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Of a total of 225 patients with suspected thoracic outlet syndrome, 37 (16.4%) underwent surgery. Some eight patients required bilateral operations. One patient had a cervical rib and one a prominent C7 transverse process. A total of 45 limbs were operated on. Thirty-nine procedures were performed as combined scalenectomy and transaxillary first rib resection, four as two-stage scalenectomy and transaxillary first rib resection and two as simple scalenectomy alone. Follow-up from 6 to 60 (mean 17) months was available for 39 operations. A two-tier assessment method was used to improve the accuracy of the results of surgery, including the patient's own evaluation of the benefit of operation communicated to an independent observer and the surgeon's clinical appraisal. Assessment of outcome by the physician was excellent in 54%, good in 28%, fair in 10% and 8% had recurrent symptoms. Similar results were achieved in the patients' subjective evaluation with approximately 50% reporting an excellent outcome, about 40% good and 10% fair. A poor result was not recorded in those who underwent combined scalenectomy and transaxillary first rib resection. A radical surgical approach combining scalenectomy and transaxillary first rib resection is advocated to minimize the recurrence rate and improve results.

Spontaneous renal artery dissection is an uncommon cause of renovascular hypertension, usually associated with fibromuscular dysplasia. Among reported nonautopsy cases (N = 80), arterial reconstruction has seldom been attempted (N = 21) and the outcome has frequently been poor (48% clinical failure rate). This is attributed in part to the frequent involvement of renal artery branches by the dissection. Furthermore, the report of spontaneous reversion to normotension among patients treated medically has also clouded the role of surgery in this disease. Since progress in the technique of renal artery repair now allows successful treatment of anatomically complex lesions, we reviewed our experience with arterial reconstruction in the management of spontaneous renal artery dissection to determine the frequency of and factors correlating with cure after operative repair. Ten patients (eight men, two women; mean age, 39.3 +/- 5.9 years) were admitted with severe hypertension (10/10), often associated with neurologic symptoms, hematuria, or flank pain (8/10). Serum creatinine was elevated in only two patients. Angiography demonstrated changes consistent with fibromuscular dysplasia in 7 of 10 patients and evidence of dissection in 6 of 10. Bilateral disease was present in three patients. Only five patients had a single renal artery on the involved side. The dissection extended into the primary branches in 8 of 10 patients and involved both renal arteries in four of the five patients with two arteries. Histologic study confirmed fibromuscular dysplasia in six and intramural dissection in all operative specimens. Five patients underwent revascularization (in one case requiring the ex vivo technique), with use of hypogastric artery as a conduit in four of five or resection and primary reanastomosis in one of five. Three patients became normotensive, and two returned to their previous level of blood pressure control. Follow-up averaged 14.5 years. Two patients underwent nephrectomy after exploration demonstrated nonreconstructible vessels, and two underwent nephrectomy when intraoperative assessment of the kidney showed that revascularization had failed to adequately reverse extensive renal ischemia. After a mean follow-up of 14.6 years these patients remain normotensive, although two require antihypertensive medications. One patient was treated medically and is currently hypertensive off all medications. Nine of 10 patients have maintained a normal serum creatinine during follow-up. We conclude that renal revascularization is frequently successful in spontaneous renal artery dissection (five of seven, 71.4%) and results in sustained relief of hypertension with maximal conservation of renal tissue. This is important because of the young age at onset and the not infrequent occurrence of bilateral fibromuscular dysplasia, and even of dissection.(ABSTRACT TRUNCATED AT 400 WORDS)

The unusual complication of an atherosclerotic abdominal aneurysm rupturing into a retro-aortic left renal vein is presented. Angiographic findings and the anatomic variations of the left renal vein are discussed.

Occlusive disease of the aortic arch vessels is relatively rare and often missed initially. Of 41 patients treated surgically for this condition over a 10-year period 38 had arteriosclerotic lesions, 2 had symptoms secondary to vasculitis (Takayasu's arteritis) and 1 had a radiation injury to a subclavian artery. In 22 cases the left subclavian artery was involved; the right subclavian and innominate arteries were the next most commonly affected. Only four vertebral stenoses were treated. Most patients presented with a combination of arm and hindbrain ischemia that was shown radiologically to be associated with a subclavian steal syndrome, but in some only isolated arm symptoms or severe vertigo alone was experienced. There was a difference in blood pressure between the arms of at least 20 mm Hg in 88% of the patients. The treatment for 28 patients was creation of a carotid-subclavian bypass, for 6 the placement of a bypass graft from the ascending aorta to the subclavian or carotid artery or both, for a 3 a subclavian endarterectomy and for 4 vertebral angioplasty. There were no operative deaths, and 90% of the grafts were patent 1 to 72 months later. however, only 30 (73%) of the patients were asymptomatic and 9 (22%) had improved.

This paper compares the management of two groups of patients with flail chest. The 25 patients in group 1 had a flail chest without other significant injuries or shock, whereas the 57 in group 2 had a flail chest with multiple injuries, shock or both. The group 1 patients were treated with repeated multiple intercostal nerve blocks or high segmental epidural analgesia, oxygen, intensive chest physiotherapy, fluid restriction, furosemide diuretics, methylprednisolone sodium succinate and colloid infusion in an intensive care unit. In addition to these measures, the group 2 patients underwent endotracheal intubation and assisted mechanical ventilation with a volume respirator that provided continuous positive airway pressure and positive end-expiratory pressure. Of the 57 group 2 patients 36 required prolonged ventilation, eventually through a tracheostomy, because of severe head injury, pneumonia, severe facial injury, quadriplegia, pre-existing lung disease or severe sepsis. However, tracheostomy was avoided in the other 21 patients in group 2. There were no deaths in group 1, but 8 (14%) of the patients in group 2 died. These results show that avoidance of tracheostomy and ventilation in selected patients with flail chest is consistent with a low morbidity and mortality.

The role of percutaneous transluminal angioplasty in treating advanced peripheral vascular disease is unknown. The authors therefore reviewed the experience of Sunnybrook Medical Centre in Toronto with 85 consecutive patients who had rest pain, ulceration, pregangrene or gangrene as a result of peripheral vascular disease and who underwent percutaneous transluminal angioplasty. Seventy-four percent were smokers and 91% were at increased risk due to one or more of the following: coronary or cerebral ischemic disease, diabetes mellitus, obesity and hypertension. Thirty-six patients underwent dilatation of iliac lesions, 46 of superficial femoral or popliteal and 3 of more distal lesions. In nine patients angioplasty was repeated on the same lesion. In 16 patients, the procedure was technically unsatisfactory. The morbidity and 30-day mortality were 5% and 2%, respectively. When the procedure was technically satisfactory, surgery was avoided and the limb was salvaged at 1, 2 and 5 years in 69%, 62% and 54% of cases, respectively (life-table analysis). The authors conclude that percutaneous transluminal angioplasty is acceptable treatment for patients with advanced peripheral vascular disease, because the morbidity and mortality are low and the long-term results are good.

Angiography plays a vital role in the investigation of the patient suffering from multiple trauma. The commonest injuries have been rupture of the thoracic aorta, renal lacerations, arterial bleeding associated with fractures and soft-tissue injuries to the pelvis, and occlusions of the arteries supplying the limbs. Transcatheter arterial embolization may be the definitive therapeutic procedure in pelvic bleeding.

To examine the morbidity and mortality associated with blunt splenic injuries, the authors reviewed the results in 106 such patients treated in the Sunnybrook Regional Trauma Unit between June 1, 1976 and June 30, 1983. Initial assessment included peritoneal lavage in 86 patients. No patient with known or suspected splenic injury was treated nonoperatively nor were any patients found to have had splenic injuries missed at the initial assessment. Seventy-one splenectomies and 35 splenorrhaphies were performed. The overall mortality was 25% and 10 surviving patients had serious complications. The splenic injury itself was never the cause of death. Only one patient who initially underwent splenorrhaphy later required splenectomy. It is concluded that blunt splenic injury is rarely the cause of death or serious morbidity when a policy of immediate diagnosis and operative treatment is carried out. Furthermore, in selected patients, splenorrhaphy is a safe and effective treatment.