complications (CISB, 23%; EISB, 4%; P = .003), mean hospital length of stay (CISB, 6.5 days ± 4.83; EISB, 3.2 days ± 3.19; P = .001), and mean hospital charges (CISB, $25,349 ± $19,476; EISB, $18,096 ± $14,573; P = .001) were all significantly reduced in the EISB group. Conclusion: The CISB and EISB midterm primary and secondary patency and limb salvage rates were statistically similar. In smaller veins (< 2.5 to 3.0 mm in diameter), however, EISB is not appropriate because overly aggressive instrumentation may cause intimal trauma, with resultant early graft failure. With the avoidance of a long leg incision in the EISB group, wound complications and hospital length of stay were significantly reduced, which lowered hospital charges and justified the additional cost of the endovascular instruments. When in situ bypass grafting is contemplated, EISB in appropriate patients is a safe, minimally invasive, and cost-effective alternative to CISB. (J Vasc Surg 2000;31:60-8.)

Objective: Hypogastric artery (HA) occlusion during aortic aneurysm repair has been associated with considerable morbidity. We analyzed the consequences of interrupting one or both HAs in the standard surgical or endovascular treatment of aortoiliac aneurysms (AIAs). Methods: From 1992 to 2000, 154 patients with abdominal aortic aneurysms (n = 66), iliac aneurysms (n = 28), or AIAs (n = 60) required interruption of one (n = 134) or both (n = 20) HAs as part of their endovascular (n = 107) or open repair (n = 47). Endovascular treatment was performed with a variety of industry- or surgeon-made grafts in combination with coil embolization of the HAs. The standard surgical techniques included oversewing or excluding the origins of the HAs and extending the prosthetic graft to the external iliac or femoral artery. Results: There were no cases of buttock necrosis, ischemic colitis requiring laparotomy, or death when one or both HAs were interrupted. Persistent buttock claudication occurred after 16 (12%) of the unilateral and 2 (11%) of the bilateral HA interruptions. Impotence occurred in 7 (9%) of the unilateral and 2 (13%) of the bilateral HA interruptions. Minor neurologic deficits of the lower extremity were observed in 2 (1.5%) of the patients with unilateral HA interruption. Conclusions: Although HA flow should be preserved if possible, selective interruption of one or both HAs can usually be accomplished safely during endovascular and open repair of anatomically challenging AIAs. We believe other comorbid factors such as shock, distal embolization, or the failure to preserve collateral branches from the external iliac and femoral arteries may have contributed to the morbidity in other reports of HA interruption. (J Vasc Surg 2001;33:S27-32.)

The problem of coexisting coronary artery disease in vascular patients is well recognized, because early and late morbidity and mortality rates in patients undergoing peripheral arterial surgery in all locations is overwhelmingly of myocardial origin. In these days of financial constraints on diagnostic resources, ascertaining the extent of coronary artery disease with a reasonable degree of precision may be more difficult than the therapeutic recommendations following the discovery of coronary artery disease. Allan D. Callow, M.D.

Injury can occur to several of the cranial nerves during carotid endarterectomy. Among these, glossopharyngeal nerve injury is an uncommon complication because it is remote from the field of dissection in most carotid procedures. From more than 2000 carotid operations four cases of symptomatic ninth cranial nerve injury were identified. Analysis revealed that dissection cephalad to the level of the hypoglossal nerve was a common feature of each and severe functional disability can result from glossopharyngeal nerve paresis. When mobilization of this nerve and division of the posterior belly of the digastric muscle and styloid process become necessary for additional exposure, the risk of glossopharyngeal nerve injury increases. Specific recommendations are made regarding management and maneuvers to help reduce the incidence of this uncommon, yet potentially serious, complication.

We report case of a subclavian artery pseudoaneurysm in a patient with type IV Ehlers-Danlos Syndrome. A 16-year-old boy underwent successful repair of a subclavian artery pseudoaneurysm that occurred after a cervical hyperextension injury. Subsequent workup included skin biopsy and fibroblast culture, which were consistent with a diagnosis of type IV Ehlers-Danlos Syndrome. This condition is a dominantly inherited connective tissue disorder, which in this patient was found to be caused by a spontaneous point mutation in the COL3A1 gene that encodes the chains of type III procollagen. The clinical, genetic, and molecular characteristics of type IV Ehlers-Danlos Syndrome are briefly reviewed. (J Vasc Surg 1998;27:549-51.)

The presence of bilateral iliac aneurysms extending to the iliac bifurcations, in conjunction with an abdominal aortic aneurysm, complicates endovascular repair because of the difficulty of preserving one or both hypogastric arteries. Several open techniques have been suggested for hypogastric preservation, but they usually involve some type of anatomic or extra-anatomic bypass. Endovascular techniques for hypogastric preservation include branch iliac grafts, chimney grafts, and bellbottom limbs. We report the use of a Viabahn stent graft (W. L. Gore and Associates, Flagstaff, Ariz) within the iliac limb of a Powerlink device (Endologix, Inc, Irvine, Calif) to preserve a hypogastric artery.

Patients under the age of 40 with colorectal cancer (29 females, 18 males) were compared with similar patients in our general hospital population and analyzed for patterns of presentation, stage at diagnosis, degree of tumor differentiation, and survival. There was a higher incidence of poorly differentiated tumors in the young patients (21% vs. 8% in the general population). Colon cancer in young adults was in a more advanced stage at presentation. The survival rate for young patients was 23% vs. 61% for the general population (p = 0.02). Stage C patients treated for cure had a survival rate of 56% in the general population compared with 34% in young adults (p = 0.05). The degree of tumor differentiation did not affect survival in those young patients undergoing curative resections (41% for well-differentiated and 30% for poorly differentiated cancers, p = 0.09). The median survival time by stage was: Stage A and B (N = 3) 36 months, Stage C (N = 26) 32 months, and Stage D (N = 18) 15.8 months. The need for early recognition of colorectal cancer in young adults is emphasized by the greater incidence of advanced disease and the high failure rate.

Duplex scanning of the carotid bifurcation has emerged as an accurate noninvasive means of predicting and quantifying carotid arterial stenoses. Compared with the more widely reported measurements of spectral broadening and peak frequency ratios, measurements of diastolic velocity ratios have theoretical advantages in predicting carotid artery stenosis. The use of diastolic velocity ratios between the internal and common carotid arteries was prospectively studied in 30 consecutive patients to determine its accuracy in predicting significant stenosis of the internal carotid artery when compared with angiography. A total of 55 carotid bifurcations were studied, and the use of diastolic velocity ratios correctly predicted high-grade stenosis (greater than or equal to 75% diameter reduction) in 52 cases (95%). We conclude that diastolic velocity ratios may be used to accurately detect significant internal carotid artery stenosis.

With demonstration of the failure of extracranial-intracranial (EC-IC) bypass to reduce the incidence of stroke in patients with internal carotid artery (ICA) occlusion, controversy continues regarding the best method of stroke prevention in these high-risk persons. One approach, endarterectomy of stenotic lesions of the contralateral carotid bifurcation, has been used for 145 patients with ICA occlusion during the past 25 years. Presenting symptoms included focal transient ischemic attacks (TIAs) in 62 patients, stroke (CVA) in 57, and nonfocal TIAs in 16. Ten patients were asymptomatic. Nine patients (6.2%) sustained perioperative strokes, only three of which were ipsilateral to the endarterectomy. There were three perioperative deaths (2.1%). During the follow-up period (mean 4 years) there were 13 new strokes (9.2%), four of which were fatal. These late results compare favorably with patients from the cooperative study of EC-IC bypass with occlusion of one ICA, whether they received surgical treatment or were managed nonoperatively. With the exception of select situations where an occluded ICA may be reopened, we conclude that the best current therapy for these patients is close observation of the nonoccluded ICA and endarterectomy once a stenotic lesion is encountered. (J VASC SURG 1987;5:856-61.)

The superior mesenteric artery is a frequent site of mycotic aneurysm formation. With the increasing popularity of parenteral drug abuse the incidence of superior mesenteric aneurysms is likely to increase. It should be suspected in any patient who has a history of bacterial endocarditis, sepsis, and abdominal pain. Abdominal CT scanning and visceral angiography are most useful in establishing the diagnosis, and surgical therapy should ensue with minimal delay. The various intraoperative methods of eradicating this lesion are described, with a review of the literature and report of successful management of one such case.

The patient with bilateral internal carotid artery occlusion is at high risk for development of stroke. Medical management and extracranial-intracranial bypass do not appear to offer these patients any protection from symptoms of cerebrovascular insufficiency. Our initial treatment in 11 of 12 patients who had this pattern of extracranial arterial occlusion has been external carotid artery revascularization. Nineteen procedures were performed for symptomatic lesions in all cases except one. There were no perioperative strokes or deaths. During a mean follow-up of 44.7 months, no new strokes occurred. Among 10 patients undergoing external carotid artery revascularization alone, only one transient ischemic attack occurred in follow-up. Seven of the eight surviving patients are presently asymptomatic. External carotid artery revascularization may be an effective and durable treatment for the patient with bilateral internal carotid artery oclusion. (J VASC SURG 1987;5:715-8.)

Heavily calcified aortic and iliac arteries are occasionally encountered that will not yield to currently available needles and sutures. The use of the Hall drill to penetrate such arterial walls, stopping short of the adventitial layer, and Teflon strips to buttress the anastomosis, is an effective means of dealing with this problem. Extensive arterial trauma is avoided and a hemostatic anastomosis may be constructed.

Compartment syndrome is a rare and dangerous complication of coronary artery bypass. All reported cases involved the vein donor limb. Once recognized, immediate fasciotomy is necessary to prevent irreversible ischemia and limb loss. Diagnosis requires a high index of suspicion and close observation of the patient, particularly those remaining intubated during the early postoperative period. (J Vasc Surg 2002;36:1069-70.)