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Significant arterial trauma can result from femoral arterial cannulation for cardiopulmonary bypass or intraaortic balloon pumping. Threat of imminent loss of limb or suture line disruption requires prompt surgical intervention. Delayed appearance of claudication, characteristically at 1 to 2 weeks postoperatively, is highly suggestive of iatrogenic iliofemoral injury. Arterial reconstructive surgery was necessary in three of five such patients.

The cases of three patients with lower extremity ischemia from ipsilateral iliac artery occlusion and contralateral iliac artery stenosis are presented. Planned treatment was percutaneous transluminal angioplasty (PTA) of the contralateral iliac artery, rendering it an adequate donor vessel for subsequent femorofemoral bypass. Because of adequate collateral vessels across the pelvis, cross-femoral bypass was unnecessary following PTA. Current technology allows simultaneous intraoperative PTA and femorofemoral bypass. We do not recommend this on the basis of our experience.

The Southern Association for Vascular Surgery, as one of the recently developed major regional vascular societies, has recognized the outstanding accomplishments of one of the vascular pioneers in the United States, Rudolph Matas, by including his profile in the Association logo. Although the contributions in vascular surgery by Matas are well known by all who have an interest in vascular surgery, the contributions of V. Soubbotitch have not been recognized widely in the English-speaking world. Matas proclaimed in an International Surgical Congress in London in 1913 that Soubbotitch had achieved clinical success that was unparalleled by repairing injured arteries and veins. Soubbotitch, Senior Surgeon, Belgrade State Hospital, Serbia (now part of Yugoslavia) and a Lieutenant Colonel in the Serbian Army Reserve during the Balkan Wars (Serbo-Turkish and Serbo-Bulgarian) initiated one of the first clinical programs that emphasized repair, rather than ligation, of injured arteries and veins. Surgeons from the capitals in Europe visited his clinic to assist in this effort, and the 1913 presentation in London included the experience of managing 77 injured large blood vessels, which resulted in 32 vascular repairs--19 arteriorrhaphies and 13 venorrhaphies. It is ironic that nearly 40 years passed before similar successful efforts were achieved during the latter part of the Korean Conflict (1952 to 1953). In this brief review we emphasize the connection between two outstanding surgical pioneers who shared mutual interest in the repair of injured vessels and in international surgical exchanges, Matas and Soubbotitch.

Perioperative fluctuation of blood pressure and the use of anticoagulants during carotid endarterectomy may potentiate lethal aneurysm rupture in patients who have symptomatic extracranial carotid artery occlusive disease with incidental, asymptomatic, intracranial berry aneurysms. Ten patients having this combination are described in the present study. Of five men and five women whose mean age was 63 years, nine had symptomatic carotid bifurcation atherosclerosis, one had internal carotid fibromuscular dysplasia, and all had intracranial berry aneurysms ranging from 2 to 13 mm in diameter (mean diameter 6.6 mm). In seven patients, aneurysms were greater than or equal to 6 mm in diameter. Hypertension was present in seven patients and moderately severe in five. Three of the aneurysms were located in the intracranial internal carotid artery, five in the middle cerebral artery, three in the posterior communicating artery, one in the anterior cerebral artery, and one in the superior cerebellar artery. Twelve carotid reconstructive procedures were performed without morbidity related to aneurysm rupture. These included 10 carotid endarterectomies, one of which was combined with Dacron patch angioplasty and one of which was combined with a simultaneous coronary artery bypass; one carotid artery dilatation for fibromuscular disease; and one reoperative carotid endarterectomy with patch angioplasty. Three patients had correction of hemodynamically significant lesions, two of which were proximal to ipsilateral anterior circulation aneurysms. An intraluminal shunt and heparin anticoagulation therapy were used in all patients. Despite a concerted effort to control blood pressure, the patients' perioperative blood pressures ranged from 60/30 to 240/110 mm Hg. Three patients had subsequent elective clipping of intracranial aneurysms.(ABSTRACT TRUNCATED AT 250 WORDS)

Perioperative low dose heparin was administered to 24 patients who were compared with 19 control patients undergoing peripheral vascular surgical procedures. This prophylactic measure was ineffective in reducing the incidence of subclinical, postoperative deep venous thrombosis, as indicated by iodine-125 fibrinogen scanning. The data suggest that patients undergoing vascular surgery will not benefit from the routine application of this prophylactic regimen.

Since 1966, 29 patients with recurrent carotid artery stenosis have been encountered. The mean (+/- SEM) internal between initial carotid endarterectomy and secondary presentation was 67.5 +/- 9.2 months (range 6 to 180 months). There was a disproportionate number of women with recurrent stenosis. The mean age at initial endarterectomy in patients with recurrent stenosis, 54.6 +/- 1.4 years, was significantly less (P less than 0.001) than that of all patients who had endarterectomy. To define the etiologic factors for recurrence, 21 of these patients were matched with case-control patients of the same age and sex who had undergone endarterectomy the same year but did not develop recognized recurrent stenosis. There was no significant difference in the incidence of hypertension, diabetes mellitus, coronary artery disease, bilateral carotid disease, other vascular operations, or family history for atherosclerosis in patients with recurrent stenosis compared to control patients. The indications for primary endarterectomy, angiographic distribution of disease, and operative details were similar in both groups. There was no difference in the incidence of regular, therapeutic aspirin ingestion following initial endarterectomy (52.5% in both groups). There was a striking difference in smoking habits. Ninety-five percent of patients with recurrent stenosis continued to smoke following initial endarterectomy, compared to 23.8% of control patients (P less than 0.001). Lipid fractionation studies were performed in both groups, and there were no significant differences in levels of cholesterol, triglycerides, high-density lipoprotein (HDL)-cholesterol, and total cholesterol/HDL-cholesterol ratio. Dose-response platelet aggregometry detected no differences between groups in the sensitivity of platelets to adenosine diphosphate (ADP), collagen, and epinephrine. Reoperation in patients with recurrent stenosis was associated with minimal morbidity, no deaths, and generally excellent results.

The results of randomized clinical trials evaluating commonly used methods of deep vein thrombosis (DVT) prophylaxis in moderate- and high-risk general surgery patients were pooled to obtain an unbiased estimate of efficacy and risks. Low-dose heparin (LDH), dextran, heparin-dihydroergotamine (HDHE), intermittent pneumatic compression (IPC), and graded elastic stockings significantly reduced the incidence of DVT; aspirin was ineffective. In contrast to other methods, elastic stockings have not been adequately studied to determine their value in reducing DVT in high-risk patients, such as those with malignancy. Only LDH and dextran were studied in numbers of patients sufficient for demonstrating a clear reduction in pulmonary embolism (PE). In comparison studies, LDH was superior to dextran in preventing DVT, but the two agents were equivalent in protecting against PE. Although HDHE was marginally better than LDH in preventing DVT, it appeared to have no advantage in preventing PE--at least in moderate-risk patients. The incidence of major hemorrhage was not increased with any of the prophylactic agents. However, wound hematomas occurred significantly more frequently with LDH, an effect noted in the pooled data from double-blind and open trials. In comparison trials with LDH, both dextran and HDHE had significantly fewer wound hematomas. LDH administered every 8 hours appeared more effective in reducing DVT than LDH administered every 12 hours; the incidence of wound hematomas was equivalent with both regimens.

Thirteen patients with internal carotid occlusion underwent 14 primary external carotid revascularization procedures over a 31 month period. Ten patients had obliteration of their internal carotid stump combined with patch angioplasty of the external carotid artery, and 3 had vein bypasses from the common carotid artery to the external carotid artery. Eleven patients were symptomatic with either amaurosis fugax or hemispheric transient ischemic attacks. Two patients were asymptomatic. All patients had serial carotid noninvasive tests (B-mode ultrasonography, spectral analysis, and oculoplethysmography). The mean follow-up was 22 months. Recurrent amaurosis fugax secondary to recurrent stenoses developed in two patients. These were correctly predicted by B-mode imaging and altered flow characteristics on spectral analysis. Both patients were successfully treated with reoperative procedures to prevent failure of the primary reconstruction. External carotid revascularization is a safe and durable procedure, but careful periodic follow-up is necessary to detect stenoses developing at or remote from the initial operative site. Carotid noninvasive tests appear to be helpful in detecting recurrent disease. Carotid revascularization is superior to other forms of therapy in patients who have development of neurologic symptoms ipsilateral to a chronically occluded internal carotid artery.

One-hundred nineteen patients with 125 iatrogenic vascular injuries requiring surgical intervention were treated at Walter Reed Army Medical Center from 1974 through 1982. This experience was compared with that from 1966 through 1973 [1]. A decrease in the proportion of cases resulting from cardiac catheterization was partially offset by an increase in injuries from invasive monitoring and injuries from percutaneous transluminal dilation procedures. A threefold increase in cases resulting from urologic surgery was related to the evolution of an aggressive approach toward retroperitoneal metastatic tumor. Over half of the arterial injuries are now iliofemoral in location because of the routine use of the femoral approach for angiographic and cardiac catheterization procedures. The need for complex reconstruction in addition to thrombectomy increased fourfold. Delayed surgical intervention was a factor in 9 of the 12 patients with permanent disability. There was no death attributable to vascular reconstruction.

Experience has established a major role for platelets in the pathogenesis of a variety of thromboembolic disorders. Despite advances in several areas, many problems remain. The relevance of platelet function testing to thromboembolic disorders needs clarification. Whether the association of enhanced platelet function and the aforementioned disorders represents cause, effect or nonspecific accompaniment is unknown. The concept of identifying individuals at risk by platelet function testing is attractive but unproved. Whether such individuals would benefit from prophylactic antiplatelet therapy is also unknown. For treatment of most established thromboembolic disorders as well as prophylaxis, the place of antiplatelet drugs is not established. Whether this form of therapy is superior to conventional treatment, adjunctive or of no benefit is not resolved in most instances. Also, the most appropriate antiplatelet drug or combination of drugs, and in which dosages for specific disorders, remains unclear. Well designed, prospective clinical investigation, although cumbersome and time-consuming, will be necessary to answer most of these questions. A final problem area concerns research into the pharmacology of platelet inhibition. It is probable that the ideal antiplatelet agent remains undiscovered. Currently, several investigators are looking into the possibility of manipulating prostaglandin metabolic pathways in hopes of specifically blocking thromboxane generation while allowing production of metabolites inhibitory to aggregation. This exciting approach and other investigations into the biochemical basis of platelet function should lead to the discovery of new antiplatelet agents.

The management of patients with esophageal compression by an anomalous right subclavian artery (dysphagia lusoria) has been controversial. A classic approach involves left thoracotomy, with resection of the aberrant subclavian artery from its origin to the right border of the esophagus. To prevent possible ischemic complications, most surgeons favor revascularization of the distal subclavian artery. Thoracotomy has been the traditional approach for division or reimplantation of the aberrant right subclavian artery. We describe a modification (right supraclavicular incision) of an extrathoracic approach, which was first described by Orvald in 1972, to simplify simultaneous correction of dysphagia lusoria and revascularization of the right upper extremity.

Experience with 11 cases of thromboembolectomy of leg arteries explored at the ankle is presented. Patency was established in 19 of 23 arteries (83%), resulting in salvage of 11 of 14 limbs (79%). This experience documents success of this technique with follow-up ranging from 2 to 70 months (mean followup, 24.7 months). Current indications for the procedure include 1) incomplete extraction of thrombus via the popliteal trifurcation, 2) incomplete transfemoral extraction of thrombus with restoration of a popliteal pulse, and 3) thromboembolus initially confined to the infrapopliteal arteries.

Twenty-three consecutive patients with limb-threatening ischemia underwent proximal arterial revascularization. In all patients Doppler ankle pressure was measured hourly in the postoperative period. In 16 limbs with patent superficial femoral arteries, the pressure index increased from 0.55 +/- 0.06 to 0.78 +/- 0.06 within the 1st hour postoperatively. Twenty limbs with occluded superficial femoral arteries, did not demonstrate a significant increase until 3 hours postoperatively (from 0.41 +/- 0.06 to 0.62 +/- 0.05). Immediate improvement in the Doppler pressure index is to be expected in patients with isolated aortoiliac disease who undergo successful arterial reconstruction. Failure to demonstrate such improvement is diagnostic of an intraoperative accident. Lack of immediate improvement in patients with combined aortoiliac and femoropopliteal disease should not be construed as evidence of intraoperative failure. With 3 to 4 hours, however, the ankle/arm pressure ratio should exceed the preoperative value. The failure to do so within that interval is strongly suggestive of inadequate revascularization, and in most cases immediate operative revision or the later addition of a distal bypass procedure will be necessary.

Coagulopathy, or non-mechanical hemorrhage, complicated the operative course of 17 of 33 (51.5%) patients suffering severe liver trauma. The highest incidence of non-mechanical hemorrhage (66.7%) occurred in patients undergoing anatomic lobectomy. Serial hemostatic parameters were assessed and thrombocytopenia was the most striking abnormality in patients with non-mechanical hemorrhage. The degree of thrombocytopenia was directly correlated with the number of blood transfusions administered. The mean operative blood transfusion requirement was significantly greater in patients with non-mechanical hemorrhage, 25.1 +/- 2.87 (S.E.M.) units, than in those without, 12.2 +/- 1.83 units (p < 0.001). The bulk of this transfusion was given before the onset of clinically overt coagulopathy. Massive transfusion of stored blood was felt to be the most important factor in causing non-mechanical hemorrhage. Convincing evidence for disseminated intravascular coagulation was lacking, and abnormal fibrinolysis was infrequent and mild when observed. Although uneventful in most, in six patients non-mechanical hemorrhage resulted in excessive blood transfusion, unnecessary operation or death. Infusions of platelet concentrate, fresh frozen plasma, and fresh blood were used to successfully treat most cases of non-mechanical hemorrhage. In all cases, these components were not started until non-mechanical hemorrhage was clinically apparent. The value of prophylactic use of blood components is stressed. Because of troublesome side effects associated with the use of prothrombin complex concentrates, these agents are contraindicated in patients with severe liver injury. After receiving concentrates, one patient developed severe hypotension leading to ventricular fibrillation, two developed transient thrombocytopenia and two others demonstrated multiple pulmonary microthrombi at autopsy, a finding not observed in autopsied patients not receiving the concentrates.