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A 58-year-old man had sudden and progressive heart failure after a severe myocardial infarction. Aggressive medical treatment consisting of diuretics, vasopressors, and digitalis failed to improve his condition significantly. Cardiac catheterization disclosed a critical stenosis in the left anterior descending branch of the left coronary artery, a large posterior left ventricul aneurysm, and severe mitral insufficiency. Intermittent third degree heart block developed after admission. Surgical correction resulted in a dramatic recovery, and three years after operation he is fully recovered and asymptomatic.

Analysis of the short term results following end-to-side anastomosis of five arterial homografts is presented. Our immediate results indicate a high percentage of patency with excellent blood flow distally, as demonstrated by bounding peripheral pulses and postoperative arteriograms. Symptomatology of intermittent claudication, rest pain, etc., is either markedly reduced or completely eliminated. As demonstrated by one of our cases, even though the extremity may not be completely restored to normal function if gangrene is present, the level of amputation may be markedly lowered so that a digital removal can be effected instead of an above-the-knee amputation. Performance of end-to-side anastomosis preserves the collateral circulation, which is a safety factor if thrombosis of the graft occurs. It permits placement of the proximal anastomosis at a much higher level so that a greater blood flow under higher pressure is assured. By the utilization of a side of the host artery which is soft and pliable and free from atheromatous plaques, better tissue can be used to fashion the anastomosis without performing an endarterectomy. It is recommended that end-to-side anastomosis to the aorta be used for bifurcation grafts for all the foregoing reasons. Of particular importance is the preservation of essential collaterals such as those originating from the inferior mesenteric and hypogastric arteries which are usually sacrificed by replacement technics.

Summary Experimental and clinical evidence is reported which justifies the conservative treatment of thoracic duct lacerations in patients in whom complete severance of the duct has not occurred. Lymphangiography of the lower extremity has proved reliable in demonstrating the extent of the injury of the thoracic duct and the adequacy of the collateral circulation. A case of chylothorax is reported in which conservative treatment based upon lymphangiography permitted the sealing of a traumatic (operative) thoracic duct fistula without surgical intervention.

An occurrence of isolated chylopericardium in a 27 year old man is described. The asymptomatic nature of this disease in some patients is emphasized to reveal the chronic course of the process. No cause was found for the development of the chylopericardium. However, lymphangiography of the lower limbs demonstrated the communication between the branches of the thoracic duct and the pericardial sac and the point of obstruction of the thoracic duct at the level of the fistulous communication. To our knowledge, this is the first demonstration of a communication between the lymphatic vessels of the thoracic cavity and the pericardium associated with the development of chylopericardium. External drainage of the pericardial sac by means of a pericardial window using the subxyphoid route resulted in complete relief of the pericardial effusion. No recurrence of the chylopericardium was observed in this patient up to 8 months after the external drainage.