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Normal variations in the crossflow capacity of the Circle of Willis, and the effects of disease upon this and on the thromboembolic potential of the cervical carotid, together account for the clinical unpredictability of strokes. These two factors form a recurring theme in the history of stroke studies, from 1664 with the publication of Cerebri Anatome, to the duplex and computer-assisted scanning techniques of today. The path followed by the discoverers is traced from Hippocrates to Moniz and Miller Fisher, to show how their work led directly to the technique of carotid endarterectomy.

One hundred consecutive patients with intermittent claudication were screened noninvasively with electrocardiography chest wall mapping stress test and transcutaneous aortovelography during bicycle ergometry. Electrocardiographic chest wall stress testing indicated three-vessel coronary disease in 25 patients and left anterior descending plus circumflex (left main stem equivalent) disease in seven. In these 32 patients transcutaneous aortovelography demonstrated a decrease in stroke distance (an index of cardiac stroke volume) (median, -28%; 90% range, +5% to -48%), and coronary angiography confirmed the presence and severity of the disease. The claudication distance ranged between 50 and 250 meters. After myocardial revascularization or medical therapy a significant increase occurred in the stroke distance after exercise (median, +20; 90% range, +40% to -25%); also a significant increase in the postexercise pressure index and a reduction in the recovery time (p less than 0.01). No change occurred in the ankle/pressure index at rest. Twelve patients were able to walk without being limited by claudication; 15 reported improvement with a two to tenfold increase in claudication distance. No change occurred in three. The results indicate that silent myocardial ischemia is a common finding in patients with intermittent claudication. It produces left ventricular dysfunction and a decrease in stroke volume leading to a large fall in ankle pressure and early onset of claudication during exercise. Niltrates and myocardial revascularization tend to reverse this.

There is a growing appreciation for the high incidence of silent cerebral infarction and cerebral atrophy on CT scans in patients with amaurosis fugax (AF) and hemispheric transient ischemic attacks (TIAs). Seventy patients with AF only (no TIAs), 104 patients with hemispheric TIAs (no AF), 185 patients without focal carotid territory symptoms (i.e., vertebrobasilar TIAs or asymptomatic carotid bruit only), and 129 patients with stroke and good recovery were studied with CT scan and duplex scanning to grade the degree of stenosis of the internal carotid artery (grades: A = normal, B = 0% to 15% stenosis, C = 16% to 49%, D = 50% to 99%, and E = occlusion). In patients with AF, the incidence of infarction increased from 20% in grades A, B, and C to 40% in grade D and 58% in grade E. The incidence of atrophy increased in parallel from 10% in grade A to 30% in grade E. The increased incidence of atrophy with increasing degrees of stenosis was not the result of increasing degrees of stenosis per se, but the associated increase in the incidence of infarction (patients without CT infarcts in grades D and E had 5% and 0% incidence of atrophy). In patients with hemispheric TIAs, the incidence of CT infarction increased from 25% in grades A and B to 48% in grades D and E. The incidence of atrophy did not show a parallel increase. Our findings support the hypothesis that atrophy is associated not only with cerebral infarction but may be causally related.(ABSTRACT TRUNCATED AT 250 WORDS)

Carotid endarterectomy is a valuable preventive measure in some carefully selected patients with warning attacks. The cooperation of a specified neurologist is essential. Higher than average coronary and other morbidity risks require thorough general review, preferably by a cardiologist member of the vascular team. Well timed coronary bypass surgery can reduce the unacceptable high operative and late mortality in patients with manifest ischaemic heart disease. Perioperative stroke may be more related to overall vascular surgical experience than to the particular method of cerebral protection adopted. Combined stroke/mortality figures of less than 5% should be the objective.

Severe extremity ischemia frequently cannot be relieved by surgical means and failure of current drug therapy may then result in prolonged disability or amputation. Prostaglandins E1 (PGE1) and I2 (prostacyclin, PGI2) are potent vasodilators and inhibitors of platelet aggregation which have been reported to be of value in the treatment of peripheral ischemia. Nineteen patents with severe extremity ischemia and one with vasculitic leg ulceration were treated on 25 occasions by intravascular infusion of PGE1 or PGI2 for 72 to 96 hours. Causes of ischemia were arteriosclerosis, Raynaud's phenomenon (secondary), Buerger's disease, and "trash" foot. Prolonged pain relief and promotion of tissue healing occurred mainly in patents with patent proximal axial arteries. Patency of the superficial femoral artery was associated with a good clinical response in eight of nine cases of foot ischemia, and mean hallux temperature rose 4.6 +/- 2.5 degrees C. In contrast, occlusion of the artery was associated with failure in eight of nine cases, and hallux temperature rose 0.6 degrees +/- 1.3 degrees C. PGE1 or PGI2 administered intravenously may be the treatment of choice for severe ischemia in distal arteriopathy, although the exact mechanisms by which these prostaglandins act are far from clear.

A review of 50 cases of acute dissection of the aorta managed over a period of almost 15 years showed that patients with either proximal or complex dissections had a better prognosis when managed surgically, whereas medical treatment offered a better change of survival in patients with distal dissection. Angiography was generally safe and reliable, most cases being correctly diagnosed by this means. The majority of patients can be managed conservatively in the initial stages.

Twenty-one patients with severe Raynaud's phenomenon were treated on 29 occasions with prostaglandin E1 (PGE1), a potent vasodilator and pyrogen. A history of finger sepsis or necrosis was absent in 8 (group I) and present in 13 (group II). Three group I and eight group II patients had an associated connective tissue disease, and previously eight upper limbs had been sympathectomized in six group I patients and 14 upper limbs in eight group II patients. A total of 12 fingers had been amputated in six group II patients. Treatment comprised antibiotics for sepsis, PGE1 intravenously for 72 hours, and subsequent surgical debridement of septic and necrotic tissue in 30 fingers of eight group II patients under general anesthesia. Finger skin temperature measured half-hourly in a temperature-controlled ward cubicle (23.7 degrees +/- 0.7 degrees C), Doppler-detectable digital arterial flow, and finger/brachial systolic pressure index with local finger cooling to 10 degrees C were not improved by the administration of 0.9% saline for 72 hours, but were all significantly improved after PGE1 administration. Finger skin temperature was significantly elevated 11 weeks after treatment. The symptoms did not improve after PGE1 administration in group I patients but did improve in 12 of 13 group II patients. No finger deteriorated, and all debrided fingers healed after surgery. Nail bed removal in 11 fingers met with patient approval and prevented recurrent sepsis and necrosis. PGE1 provides a means of increasing finger blood flow during acute exacerbations of finger sepsis and necrosis; unlike sympathectomy, it is a minor procedure without prolonged side effects and is repeatable.

The three main risk factors for cardiovascular disease, smoking, hypertension, and hyperlipidaemia, are examined in the light of changing world trends and the mechanisms by which they aggravate this large group of conditions. Prostaglandin activity within the vessel wall and the blood platelets may be disturbed by the risk factors, the control of which in programmes of primary prevention has been followed by striking reductions in cardiovascular morbidity and mortality in two of the world's worst-affected areas. Secondary preventive application of these same measures may improve the outcome in the treatment of established cardiovascular disease in the heart, brain, or limbs. Present advances in combined investigation and multifocal surgical treatment are described against a background of increasing safety throughout the perioperative period.

The aim of the study was to measure the haemodynamic effect of percutaneous transluminal angioplasty (PTA). Twenty-one consecutive patients with unilateral stenosis of the iliac (n = 13) or femoropopliteal arteries (n = 8) causing intermittent claudication were studied with ankle and brachial systolic pressure measurements before and after PTA and at six monthly intervals. In 15 patients, the pressures were measured not only at rest, but after exercise on a standard treadmill. There were six technical failures. All of the remaining patients were improved clinically and objectively. The resting pressure index increased from mean (+/- ISD) of 0.65 +/- 0.22 to 0.88 +/- 0.17 and the postexercise index from 0.43 +/- 0.21 to 0.82 +/- 0.22. The preoperative claudication distance was improved from 83 m +/- 31 to 252 m +/- 104 and the recovery time from 6.3 mins +/- 5.7 to 1.5 mins +/- 2.3. During the follow up period of six weeks to 2 1/2 years, the initial improvement was maintained and there were no failures clinically or on further Doppler examination. The results suggest that for patient with a single significant stenosis, PTA is an effective alternative method of treating claudication.

Leg volume changes during exercise have been measured in absolute units (milliliters) by means of a new method of air-plethysmography. Venous volume (VV), venous filling time, and venous filling index on standing from the recumbent position, ejected volume (EV) and ejection fraction (EF = EV x 100/VV) with one tiptoe movement, and residual volume (RV) and residual volume fraction (RVF = RV x 100/VV) after 10 tiptoe movements were measured in normal limbs, limbs with superficial venous incompetence, and limbs with deep venous disease. The same measurements were repeated with a graduated medium compression stocking in limbs with SVI and graduated high compression stockings in limbs with DVD. Ambulatory venous pressure was measured at the same time, with a needle in a vein in the foot. The results indicate that this method of air-plethysmography is not only of diagnostic value but offers a new and unique technique to assess and study the hemodynamic effects of different forms of elastic compression. The lower ambulatory venous pressure, produced by the elastic compression, was the result of a reduction in reflux and an improvement in the calf muscle ejecting ability during rhythmic exercise.

A series of 245 patients was operated upon for abdominal aortic aneurysm during the years 1969-77, of whom 162 were elective cases while in 83 the aneurysm was leaking or had ruptured. The hospital mortality for the latter group fell from 77 per cent at the beginning of the study period to 30 per cent at the end. For elective operations, hospital mortality averaged 9.3 per cent, though during the last 2 years there were no deaths in the 51 consecutive cases. Operative methods and postoperative treatment changed during the years of the study, with few excision-replacement grafts and greater use of the inlay technique, most of the latter being simple unbranched Dacron tubes. Early graft infection, the most important and serious surgical complication, caused 9 deaths, an overall incidence of 3.7 per cent, of which 8 were in patients who received no perioperative antibiotics and only 1 among the patients who did receive them. All deaths were in the inlay group. The reasons for this are discussed. Since July 1976 perioperative antibiotic treatment has been routine for all arterial prosthetic graft patients in our hospital.

A new jig is described which enables the technique for abdominal aortic aneurysm to be taught and practiced as it is performed by arterial surgeons at the present time. The aneurysm jig enables a plastic simulated aortic aneurysm to be opened as at operation to allow the inlaying of a Dacron tube sutured into place with continuous sutures.

We measured the hemodynamic improvement after femorofemoral grafting and determined the five-year cumulative patency rate in 54 consecutive high-risk patients with unilateral iliac artery occlusion who had femorofemoral grafts who were studied with ankle and brachial systolic pressure measurements before and after operation and at six-month intervals. There were two early deaths and seven early graft failures (less than 30 days) with four amputations (all operated on for rest pain). All of the remaining 45 patients' conditions improved clinically and objectively. The resting pressure index (mean +/- SD) in claudicants (n = 23) increased from 0.35 +/- 0.15 to 0.67 +/- 0.20; in patients with severe ischemia (n = 31) it increased from 0.25 +/- 0.15 to 0.50 +/- 0.20. During the follow-up period (six months to ten years), there were eight deaths and 12 late graft failures (greater than 30 days). The late cumulative patency rate was 60% at five years. Hemodynamic improvement parallels clinical success and for these high-risk patients, the femorofemoral bypass is a satisfactory alternative to a more major operation.

Velocity tracings obtained with a Doppler ultrasound probe located over the common femoral artery have been evaluated as to their ability to predict the state of the proximal aortoiliac segment. Aortography was used as the assessor of the extent of aortoiliac disease. Five parameters of the tracings sensitive only to aortoiliac disease were submitted to miltivariate analysis. The probability of the aortoiliac segment having greater or less than 10% stenosis was calculated. In 86% of limbs, a high probability of diagnostic value and practical use resulted.