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Clinically significant arterial occlusive disease developed in 26 patients at between 5 months and 44 years (mean(s.d.) 10.7(12.0) years) following radiation therapy. Therapeutic radiation was associated with lesions of the carotid artery (nine patients), subclavian-axillary arteries (seven) and the abdominal aorta and its branches (10). Clinical presentations included transient ischemic attack, stroke, vertebrobasilar insufficiency, carotid bruit, upper- or lowerextremity ischemia and renovascular hypertension. Surgery for cerebrovascular insufficiency included carotid endarterectomy with vein patch, interposition grafting or subclavian-to-carotid bypass. Carotid or subclavian-to-axillary bypass was performed for upper-extremity ischemia. A combination of endarterectomy and Dacron or saphenous vein grafts was used for infrarenal reconstruction. Tunnels were placed orthotopically. Musculocutaneous flaps assisted in healing selected wounds. Ureteral catheters were useful adjuncts in abdominal vascular reconstructions. There were no operative deaths, strokes or amputations. One patient had recurrent transient ischemic attacks following subclavian-to-carotid bypass. The mean(s.d.) postoperative follow-up was 48.1(39.6) months. Patients presenting with end-organ ischemia following radiation therapy can be managed successfully with aggressive surgical revascularization using a broad spectrum of reconstructive techniques.

Purpose: Autogenous vein bypass grafts to infrapopliteal outflow sites have patency and limb salvage rates significantly superior to those obtained with prosthetic grafts. However, when infrageniculate bypass is required for limb-threatening ischemia in the patient lacking suitable autogenous veins, nonautogenous reconstruction or primary amputation are the only other alternatives. Methods: During a 2-year period we implanted 25 cryopreserved allograft saphenous vein bypass grafts in 24 patients (median age 76 years) with tissue necrosis (20 patients), rest pain (4 patients), or acute ischemia (1 patient); 16 patients were men and 8 were women. As many as six previous revascularizations were performed in 79%; two grafts extended to the infrageniculate popliteal artery; 23 grafts extended to a paramalleolar vessel. Results: Secondary patency at 1 month was 87%, but only 36% at 1 year. Use of warfarin (Coumadin) failed to improve the patency rate (five of nine occlusions treated with Coumadin versus eight of 16 not treated with Coumadin). Only eight of 24 patients are alive with open grafts; nine patients have died. Conclusions: Unheralded occlusions more typical of prosthetic graft failure tempered the initial enthusiasm and effectiveness of vein allografts. All autogenous options must be exhausted to complete distal, secondary revascularization before resorting to nonautogenous conduits. Use of allograft veins must be viewed with continued skepticism. (J VASC SURG 1993;18:553-60.)

As vascular surgeons, we performed 376 percutaneous transluminal angioplasties as follows: aorta and iliac arteries (148), infrainguinal arteries (191), and bypass grafts (21). Sixteen procedures were attempted but not completed. Neodymium-yttrium-aluminum-garnet laser thermoprobe was successfully used prior to balloon dilatations in 49 procedures. In contrast to our experience with operative intervention, percutaneous transluminal angioplasty was performed more frequently for claudication (75%), nondiabetics (72%), and women (45%). Median age was 71 years. Percutaneous transluminal angioplasty either preceded or followed proximal or distal open reconstruction in 58 extremities. Primary patency rates for iliac percutaneous transluminal angioplasties were: 94% at one month, 93% at six months, and 88% at one year. For infrainguinal percutaneous transluminal angioplasties they were 95%, 82%, and 70% at 1, 6, and 12 months, respectively. Repeat percutaneous transluminal angioplasty increased the one-year patency rates to 92% and 86% for iliac and infrainguinal percutaneous transluminal angioplasties, respectively. Preliminary data indicate that the six-month secondary patency rates were 82% for laser-assisted percutaneous transluminal angioplasty and 65% for percutaneous transluminal angioplasty of distal bypass grafts. The implementation of balloon angioplasty was facilitated by our 21 years of experience with arteriography. Percutaneous transluminal angioplasty has become a valuable adjunct to the practice of vascular surgery by expanding the therapeutic options for managing peripheral vascular occlusive disease.

Although balloon angioplasty for the management of failing bypass grafts has been well documented, little mention has been made of its use in treating the occlusive lesion within the native artery after a failed bypass graft. We report our experience with five patients in whom successful balloon angioplasty was carried out subsequent to failure of a femoral popliteal bypass graft. Increasingly aggressive percutaneous therapy of arterial occlusive disease may now be expanded to include a unique group of patients with chronically failed bypass grafts and occlusive disease within the native artery conducive to percutaneous transluminal angioplasty. This group of patients would previously have been relegated to repeat bypass grafts with its inherently inferior patency and recognized added technical demands. Percutaneous balloon angioplasty appears to be a plausible alternative in selected cases for repeat lower extremity revascularization.

Purpose: Percutaneous access to the arterial system for endovascular procedures is usually achieved through the femoral arteries. When femoral access is precluded, the axillary or brachial arteries serve as alternatives. Complications associated with the use of the latter arteries have led us to develop subclavian arterial catheterization. Methods and Results: From 1978 to 1993, 569 patients underwent angiography via the subclavian artery (>99% left subclavian artery); 134 were studies of the aortic arch and brachiocephalic vessels; 435 studies involved the descending and abdominal aorta and its branches and runoff. Coronary arteriography was also feasible. Since 1986, 44 patients have undergone endovascular procedures: 33 percutaneous transluminal angioplasties of the visceral, iliac, femoral, and popliteal arteries and 11 thrombolytic procedures of aortofemoral graft limbs ( n = 3) and femoral distal bypasses ( n = 8) were performed. Complications (1.2%) included partial pneumothorax ( n = 2), hemorrhage requiring operative control ( n = 2), causalgia ( n = 1) and embolization ( n = 2). Conclusions: Whenever percutaneous femoral catheterization cannot be achieved or an alternate access point is indicated, we select the subclavian approach as an alternative to axillary, brachial or translumbar access. It is safe, expeditious, and versatile for virtually all types of systemic and cardiac catheterization; it is also applicable to thrombolysis and balloon angioplasty. (J VASC SURG 1994;20:566-76.)

Hypothesis Infragenicular polytetrafluoroethylene (PTFE)–venous cuff bypass grafting provides acceptable graft patency and limb salvage rates for limb salvage. Design Retrospective clinical review of a consecutive series. Setting Vascular surgical practice during the interval October 1, 2000, to September 1, 2004. Patients Fifty-one male and 49 female patients whose mean age was 76.9 years were operated on for tissue loss (67%), chronic rest pain (28%), and severe claudication (6%). Fifty-two percent of patients were diabetic and 49% had undergone previous leg bypass surgery. All patients had absent or inadequate greater saphenous vein, and 84 patients had absent or inadequate arm vein. Interventions One hundred five infragenicular PTFE bypasses were performed in these 100 patients. Distal targets were the infragenicular popliteal (40), posterior tibial (35), anterior tibial (16), and peroneal arteries (14). Sixty-eight venous cuffs were constructed from lesser saphenous vein. Main Outcome Measures Graft patency, limb salvage, and patient survival were analyzed. Results Twelve early graft failures resulted in 7 leg amputations. The mean ± SE 3-year primary patency and limb salvage rates were 64.4% ± 12.8% and 74.4% ± 11.9%, respectively. Perioperative mortality was 2.9% and 3-year survival was 38%. Graft follow-up ranged from 1 to 47 months with a mean of 13 months using life-table methods. Conclusions For patients requiring arterial revascularization for limb salvage, in which autologous venous conduit is unavailable, distal venous cuff–PTFE bypass provides acceptable patency and limb salvage rates when viewed in the context of short life expectancy for these elderly patients.

We measured ankle/arm pressure indexes and blood flow rates before and after performing percutaneous transluminal angioplasty in 36 extremities. Flow rates through the leg were determined with a magnetic resonance blood flow scanner. All patients had claudication; one had gangrene, another had an ulcer, and two complained of rest pain. The median age was 65 years, and 72% were men. There were 25 dilations of the iliac artery, 12 of the superficial femoral artery, and eight of the popliteal arteries; nine patients had two arterial segments dilated. Nineteen legs had ankle/arm pressure indexes before percutaneous transluminal angioplasty of less than 0.80 (range 0.51 to 0.75); their flow rates averaged 40 ± 20 (SD) ml/min. After percutaneous transluminal angioplasty flow and pressure increased significantly in 14 of these 19 legs, and three had no hemodynamic improvement; in one leg only pressure and in another only flow increased significantly. The remaining 17 extremities had ankle/arm pressure indexes before percutaneous transluminal angioplasty ranging from 0.81 to 1.09; their flow rates averaged 53 ± 27 (SD) ml/min. Abnormal flow rates were detected in 15 of these 17 extremities. With near-normal ankle/arm pressure indexes no significant increase in pressure was anticipated. Flow rates augmented to 75 ± 28 (SD) ml/min after percutaneous transluminal angioplasty; a significant increase in flow was noted in 12 legs (71%). For patients with ankle/arm indexes before percutaneous transluminal angioplasty. of less than 0.80, either pressure or flow measurements should corroborate the benefits of the operation, whereas if the ankle arm index is greater than 0.80, flow measurements are most likely to substantiate changes in peripheral hemodynamics. (J Vasc Surg 1989;10:338–42.)

The results of 160 infrainguinal bypasses with arm vein grafts were analyzed. Seventy-three arteriograms were reviewed to identify early and late graft defects; arteriographic findings paralleled those described for saphenous vein grafts. Intimal fibrosis during the first postoperative year, observed in 16 grafts, was the most common defect. Aneurysmosis and elongation were rare, resulting in two graft replacements. Patency and limb salvage rates were calculated for 88 single-length femorodistal bypass grafts; the other 72 were inflow (eight) or outflow (22) jump grafts, sequential (eight) and composite autogenous vein grafts (34). The primary and secondary patency rates for single-length grafts were 74% and 80% at 1 year and 51% and 57% at 5 years, respectively. The limb salvage rate at 5 years was 82%. The survival rate for all patients was 44% at 5 years. These findings reconfirm our use of arm veins as bypass grafts when the saphenous vein is unavailable. (J VASC SURG 1986;4:416-27.)

Glutaraldehyde treated human umbilical veins (Dardik Biograft) were used to bypass short segments of the femoral artery in 15 dogs and were compared to autogenous jugular veins placed in the contralateral femoral artery of each animal. All 15 autogenous jugular veins remained patent for the four month period of observation whereas thrombosis occurred in seven of 15 umbilical vein grafts. This patency rate of 53% was significantly lower than that observed for autogenous jugular veins (p less than 0.01). Neointimal Fibrous Hyperplasia (NFH) a the proximal anastomosis was responsible for six of the seven umbilical vein graft occlusions. Of the eight patent umbilical veins, five had varying degrees of proximal anastomotic stenosis secondary to NFH. Histological examination of each graft revealed significant fibroblastic proliferation and collagen deposition within the lumen of stenosed and thrombosed grafts. Although human umbilical veins have distinct advantages over other prosthetics, such as availability and flexibility, the incidence of experimental neointimal fibrous hyperplasia causing anastomotic stenosis and thrombosis is prohibitively high.

A case of acute aortic occlusion caused by embolization of malignant melanoma tumor fragments is presented. Transfemoral catheter embolectomy restored normal lower extremity circulation. Noncardiac tumor emboli, although rare, originate either from primary pulmonary malignancies or nonpulmonary malignancies with pulmonary metastases and pulmonary vein invasion. Tumor embolization should be considered a possible source of peripheral arterial emboli when there is no other obvious source, such as the fibrillating or infarcted heart. In such cases, early surgical intervention should be considered in preference to therapy with heparin or streptokinase.

Nonthrombotic iliofemoral venous obstruction, masquerading as deep vein thrombosis, was diagnosed in four patients. In each instance the patient was hospitalized and intravenous heparin therapy was started. Phlebography demonstrated venous outflow obstruction without thrombosis; subsequent CT scanning revealed an obstructing lesion in each case. At surgical exploration, (1) endoaneurysmorrhaphy of a hypogastric artery aneurysm decompressed an obstructed right iliac vein; (2) a primary iliac vein leiomyosarcoma was extirpated; (3) a synovial cyst arising from the right hip joint, which obstructed the femoral vein, was excised; and, (4) a postherniorrhaphy inflammatory mass obstructing the left iliofemoral vein junction was confirmed with biopsy results. Improved diagnostic accuracy with its attendant specific therapy is achieved in suspected cases of iliofemoral vein thrombosis if, in addition to noninvasive venous studies or phlebography, CT scanning of the abdomen and pelvis is performed.

Preoperative noninvasive imaging of the veins of the upper extremities has been included in the protocol to select an autogenous vein for a distal bypass in the lower extremity. Arm veins are sought as bypass grafts when the saphenous vein is absent or not usable. Duplex ultrasound provided images of the cephalic and basilic veins in 10 patients in whom visual inspection failed to reveal usable grafts. All arm veins implanted were at least 2 mm (range 2 to 6 mm) in internal diameter determined by ultrasound and were, on the average, 2 mm larger when unroofed. This noninvasive technique has decreased the number of fruitless surgical explorations to obtain a suitable arm vein and has increased the use of arm veins by revealing veins previously not anticipated by physical examination, which virtually eliminated the use of nonautogenous conduits in our practice.

Two hundred forty-three bypasses to paramalleolar arteries were performed in 224 extremities of 208 patients since 1971; 166 were implanted in men (68%) and 77 in women (32%). The median age was 73 years. Gangrene (61%), nonhealing ulcer (15%), rest pain (22%), and trauma (2%) were the indications for bypass. Usual risk factors were noted: diabetes (65%), smoking (51%), heart disease (46%), and hypertension (45%). The extent of occlusive disease dictated three graft configurations: long grafts originating in arteries proximal to the adductor tendon (n = 111), short grafts originating at or below the popliteal artery (n = 88), and jump grafts originating near the distal end of a previous femorodistal bypass (n = 44). The association between diabetes (incidence 80%) and gangrene (75%) in patients with short grafts was statistically significant (p less than 0.01). The 2-year secondary patency rate of long in situ grafts was 92% compared with 72% for other autogenous vein long grafts. The limb salvage rate for all autogenous vein long grafts was 90% at 3 years. The secondary patency rate at 3 years for short grafts was 81% and the limb salvage rate was 80%. There were four amputations with patent grafts. Primary and secondary patency rates of jump grafts were similar (53%), whereas the limb salvage rate was 89% at 2 years. Patency and limb salvage rates of rarely employed nonautogenous conduits were less than 35% at 1 year (long grafts). Bypass grafts to the ankle and foot are effective and durable and should be performed with autogenous vein.

We placed 20 bypass grafts to the lateral plantar artery in 18 extremities to salvage feet with wet (12) or dry (six) gangrene; 15 grafts were implanted in men (75%), and five were implanted in women (25%). The median age was 65 years. All except two patients had diabetes; eight were treated with insulin. One patient had Buerger's disease, and another had vasculitis with chronic lymphocytic leukemia. History of smoking (65%), hypertension (53%), heart disease (71%), and osteomyelitis in the foot (35%), were noted. Cultures were positive in 15 gangrenous feet, 11 with gram-negative bacilli. Four long femoroplantar bypasses were placed. Ten short grafts were placed from the popliteal artery, and six jump grafts were placed distal to a femoropopliteal or tibial bypass. Hospital stay ranged from 8 to 38 days (median 16 days), and there were two in-hospital deaths. Transmetatarsal or button toe amputations were performed in nine feet. There were two below-knee amputations, one with a patent graft, for a foot salvage rate of 89% at 2 months. In four instances the gangrenous ulcers took longer than 6 months to heal; all other wounds healed within 6 months. The primary and secondary patency rates were 85% at 1 month, and 73% at 3 months and thereafter. Four of five graft failures occurred in the two legs with repeat bypass graftings. All patients with successful revascularization are able to walk, and seven returned to work full time.

The total analysis of 204 cases of myocardial rupture which occurred in the Los Angeles County Hospital was reported. Myocardial rupture rarely occurs under the age of 50 years. Although the incidence of myocardial infarction invariably is reported to be higher among men than women our material indicates that cardiac rupture is somewhat more likely to develop in women [110 women (53.9 per cent), ninety-four men (46.1 per cent)]. Myocardial rupture is relatively rare in Negro patients. In our material reasonably good correlation was obtained between electrocardiographic indication of acute myocardial infarction and necropsy incidence of myocardial necrosis. As was anticipated, myocardial rupture occurred at or immediately adjacent to the site of necrosis. Ordinarily, myocardial ruptures occur in the left ventricle. In our series the most frequent site of rupture was in the anterior wall, especially at the junction of the anterior wall and the septum. Average survival time for twenty-one patients admitted to the hospital within 6 hours of the clinical onset of myocardial infarction was 9 days, whereas average survival time for twentyone patients hospitalized 7 hours or longer after the myocardial infarction was only 2.6 days. The longer survival time for patients hospitalized within the first 6 hours may be due to greater restriction of their activity in the immediate postinfarction period. Death usually is immediate in ventricular rupture, whereas in the interventricular septal rupture most of the patients survive a few days. In the final 8 years and 3 months of our survey, the incidence of rupture following myocardial infarction has undergone a sharp decrease at the Los Angeles County Hospital. This decrease is presumably due to better management of the acute episode of myocardial infarction and more particularly to the use of vasopressor drugs and anticoagulants. Anticoagulants did not increase the incidence of the rupture but cardiac tamponade is relatively frequent in patients with myocardial rupture maintained on anticoagulants. The physician must be alert for signs of tamponade (i.e., pulsating neck veins, increase in cardiac dullness) because tamponade can be managed surgically. Except for the reduced incidence of myocardial rupture in the period of survey, the findings are in agreement with earlier reports from the same hospital.

The four auricular arrhythmias, premature systoles, paroxysmal tachycardia, flutter, and fibrillation, have been investigated in over 200 dogs by three methods: (1) high speed cinematography, (2) cathode-ray oscillography, and (3) multiple-channel electrocardiography. The hitherto unexplored body of the left auricle has been surgically exposed and thoroughly studied. Results indicate that all four arrhythmias are of unitary origin and may occur from one ectopic focus. The resulting arrhythmia depends largely upon the rate of discharge from that focus. There is no circus movement. Corroborative observations have been made on the arrhythmias in man. This conception of the auricular arrhythmias simplifies the understanding of their mechanism.

Pivalylbenzhydrazine was administered to forty patients over a period ranging from one to ten months in maintenance doses of 50 to 300 mg. per day. The majority required 100 to 200 mg. daily for therapeutic effect. Excellent results were obtained in nineteen (47.5 per cent), good or fair results in fourteen (35 per cent), and no effects in four (10 per cent). This is similar to the results obtained with isocarboxazid, though the latter appeared to be a better analeptic agent. No serious side effects or toxicities have been noted clinically or in the laboratory, particularly as related to orthostatic hypotension or hepatitis, neither of which was observed. A study of the effects of monoamine oxidase inhibitors on trace metals in humans is now being made. Preliminary results indicate elevation of serum manganese, copper and aluminum, but no effect on zinc, lead and iron. We have found pivalylbenzhydrazine to be an effective and apparently safe agent in the treatment of angina pectoris.

1.1. Mean levels of right ventricular pressure, flow, and work, but particularly mean levels of right ventricular work, are considerably higher in congenital heart disease than in mitral stenosis. 2.2. In congenital heart disease only abnormal electrocardiograms appeared above a mean right ventricular systolic ejection pressure of 30 mm. Hg. In mitral stenosis normal or borderline electrocardiograms appeared frequently up to a mean pressure level of 60 mm. Hg. 3.3. In congenital heart disease almost all electrocardiograms were abnormal above a right ventricular work load of 1 kg. M./min./sq.M. In mitral stenosis, normal electrocardiograms often occurred at work levels above 1 kg. M./min./sq. M. 4.4. In both mitral stenosis and congenital heart disease, the pattern of partial right bundle branch block appeared at almost all levels of right ventricular pressure and work, and thus this pattern appeared to be almost as significant as the classic pattern of right ventricular hypertrophy in the detection of right ventricular hypertension and presumptive right ventricular hypertrophy. 5.5. Gross electrocardiographic differences between congenital heart disease and mitral stenosis were present in all precordial leads; this was most marked in V 3R and V 1 , where the R wave in congenital heart disease was three to four times as tall as the comparable R wave in mitral stenosis. 6.6. In congenital heart disease, the electrocardiogram is remarkably accurate (91 per cent of cases) in the detection of right ventricular hypertrophy. In this disease no definite correlation was present between abnormalities of individual waves such as the height of R or RS ratio over the right precordium and levels of pressure or work. 7.7. The electrocardiogram in mitral stenosis is less diagnostic (51 per cent of cases) in the detection of right ventricular hypertrophy. But when the electrocardiogram is abnormal, a definite correlation is present between the height of R and RS ratios over the right precordium and levels of right ventricular pressure and work. 8.8. These differences in the total electrocardiographic picture suggest fundamental differences in the genesis of right ventricular hypertrophy in the two diseases.

The atherogenic regimen imposed upon the animals studied here resulted in several distinct abnormalities of the coronary circulation. The structure of the coronary arteries was modified by extensive atheromatous deposits. During control states before the administration of vasoactive drugs, coronary flow per unit of net propulsive force and heart weight was unvaried or increased. The ability of the atheromatous coronary tree to increase or decrease its vasomotor tonus was markedly curtailed. The abnormalities mentioned here were proportional with the severity of the atherogenic regimen.

… "To stimulate significant intellectual contributions to scientific knowledge, … "To advance physician knowledge and practice regarding cardiovascular disorders, … "To honor a great Los Angeles physician, teacher and humanitarian. " Cardiovascular disorders are Twentieth Century man's worst scourges and greatest challenges. Valuable advances are being made against these health problems as a result of the investments that have been made in research . " With the machinery of research set in motion, transmission and application of new medical knowledge is the most pressing need, now and for the future. Professional education, planned to establish the highest standards of knowledge and practice, will result in improved care of heart patients ."

Publisher Summary This chapter discusses the use of cephalic vein as a conduit. The choice of cephalic vein as an arterial conduit requires the surgeon to consider the relative merits and shortcomings of all currently employed grafts for leg revascularization. Arm veins are evaluated preoperatively and intraoperatively. The cephalic and basilic veins are assessed, preferably in a warm room, by inspection and palpation, employing tourniquets, exercise, and dependency. Special attention is directed to the antecubital fossa as variations in venous anatomy are sometimes encountered. Inexact preoperative assessment may result from hair, obesity, or tattoos. The median antecubital vein receives a deep muscular branch and the forearm branch of the basilic veinand, thereafter,continues as the basilic vein to the axilla. In the forearm, the basilic vein diameter is smaller and more variable than the forearm portion of the cephalic vein. Moreover, it lies posteriorly, its excision is awkward, and it is not a useful saphenous vein substitute. Males and females appear to have equally usable cephalic veins. Cephalic vein diameter, generally 5-6 mm distally and 6-8 mm proximally, tends to be more uniform than that of the saphenous vein.

• When a suitable single length of saphenous or arm vein is unavailable, the elderly patient with a profoundly ischemic extremity, poor runoff, and a distal outflow vessel frequently undergoes amputation. Rather than performing primary amputation or resorting to nonautogenous conduits, we used 21 different combinations of available vein segments of ipsilateral or contralateral greater saphenous, lesser saphenous, cephalic, and basilic veins as composite autogenous bypass grafts. Fifty-four extremities, of which 21 (39%) had one or more failed previous bypasses, were revascularized. Tissue necrosis necessitated operation in 74% (40 instances) and rest pain in 19% (ten instances). All grafts extended below the knee, 22% (12 grafts) to the infrageniculate popliteal artery, 78% (42 grafts) to an infrapopliteal runoff vessel, and 28% (15 grafts) to the ankle or foot. The patency rate at one month was 81%. Thrombectomy alone or with local graft repair increased the one-month patency rate to 96%. At one year, the patency and limb salvage rates were 74% and 82%, respectively. ( Arch Surg 1986;121:1128-1132)

Successful long-term limb salvage using cephalic vein bypass grafts was attained in 70 limbs of 67 patients over the past 11 years. The saphenous vein was absent in 76% and inadequate in 24% of the cases. Revascularization for limb salvage was carried out in 83%. Ninety per cent of the grafts were extended to the infrageniculate level while 56% were to a tibial vessel. Patency rates at 1, 3, and 5 years were 85%, 72%, and 68%, respectively. Limb salvage rate was 85% at 5 years and thereafter. There were no operative deaths or upper extremity morbidity. The 5-year survival rate was 50%. The results obtained with cephalic vein were comparable to those reported using saphenous vein but superior to those reported for nonautogenous bypass grafts.

A patient with severe respiratory failure due to overwhelming pneumonia was monitored with a Swan-Ganz catheter. Postmortem examination revealed massive antemortem thrombosis surrounding the Swan-Ganz catheter tip. The presence of the thrombus about the catheter tip was not suspected before death, but retrospective analysis of a variety of parameters suggested massive pulmonary vascular obstruction.

Neutral, isotonic Na24Cl solution was injected into the left ventricular wall of open-chest dogs. The disappearance of local radioactivity was recorded. Individual injections that exceeded 5 mm3 retarded Na clearance. The rate of Na clearance from individual deposits did not measure coronary flow in absolute terms; however, when one hemodynamic parameter was suddenly changed 50–200 sec after the injection of a radioactive deposit, the changed Na clearance slope reflected directional variations of coronary flow. In ischemic regions of self-perfused hearts, elevation of aortic pressure that was paralleled by increased left ventricular and central coronary pressures did not always result in more rapid Na clearance. Submitted on November 24, 1961

The selection of patients for mitral commissurotomy must be made after considering all manifestations of the rheumatic state. A conservative approach is urged and no patients should be operated upon without evidences of increasing pulmonary hypertension and right heart strain. The preparation of the patient, the management of the arrhythmias during surgery and the postoperative care are the full responsibilities of the physician. A team composed of physiologists, cardiologists and surgeons must work together.

SUMMARY 1) The resting cardiac output of patients with mitral stenosis is normal, and does not decrease until the onset of heart failure. 2) Pressure levels are more critical than flow levels in estimating the function of the right heart. 3) The most adequate picture of the right ventricular function is obtained from an analysis of pulmonary resistance and of the work of the right ventricle. 4) Patients who are most likely to benefit from mitral commissurotomy are those with high pulmonary artery pressures. 5) The degree of fall of the pulmonary artery pressure following commissurotomy is roughly parallel to the degree of clinical improvement in the few cases studied. 6) Patients with very low pulmonary artery pressures are not benefited by mitral commissurotomy and such low initial pressures may be present in patients with low grade rheumatic myocarditis. 7) Comparison of pre- and postoperative catheterization findings is the only critical method of evaluating results of mitral commissurotomy and should be further pursued. We wish to acknowledge the technical assistance of Mrs. Helen Obernolte, Dr. Andrew Farr, Miss Mary Mayo and Mr. Lucius Collier.

1.1. Ten proven and seven presumptive cases with atrial septal defects have been presented. 2.2. The importance of catheterization of the left auricle is emphasized, together with the differential diagnosis of atrial septal defect from transposed pulmonary veins. 3.3. A rise of oxygen content in the right atrium in comparison to the oxygen content of the superior vena cava is not necessarily present in proven atrial septal defects. 4.4. The cause for cyanosis in atrial septal defect lies primarily in the presence of a right to left shunt. 5.5. The direction of shunt is determined by the pressure gradient between the atria during the cardiac cycle. 6.6. Pulmonary vascular disease may contribute to the pulmonary resistance but is not a significant factor in the production of cyanosis.

• Subclavian and axillary artery occlusive disease resulted in sufficient upper extremity symptoms to necessitate 30 vascular reconstructions in 28 patients over the past ten years. Female patients predominated, with a ratio of 2.5:1. The average age of the patients was 61 years. The incidence of diabetes mellitus was low (7%). Sixteen of 18 proximal subclavian lesions were on the left side, while more distal lesions were equally distributed on the left and right. Extrathoracic bypasses were used in all cases. Dacron grafts were used in 16 of 17 carotid-subclavian bypasses. Autogenous vein grafts were used in 11 of 13 bypasses to the axillary or brachial artery. Concomitant cervicodorsal sympathectomy was done in only four patients. The in-hospital graft patency rate was 93% and the long-term graft patency rate at one year and beyond was 88%. (Arch Surg1984;119:1277-1282)

• A group of five diabetic patients had gangrene or failed limited amputations and palpable foot pulses in a total of seven limbs. Because a failure to heal persisted and gangrene progressed, arteriography was performed and disclosed occlusion of all three infrapopliteal arteries. Tibial bypass grafting resulted in complete healing in four of the five patients. The fifth patient refused surgery and died with progressive sepsis. The incidence of this unusual syndrome is unknown, but presumably it is rare. The mechanism of pulse formation in the foot, despite occlusion of the infrapopliteal vessels, is dependent on good flow to the popliteal artery, collateral flow to the rigid distal tibial-peroneal vessels, compliant ankle arteries, and highly resistive distal foot vessels. Although healing of limited amputations is usual in diabetic patients with foot pulses, it is not universal. We recommend that arteriography be performed routinely if gangrene is present and the foot is salvageable, irrespective of pedal pulse status. (Arch Surg1984;119:1260-1263)

It is the purpose of this paper to review the factors related to the occurrence of rupture or perforation of the heart after myocardial infarction. Rupture of the heart has been recognized for over 300 years, and in recent times it has been the subject of thorough autopsy and clinical evaluation. The following salient facts have become established through previous investigations: 1. Such ruptures rarely occur in patients younger than 50 years of age.12. Patients who have unlimited activity after infarction occurs apparently have a higher incidence of rupture than those treated with "adequate" rest.23. Rupture associated with infarction almost universally occurs in the first few weeks following infarction; it rarely if ever occurs in an old scar.34. The chances of rupture occurring are three times greater in patients in whom hypertension persists after infarction than in those who have normal or subnormal blood