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Background and Purpose —This study reports the surgical results in those patients who underwent carotid endarterectomy in the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Methods —The rates of perioperative stroke and death at 30 days and the final assessment of stroke severity at 90 days were calculated. Regression modeling was used to identify variables that increased or decreased perioperative risk. Nonoutcome surgical complications were summarized. The durability of carotid endarterectomy was examined. Results —In 1415 patients there were 92 perioperative outcome events, for an overall rate of 6.5%. At 30 days the results were as follows: death, 1.1%; disabling stroke, 1.8%; and nondisabling stroke, 3.7%. At 90 days, because of improvement in the neurological status of patients judged to have been disabled at 30 days, the results were as follows: death, 1.1%; disabling stroke, 0.9%; and nondisabling stroke, 4.5%. Thirty events occurred intraoperatively; 62 were delayed. Most strokes resulted from thromboembolism. Five baseline variables were predictive of increased surgical risk: hemispheric versus retinal transient ischemic attack as the qualifying event, left-sided procedure, contralateral carotid occlusion, ipsilateral ischemic lesion on CT scan, and irregular or ulcerated ipsilateral plaque. History of coronary artery disease with prior cardiac procedure was associated with reduced risk. The risk of perioperative wound complications was 9.3%, and that of cranial nerve injuries was 8.6%; most were of mild severity. At 8 years, the risk of disabling ipsilateral stroke was 5.7%, and that of any ipsilateral stroke was 17.1%. Conclusions —The overall rate of perioperative stroke and death was 6.5%, but the rate of permanently disabling stroke and death was only 2.0%. Other surgical complications were rarely clinically important. Carotid endarterectomy is a durable procedure.

The field of peripheral vascular surgery is changing as a result of many forces, including altered disease demographics, advances in technology, encroachment by competing specialties, evolution of training programs, governmental and reimbursement controls, and changing public expectations. The gradual evolution of program content of the annual meetings of the North American Chapter of The International Society for Cardiovascular Surgery for the past 20 years and the challenges for the future of vascular surgery in the USA are reviewed. During the past 20 years, 455 scientific papers and 20 presidential addresses were delivered to the North American Chapter. Papers on peripheral arterial and cerebrovascular disease have remained constant in number. Venous and cardiac contributions have declined in number and are covered in other societal meetings. Vascular radiologic interventions, diagnostic technology and research presentations have filled the void. Other topics, including epidemiology, manpower, outcomes, economics and governmental relations, have increased in number. The presidential addresses, while including topics of historical and clinical interest, have increasingly emphasized educational and socioeconomic issues. Vascular surgery, like other disciplines, is a dynamic specialty. As with medicine in general in the USA, this specialty will be increasingly challenged by socioeconomic pressures, which will lead to new issues that have not previously been addressed in the Chapter program, including preventive medicine and health services research.

Vascular surgery has matured as a subspecialty of general surgery during the past 25 years. The discipline currently faces a number of challenges including duration and scope of training, financing of graduate medical education, specialty and subspecialty certification, hospital privileging or credentialing, and practice opportunities. This article reviews these issues in terms of present realities and future opportunities. Emphasis is placed on curricular redesign to tailor length and breadth of training to future career goals, be they private practice as a general surgeon with vascular surgery interests, a vascular surgical subspecialist, a rural versus an urban practice, or a subspecialist in an academic setting. A plea is made for regulatory bodies, including the Residency Review Committee for Surgery and the American Board of Surgery, as well as specialty societies, particularly the American College of Surgeons, to maintain a flexible and constructive posture in dealing with proposed educational innovations. With cooperative efforts of both the Association of Program Directors in Surgery and the Association of Program Directors in Vascular Surgery, vascular surgery education and training of both general surgeons and vascular surgeons should be enhanced to fulfill the workforce needs as we enter the next millennium.

Cardiac autonomic activity, as assessed by heart rate variability, has been found to be associated with postmyocardial infarction mortality, sudden death, and all-cause mortality. However, the association of heart rate variability and the incidence of coronary heart disease (CHD) is not well described. The authors report on the association of baseline cardiac autonomic activity (1987-1989) with incident CHD after 3 years (1990-1992) of follow-up of the Atherosclerosis Risk in Communities Study cohort selected from four study centers in the United States by using a case-cohort design. The authors examined 137 incident cases of CHD and a stratified random sample of 2,252 examinees free of CHD at baseline. Baseline, supine, resting beat-to-beat heart rate data were collected. High- (0.16-0.35 Hz) and low- (0.025-0.15 Hz) frequency spectral powers and high-/low-frequency power ratio, estimated from spectral analysis, and standard deviation of all normal R-R intervals, calculated from time domain analysis, were used as the conventional indices of cardiac parasympathetic, sympatho-parasympathetic, and their balance, respectively. Incident CHD was defined as hospitalized myocardial infarction, fatal CHD, or cardiac revascularization procedures during 3 years of follow-up. The age, race, gender, and other CHD risk factor-adjusted relative risks (and 95% confidence intervals) of incident CHD comparing the lowest quartile with the upper three quartiles of high-frequency power, low-frequency power, high-/low-frequency power ratio, and standard deviation of R-R intervals were 1.72 (95% confidence interval (CI) 1.17-2.51), 1.09 (95% CI 0.72-1.64), 1.25 (95% CI 0.84-1.86), and 1.39 (95% CI 0.94-2.04), respectively. The findings from this population-based, prospective study suggest that altered cardiac autonomic activity, especially lower parasympathetic activity, is associated with the risk of developing CHD.

The Atherosclerosis Risk in Communities (ARIC) study is a prospective investigation of the etiology and natural history of atherosclerosis and cardiovascular disease in four U.S. communities. The purpose of this work is to investigate the relationship between common carotid artery elasticity and intimal-medial thickness (IMT) in the four race-gender groups represented in the ARIC cohort. Noninvasive ultrasonic methods were used to measure IMT and the [systolic minus diastolic] diameter change (DC) of the left common carotid artery in 10,920 black and white, men and women between the ages of 45 and 64 y. The relationship between DC and IMT and IMT2 was examined after adjustment of DC for age, height, diastolic diameter, diastolic blood pressure and linear and quadratic terms for pulse pressure. This adjusted value of DC was used as an index of elasticity of the common carotid artery in the ARIC cohort with larger values of adjusted DC implying a more elastic vessel. The general behavior of adjusted DC with increasing IMT was observed to be qualitatively similar in all four race-gender groups. Adjusted DC remained nearly constant or increased slightly for values of IMT between approximately 0.4 and 0.8 mm, up to approximately the 90th percentile of IMT, and then decreased above the 90th percentile of IMT. Common carotid artery elasticity, defined as adjusted DC, varies with increasing IMT in the ARIC cohort in a manner consistent with results from previous studies in animals and human subjects addressing the variation of several elasticity indices with atherosclerotic involvement and risk factor exposure in the aorta, and brachial and radial arteries. Our results suggest that thicker common carotid artery walls in middle-aged U.S. populations are no stiffer than thinner walls, except for the thickest 10% of arteries. Since the distal common carotid artery frequently contains atheromatous plaques in this population, the lack of change in stiffness, indeed, the reduction in stiffness per unit thickness, may reflect the various stages of early common carotid atherosclerosis most often found in this population. These are characterized more by destruction of arterial wall structural elements than by changes such as widespread or circumferential sclerosis, which would strengthen and stiffen the artery.

Clinically based studies have indicated that patients who have suffered myocardial infarction (MI) exhibit lower heart rate variability (HRV). Such associations have not been reported at the population level. To investigate whether MI is related to lower HRV in the general population, the authors examined a stratified random sample of 2,243 men and women aged 45-64 years, of whom 260 had had MI and 1,983 were free of any coronary heart disease manifestations. All were part of the biracial cohort of the Atherosclerosis Risk in Communities study sampled from four United States communities. Resting, 2-minute supine heart rate data were analyzed using spectral analysis to estimate high-frequency (0.16-0.35 Hz) and low-frequency (0.025-0.15 Hz) spectral powers as conventional indices of HRV. The mean levels of high-frequency powers were 1.02 and 1.23 (beats/min)2 for MI and non-MI groups, respectively (P.05), and the low-frequency means were 2.46 and 3.11 (beats/min)2 for MI and non-MI groups, respectively (P.01). Age, race, and sex-adjusted odds ratios (95% confidence interval) of lower high-frequency and low-frequency powers contrasting MI to non-MI individuals were 1.52 (range, 1.09-2.10) and 1.54 (range, 1.12-2.10), respectively. After adjustment for use of beta-blocker medication, the odds ratios (95% confidence interval) were 1.26 (range, 0.88-1.81) and 1.22 (range, 0.87-1.69) for lower high-frequency and low-frequency powers, respectively. The findings from this first population-based study of prevalent MI and HRV provide support for an inverse association between MI and lower HRV. However, adjusting for beta-blocker use eliminates the statistical association. These findings confirm that impaired HRV is found in individuals with prevalent MI, even when drawn as a sample of community-dwelling individuals. This impaired HRV may contribute to the increased risk of subsequent cardiovascular events previously observed in survivors of acute MI. The cross-sectional data also suggest that use of beta-blockers diminishes the odds of lower HRV associated with MI.

A 53-year-old woman, 11 years after a renal transplant on chronic immunosuppression, presented with a sudden onset of a painless left groin mass. Ultrasound revealed a 3 cm common femoral artery pseudoaneurysm and a 3 cm saccular aneurysm of the infrarenal aorta. Operative repair was excision and patch angioplasty of the aortic aneurysm with internal iliac artery and interposition grafting of the femoral artery aneurysm with saphenous vein. Postoperatively, Candida albicans was identified in the aortic and common femoral arterial cultures. Candida infections often occur in patients with impaired cellular immunity due to seeding from urinary tract infections, vascular catheters, or manipulation of the gastrointestinal tract. Our patient, without any prior history of a fungal infection, had undergone a colonoscopy 3 weeks earlier. Without any other possible source being identified, the proposed mechanism for fungal entry into the vascular system was via the gastrointestinal tract, with seeding from the portal venous system. The exact medical and surgical management of these patients remains undefined, and a transplant vascular registry is really needed. However, immunocompromised solid organ transplant recipients undergoing gastrointestinal endoscopic procedures may be at a greater risk for the development of subsequent septicemia. Further reports are really needed to confirm the possible need in these patients for both periprocedural antibiotic and antifungal prophylactic coverage.

A 74-year old woman sought medical attention for general symptoms of nausea, vomiting, and back pain. A computed tomographic scan showed gas in the wall of the descending thoracic and suprarenal aortas. Emergency thoracoabdominal exploration revealed a necrotizing infection of the thoracic aorta extending to the origin of the celiac axis. After surgery Clostridium septicum was identified in tissue culture. Surgical management consisted of in-situ graft replacement of the thoracoabdominal aorta. Three months later, a pseudoaneurysm developed at the distal anastomosis. The patient refused further surgery and died 3 days later. The cause of death was presumed to be a ruptured mycotic aneurysm as a result of recurrent C. septicum infection. The relationship of C. septicum with occult gastrointestinal and hematologic malignancy has been documented. This patient represents the 10th reported case of C. septicum arteritis. Including the nine previous case reports of C. septicum arteritis, the mortality rate is 70%. When evaluating a patient with a mycotic aneurysm or aortitis, C. septicum should be considered. If it is found, a search should be carried out for an associated gastrointestinal or hematologic malignancy. Surgical repair should include extraanatomic revascularization and wide debridement of the infected field. Consideration should be given to lifelong antimicrobial therapy for this potentially fatal infection.

The Committee on Workforce Issues of the Society for Vascular Surgery (SVS) and the North American Chapter, International Society for Cardiovascular Surgery (NA-ISCVS) generated data on the numbers and trends of operations performed and workforce requirements to provide surgical care of patients with vascular disease. Data for analysis were obtained from The National Center for Health Statistics-National Hospital Discharge Survey and questionnaires sent to 2732 vascular surgeons. The data showed that SVS/NA-ISCVS and regional vascular society (RVS) surgeons performed 51% of 583,000 vascular procedures undertaken in the United States in 1992. This represents a 24% increase over the 41% reported in 1985 by similarly defined surgeons. Analysis of 1992 index cases documented that SVS/NA-ISCVS and RVS surgeons accounted for 80% of 31,000 aortoiliofemoral bypasses, 68% of 46,000 aortic aneurysmectomies, 64% of 91,000 carotid endarterectomies, and 72% of 98,000 angioaccess procedures. The mean numbers of vascular operations performed in 1992 by SVS/NA-ISCVS and RVS surgeons were 144 and 100, respectively. These procedures represented 64% and 39% of the total surgical caseload of SVS/NA-ISCVS and RVS surgeons, respectively. American Board of Surgery (ABS)-certified vascular surgeons performed a mean of 171 vascular operations in 1992. Other surgeons, including ABS-certified general surgeons, appear to be performing fewer vascular operations. The latter fact and the increasing incidence of vascular disease in an expanding elderly population supports a continued need for vascular surgery specialists. Evolving technology and new health care delivery systems, however, may lessen the need for surgical care of these patients. Continued assessments of workforce activity will allow better definition of changing vascular surgery needs.

We examined the association of serum albumin concentration with diabetes mellitus and other cardiovascular risk factors, prevalent cardiovascular disease, and ultrasonographically assessed carotid artery intima-media thickness using data from 45- to 64-year-old adults in the Atherosclerosis Risk in Communities (ARIC) Study. The mean albumin concentration was 0.04 to 0.12 g/L lower in participants with diabetes and 0.02 to 0.06 g/L lower in those with cardiovascular disease, compared to participants without these conditions. However, lower serum albumin level was also correlated with most traditional risk factors and hemostatic variables. On adjustment for these, there was essentially no association between serum albumin and prevalent cardiovascular disease. Likewise, there was no association between albumin and carotid intima-media thickness (a marker of atherosclerosis). While hypoalbuminemia may be a marker for chronic disease and perhaps renal loss of albumin, it seems unlikely that it is an important cause of atherosclerosis.

A possible association between body iron stores, measured as serum ferritin, and carotid arterial intima-media thickening was investigated in the Atherosclerosis Risk in Communities Study during 1990-1992 using a matched case-control design. For a 143-micrograms/liter greater serum ferritin concentration (the interquartile range), the odds ratio for cases with carotid intima-media thickening versus controls was 1.12 (95% confidence interval 0.97-1.30). However, there was no association (odds ratio = 1.00) after adjusting for major cardiovascular risk factors. This analysis of carotid arterial intima-media thickening, a measure of early atherosclerosis, in relation to serum ferritin does not support the hypothesis that increased body iron stores increase the risk of atherosclerotic cardiovascular disease.

This paper reviews the evolution of sympathectomy in the management of vascular disease, hyperhidrosis and reflex sympathetic dystrophy over the past 26 years. The average general surgery resident has never been exposed to the procedure. The author feels that sympathectomy should be part of the armamentarium of vascular surgeons. An understanding of physiologic screening tests is necessary for the proper selection of patients who may benefit from sympathectomy. There has been a progressive decline in the number of publications on sympathectomy during this period. While the procedure is less commonly performed for vascular disease, sympathectomy remains a useful treatment for uncontrolled hyperhidrosis and for reflex sympathetic dystrophy.

The field of peripheral vascular surgery is changing as a result of many forces, including altered disease demographics, advances in technology, encroachment by competing specialties, evolution of training programs, governmental and reimbursement controls, and changing public expectations. The gradual evolution of program content of the annual meetings of the North American Chapter of The International Society for Cardiovascular Surgery for the past 20 years and the challenges for the future of vascular surgery in the USA are reviewed. During the past 20 years, 455 scientific papers and 20 presidential addresses were delivered to the North American Chapter. Papers on peripheral arterial and cerebrovascular disease have remained constant in number. Venous and cardiac contributions have declined in number and are covered in other societal meetings. Vascular radiologic interventions, diagnostic technology and research presentations have filled the void. Other topics, including epidemiology, manpower, outcomes, economics and governmental relations, have increased in number. The presidential addresses, while including topics of historical and clinical interest, have increasingly emphasized educational and socioeconomic issues. Vascular surgery, like other disciplines, is a dynamic specialty. As with medicine in general in the USA, this specialty will be increasingly challenged by socioeconomic pressures, which will lead to new issues that have not previously been addressed in the Chapter program, including preventive medicine and health services research.

The purpose of this study was to determine the effect of anticoagulation on the incidence of thrombotic propagation and pulmonary embolism in patients with calf vein thrombosis after total hip or total knee arthroplasty. Patients undergoing arthroplasties had prospective surveillance for postoperative deep vein thrombosis by both bilateral contrast venography and venous duplex scanning. Calf vein thrombosis was documented by venography in 42 patients (50 limbs), including 29 of 253 patients undergoing total hip arthroplasty (11.4%) and 13 of 99 patients undergoing total knee arthroplasty (13%). Of patients on whom follow-up duplex scans were performed, heparin followed by warfarin anticoagulation was used in 11 (13 limbs) and withheld in 21 (25 limbs). Propagation of thrombosis to the popliteal or superficial femoral vein or both was detected by serial duplex scanning in 3 of 13 treated limbs (23%) and 2 of 25 untreated limbs (8%), (p = 0.43). All thrombus propagations were detected within 2 weeks of the operative procedure. There were no pulmonary emboli or deaths. Propagation of asymptomatic calf vein thrombosis after arthroplasty was not influenced by anticoagulation, suggesting that postoperative calf vein thrombosis need not be routinely treated. Serial venous duplex scanning is useful to identify the occasional patient in whom thrombotic propagation requiring anticoagulation develops.

A tunneling device can be used to ensure easy placement of a prosthetic or autogenous graft. This can be done without the danger of the graft twisting, kinking or having the clips and ties pulled off. The often frustrating problem of ensuring that the arterial graft lies properly in position can be greatly simplified with the use of this technique.

Combined B-mode/Doppler (duplex) scanning and venography were compared in routine perioperative screening for proximal deep vein thrombosis (DVT) in 158 total hip arthroplasty (THA) patients. Preoperative scans were performed in the first 60 patients; the low preoperative prevalence of 2% for proximal DVT was thought not to warrant routine preoperative scanning. Postoperatively, duplex scanning had a sensitivity of 79%, a specificity of 98%, and an accuracy of 97% when venography was considered as the gold standard. The postoperative incidence of proximal DVT was 12% in this group of THA patients treated with mechanical and pharmacologic prophylaxis. Including calf vein thrombosis, 30% had DVT postoperatively. This study demonstrates the efficacy of duplex scanning for diagnosing proximal DVT and describes an effective noninvasive method of screening THA patients for the presence of proximal DVT.

The presence of extension into the vena cava does not preclude curative resection for extensive renal cell carcinomas. However, preoperative assessment of (1) the proximal extent of the tumor and (2) the degree of adherence within the vena cava is necessary to plan operative strategies. The following report describes the successful use of intravascular ultrasonography in the preoperative evaluation of a patient with recurrent renal cell carcinoma with vena caval extension.

Noninvasive techniques have assumed an increasingly important role in the management of patients with vascular disease. Both ultrasonic and plethysmographic instruments allow objective evaluation of vascular disorders by the measurement of segmental limb blood pressures, analysis of blood velocity disturbances, recording of digit or limb pulse waveforms, or imaging of vascular disease, with or without Doppler flow analysis or color-flow mapping. These techniques have been applied for screening asymptomatic individuals, diagnosis of symptomatic patients, monitoring of interventional or surgical procedures, and follow-up of the natural history or the efficacy of medical, interventional, or surgical therapy of vascular disease. This article reviews the clinical application of these modalities to patients with peripheral arterial disease and briefly discusses cost-effectiveness and potential abuses of noninvasive technology.

Crohn's disease is less prevalent in blacks than in whites. However, when it does occur, it is associated with a high degree of morbidity and is frequently unrecognized at initial presentation. Forty-three patients with Crohn's disease presented to Howard University Hospital between 1965 and 1987. There were 156 hospital admissions, 47 emergency room visits, and 76 clinic visits over this 22-year period. Twenty-eight patients were female and 15 were male. The age of presentation for males ranged from 18 to 63 years and for females, 12 to 74 years. Crohn's disease should be considered in black patients who present with chronic abdominal pain and diarrhea. With correct diagnosis and appropriate medical therapy, patients should have an enhanced quality of life with less morbidity.

Routine follow-up of patients after carotid endarterectomy with duplex scanning is commonly practiced, yet the clinical significance of identifying those with asymptomatic restenosis is unclear. To address this issue we reviewed 120 consecutive patients who underwent 143 carotid endarterectomies from August 1983 to December 1988. One hundred one patients (118 operations) were available for clinical follow-up, and the overall incidence of recurrent symptoms was 6% (6/101). Sixty-three of these patients (78 carotid endarterectomies) had postoperative duplex examination. Two had evidence of residual disease from the time of surgery and were not included in further analysis. Significant recurrent stenosis (greater than 50% diameter reduction) developed in 14 of the remaining 76 arteries (18.2%). Twelve of 14 stenoses remained asymptomatic during follow-up from 18 to 72 months (mean 47.0 months) and did not undergo reoperation. Recurrent ipsilateral hemispheric symptoms developed in two patients with restenosis (14.3%). Four of the 62 arteries without significant recurrent stenosis developed ipsilateral symptoms (6.5%), but none required reoperation during follow-up from 1 to 71 months (mean 31.6 months). Life-table analysis showed no increased risk of transient ischemic attack, stroke, or death in patients with restenosis. This study supports regular clinical follow-up after carotid endarterectomy with emphasis on patient education in the recognition of symptoms. Although duplex scanning may be useful to follow known contralateral asymptomatic disease or evaluate those with recurrent symptoms, its routine use to identify patients with asymptomatic restenosis after carotid endarterectomy may be unnecessary.

Absorbed radiation dose in bone marrow, thyroid, salivary gland, eye, and skin entrance was determined by placement of lithium fluoride thermoluminescent dosimeters (TLD's) at selected anatomical sites within and on a human-like x-ray phantom. The phantom was exposed to radiation from linear tomographic and computer-assisted tomographic (CT) simulated dental implant radiographic examinations. The mean dose was determined for each anatomical site. Resulting dose measurements from linear tomography and computer-assisted tomography are compared with reported panoramic and intra-oral doses. CT examination delivered the greatest dose, while linear tomography was generally lowest. Panoramic and intra-oral doses were similar to those of linear tomography.

SUMMARY— Incontinence is an unwelcome complication of transurethral resection (TUR) of the bladder neck in the female. A computerised analysis of 238 procedures performed during the period 1940 to 1972 was carried out to assess the morbidity due to this complication and to evaluate possible predisposing factors. Initially 1 5.2% of patients were incontinent but 70% of these soon became continent without further treatment. The remaining 4.7% were treated by surgical or other measures. The incidence of incontinence was unrelated to the amount of tissue removed or to the number of operations, but was significantly lower when the operation was done for polypi of the bladder neck and significantly higher in patients with a cystocele or urethrocele. It seems possible to reduce the incidence of incontinence by careful selection of cases.

Studies of platlet function were performed in 30 patients with idiopathic recurrent venous thrombosis. Evidence of platelet hyperactivity was found in 14 patients who exhibited spontaneous platelet aggregation and in 13 patients who had evidence of circulating platelet aggregates. No other differences in clinical characteristics or coagulation parameters could be elucidated between these two subgroups. In nine patients who had 51Cr-labeled platelet survival studies, there was a good correlation between the platelet hyperactivity and shortened platelet survival. Spontaneous platelet aggregation was inhibited both in vivo and in vitro by aspirin. In addition, the circulating platelet aggregates were normalized by combination treatment with aspirin and dipyridamole. The results indicate that the idiopathic recurrent venous thrombosis patient population could be differentiated by the platelet function tests into subgroup I, in which no platelet abnormality could be detected, and subgroup II, where platelet hyperaggregability was present. These results indicate that the role of platelets should be considered in the pathogenesis of recurrent venous thrombosis and therapy with agents which inhibit platelet aggregation may be beneficial in the patients with platelet hyperaggregability.

Proper management of patients with venous disease requires recognition of the various syndromes and an accurate objective diagnosis. Unfortunately many physicians are unfamiliar with the different venous disorders and are unaware of the fallibility of the clinical diagnosis of these syndromes. This article reviews the six common venous conditions that collectively are more common than coronary or peripheral arterial disease. Acute and recurrent deep vein thrombosis, postthrombotic syndrome, superficial thrombophlebitis, varicose veins, and pulmonary embolism may all confront the physician regardless of his or her specialty. Clinical recognition and differentiation of these disorders along with appropriate use of objective, noninvasive isotopic and venographic studies should lead to accurate diagnosis and management of these venous syndromes. Such an approach will permit prompt and appropriate therapy for disabling and potentially life-threatening venous thromboembolism while avoiding unnecessary anticoagulation of patients with disorders mimicking venous disease.

This prospective study used non-invasive techniques to screen for asymptomatic carotid occlusive disease in 314 patients who were to have coronary or peripheral arterial reconstruction. Hemodynamically significant carotid obstruction (greater than or equal to 50% stenosis or occlusion) was present in 54 arteries of 41 patients (13.1%), but only one-third of these lesions were accompanied by a cervical bruit. Among 48 carotid arteries where a bruit was heard, only 18 (37.5%) were associated with significant obstruction demonstrated by non-invasive screening. No prophylactic carotid endarterectomies were performed. There was only one perioperative TIA and one non-fatal stroke, neither of which was related to detectable carotid obstruction. In patients with peripheral vascular disease and detectable carotid obstruction or bruit, the perioperative mortality was higher than in patients without carotid obstruction or bruit (15.0% and 18.2 vs 3.1% and 2.1%, respectively). The deaths were primarily due to myocardial infarction. This study suggests that asymptomatic carotid occlusive disease, while common in patients with other cardiovascular disease, does not necessarily predispose to perioperative stroke and thus does not necessitate prophylactic carotid endarterectomy prior to indicated coronary or peripheral vascular reconstruction.

Transurethral resection of the bladder neck in the female is unpopular because of complications and indifferent results. This retrospective study of 238 procedures (carried out over the period 1940-72) documents the various complications and shows that the fears generally held are exaggerated. Most complications are of moderate incidence and can be easily and satisfactorily managed. The incontinence rate (4.7% in this study) can be further reduced by selection of cases after careful urodynamic evaluation and avoiding certain types of cases. It is related more to the type of patient than to the procedure itself.

Noninvasive ultrasonic examinations were performed in 1984 on a biracial sample of 109 10- to 17-year-old adolescents to determine whether elastic properties of the carotid arteries are associated with cardiovascular disease risk factors in the young. The subjects examined were in either the upper (high risk) or lower (low risk) race-, sex-, and age-specific tertile for both serum total cholesterol (TC) and systolic blood pressure (SBP) during a 1981-82 community survey. The pressure-strain elastic modulus (Ep), a measure of stiffness, for the carotid arteries was calculated by dividing the pulse pressure by the fractional diameter increase in the carotid artery during the cardiac cycle, as measured by ultrasonic techniques. Repeat studies on 20 randomly selected subjects demonstrated high reproducibility of the elasticity measurements (intraclass correlation coefficient = 0.84). The mean Ep in the high risk group was 5.1 kPa higher than in the low risk group, after controlling for race, sex, and age (one-sided p value = 0.03). Furthermore, a positive parental history of myocardial infarction was related to increased Ep levels (p less than 0.05), independently of race, sex, age, TC, and SBP. The results indicate that ultrasonic techniques can detect functional differences in the carotid arteries of children and adolescents that are associated with the risk of cardiovascular disease as adults.

A simple, incompressible flow, ejector model was formulated and analysed. It was found that the results obtained analytically agreed closely with those of an experimentally conducted optimization carried out by other workers. The model was also used to compare the relative merits of constant static pressure versus constant area mixing: it was shown that the latter was superior to the former when nozzle, mixing tube and diffuser friction losses were taken into account. The work also indicated that the efficiency of an ejector tends to increase as the secondary-to-primary stream density ratio decreases.

Eighty per cent of bladder tumours can be treated by endoscopic resection of the tumour if the urological surgeon is proficient in this technique. The survival of patients having this treatment is better than more radical surgery in all grades and in all stages except stages C and D.

Indirect periorbital screening techniques may detect obstruction of the extracranial internal carotid artery, but they do not distinguish operable stenosis from inoperable occlusion. In an attempt to overcome this limitation, direct interrogation of carotid artery flow velocity by Doppler ultrasound was added to periorbital screening of 97 arteries in 53 patients. Analysis of results suggests that this assessment can improve diagnostic accuracy and distinguish stenosis from occlusion of the internal carotid arteries in stroke-prone patients.

Of 61 patients examined by Doppler ultrasound, only 23 were found to have superficial venous thrombosis. The remaining 38 patients were considered to have lymphangitis or cellulitis. An algorithm of diagnostic and therapeutic pathways has been developed for the management of the patient who has suspected superficial thrombophlebitis.

The cardiovascular surgeon may find bibliographic support for his or her particular therapeutic bias for almost any controversial clinical problem. Such management dilemmas are not unique to vascular surgery in particular or surgery in general but reflect much of the field of medicine. Therapeutic controversies usually represent our ignorance of the natural history of disease or the deficiencies in our knowledge of the efficacy of medical or surgical therapy. While prospective epidemiologic studies or randomized blind clinical trials should be the optimal basis for our therapeutic decisions, how much of medical practice can lay claim to such a foundation? This panel debate represents a programmatic attempt to accomplish what each of us should, but often fails to, do in reaching a clinical therapeutic decision in the face of controversial alternatives: namely, objectively search one's experience and the available literature, pro and con. This approach proved very popular to those attending the meeting of the Southern Association for Vascular Surgery. The audience was greeted with the fruits of labor of the panelists who had taken their charge seriously. As advocates of their particular position in the therapeutic arguments, each panelist had carefully reviewed the pertinent literature, much of which is subject to the deficiencies and bias that are reflected in our clinical approach to these problems. Indeed, some of the advocates used the same literature references to support their opposing sides of the argument. Nevertheless, the eloquence and intensity of each presentation heightened the interest and understanding of the audience to these controversies. The annotated bibliography left a tangible document of the effort that had been expended in this debate. One hopes that out of our increased recognition of the fallibility of some of our therapeutic approaches to vascular controversies will come future efforts to base our clinical decisions on the results of epidemiologic studies or properly designed clinical trials.

Angioscopy was used during in situ saphenous vein bypass grafting in seven patients. We were able to visualize valve incision, immediately identify and correct incomplete valvulotomy, identify side branches as potential arteriovenous fistulas, and assess distal anastomotic integrity. We encountered no retained valve cusps after angioscopy, as verified by Doppler ultrasound and completion angiography. Angioscopy verified distal anastomotic integrity in all patients with distal vein grafts large enough to accept the angioscope. Angioscopy requires minimal time, is relatively easy to use, serves as an adjunct to Doppler ultrasound and completion angiography, and has future potential as a therapeutic tool.

A 5 MHz continuous-wave Doppler probe was used intraoperatively to evaluate 25 in situ saphenous vein bypass grafts. At least one arteriovenous fistula per case and five retained competent posterior valvular leaflets were identified before completion angiography. The Doppler was able to distinguish a retained valve from an arteriovenous fistula on clinical grounds but not by waveform analysis. Intraoperative assessment of in situ saphenous vein bypass grafts with the continuous-wave Doppler can identify retained valves that might be missed by angiography. It can reduce the number of angiograms needed to demonstrate a technically perfect result, thus saving operative time and contrast agent load to the patient.

A new strain gauge plethysmography was developed to permit accurate electrical calibration and automatic calculation of limb blood flow from a panel meter. This instrument was used to quantitate maximum venous outflow (MVO) in both limbs of 20 normal volunteers and 387 limbs of 195 patients with clinically suspected leg vein thrombosis. The MVO of normal subjects averaged 45 +/- 18 cc/minute/100 cc of calf tissue (mean +/- 1 SD). In 69 limbs with deep vein thrombosis documented by Doppler ultrasound and/or phlebography, the MVO averaged 17 +/- 13 cc/minute/100 cc, which was significantly less than that of normal limbs (p less than 0.001). Only three of 31 limbs with venous thrombosis above the knee had MVO above 20 cc/minute/100 cc, the lower limit of normal, for a diagnostic sensitivity of 90%. The specificity of a normal MVO in excluding deep vein thrombosis was 81%, with only a 1% rate of false-negative diagnoses above the knee. This automatic strain gauge plethysmograph has the attribute of providing rapid quantitation of limb venous hemodynamics which facilitates noninvasive diagnosis and follow-up assessment of venous disease.

In a previous prospective study of 449 patients undergoing coronary or peripheral arterial reconstruction, 85 patients had preoperative evidence of asymptomatic bruit and/or greater than 50% carotid obstruction by routine Doppler screening. No patient had prophylactic carotid endarterectomy. This article reviews the late postoperative outcome (2 to 61 months, mean 35 months) of 67 patients with asymptomatic carotid disease who survived operation without perioperative deficit. Eleven patients died (16%) including four of myocardial infarction and two of stroke. Neurologic deficits occurred in the late postoperative period in 22 patients (32.8%) after an average interval of 31 months, including transient ischemic attacks in 15 patients (22.4%); only four of these 15 were appropriate to the side of carotid disease documented preoperatively. Seven patients (10.4%) suffered stroke, only three (4.5%) of which were in the territory of carotid disease detected preoperatively. The cumulative rate of carotid disease progression was 34%, including three patients who suffered carotid occlusion. Two of the latter had the only fatal strokes. This study suggests that patients with asymptomatic carotid disease, although not at significant risk of perioperative stroke, require careful follow-up for late postoperative neurologic deficits, the majority of which (68%) are transient ischemic attacks.

We compared combined B-mode/Doppler (duplex ultrasonic scanning and venography in routine preoperative and postoperative screening for major proximal deep vein thrombosis in 78 patients undergoing total hip or knee arthroplasty. Of 309 extremity examinations, duplex scanning had an overall sensitivity of 85.7% (12/14) and a specificity of 97.3% (287/295). The preoperative prevalence and postoperative incidence of major deep vein thrombosis were 2.5% and 14.1% of patients, respectively, despite intensive mechanical and pharmacologic prophylaxis. In addition, venography documented a preoperative prevalence and postoperative incidence of isolated calf deep vein thrombosis in 2.5% and 16.7% of patients, respectively. Whereas such disease extended proximally even in the absence of anticoagulation in only 18% of patients studied by serial duplex scans, calf deep vein thrombosis accounted for the only two instances of pulmonary embolism in this study. There were no deaths related to pulmonary embolism. This study suggests that duplex scanning is useful in screening for perioperative deep vein thrombosis in patients undergoing total hip or knee arthroplasty, which carries a significant risk of venous thromboembolism despite routine prophylaxis.

The Doppler ultrasonic velocity detector is a simple, inexpensive and versatile device for intraoperative monitoring of the integrity and hemodynamics result of vascular reconstructive surgical procedures. With this instrument, an ankle-arm systolic pressure index may be obtained before and after aortoiliac and femoral reconstructive surgical procedures. If the ankle pressure index does not increase following aortofemoral bypass and a thromboembolic vascular accident has been ruled out, it is unlikely that the patient will be significantly helped by that procedure alone. The use of a sterile Doppler probe permits qualitative assessment of arterial velocity signals following femoropopliteal bypass, carotid endarterectomy and mesenteric or renal vascular procedures. The Doppler detector may also be used to assess periorbital flow dynamics following carotid endarterectomy. Selective intraoperative arteriography can be based upon the presence of residual flow abnormalities detected by Doppler ultrasound.