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In an attempt to obviate the need for an incision the length of the leg during in situ saphenous vein bypass, a minimally invasive operation using 'laparoscopic techniques' was developed. At operation, standard incisions were made over the proximal femoral artery/vein and the saphenous vein at the distal popliteal artery level. An angioscopic valvulotome was used to perform valvulotomy under direct vision. After valvulotomy, a distention balloon system was used to form a 'pocket' into which a laparoscope was inserted. Trocars were then inserted under direct vision and the saphenous vein dissected and side branches individually clipped. After occlusion of the venous side branches, proximal and distal arterial anastomoses were performed in the standard fashion. This minimally invasive operation using laparoscopic techniques precludes the need for a long leg incision and saphenous vein dissection, except at the proximal and distal arterial anastomoses.

Inflow control of a rapidly expanding or ruptured femoral anastomotic "pseudoaneurysm" can be fraught with hazard. Occlusion of an anastomotic femoral aneurysm with a balloon catheter offers the surgeon a simple method of gaining inflow control prior to surgery. After achieving inflow control with the balloon catheter, the surgeon can incise the anastomotic aneurysm without significant blood loss, control back bleeding with balloon occlusion catheters, and with relative ease and safety repair or replace the anastomotic aneurysm as indicated. An illustrative case is presented.

Purpose: With 70 cm "cutter" valvulotomes for valvulotomy and an electronically steerable nitinol catheter to occlude venous tributaries with platinum coils, endovascular in situ saphenous vein (EISV) bypass can be safely performed from within the saphenous vein. To determine whether EISV bypass could reduce hospital length of stay (LOS) and perioperative morbidity without compromising patency, another 53 EISV bypasses for limb salvage were performed., Methods: Tributary occlusion was accomplished with only fluoroscopic surveillance with a new, smaller, and more steerable silicone-tipped nitinol catheter., Results: Two (3.7%) wound complications occurred. The mean hospital LOS after operation was 4.2 days (range 2 to 29 days). All tributaries initially embolized remained occluded, and three "missed" arteriovenous fistulas were identified during follow-up extending to 15 month (mean 8.4 months). Eighty-eight percent (49 of 54) of phase II bypasses remained patent, whereas life-table analysis of all bypasses (phase I and II) was 77% (69/99) at 24 months follow-up (mean 13.6 months). By comparison, 41 infrainguinal saphenous vein in situ bypasses with "classic" open techniques were performed concurrently. The mean postoperative LOS was 11.6 days (range 4 to 42 days), wound complications occurred in 24% (10) of patients, and two "missed" arteriovenous fistulas were identified during follow-up. Eighty-three percent (34 of 41) of bypasses remain patent at 24 months follow-up (mean 16.2 months)., Conclusions: If EISV bypass long-term patency rates remain similar to classic in situ bypass patency results, the additional benefits of decreased hospital LOS, reduced wound-related complications, shortened recuperation, and therefore increased health care savings gives this endovascular technique strong consideration as the possible future operation for infrainguinal saphenous veins in situ bypass.

Patients with major trauma often cannot be given the benefit of preventive measures such as pneumatic compression boots and low-dose heparin against pulmonary embolism. The Greenfield filter is accepted as a safe and effective method of prophylaxis of this complication. The aim of this study was to evaluate the efficacy of placement of the Greenfield filter in 161 patients with major trauma. Between January 1984 and July 1988, 94 patients with an injury severity score (ISS) of > 16 were treated. This score is predictive of a mortality rate of at least 10% and defines major trauma based on anatomic injury. Some 20% (19 of 94) of these patients developed deep vein thrombosis despite standard prophylactic measures and 8% (eight of 94) suffered pulmonary embolism, two of which were fatal. Pulmonary embolism occurred without antecedent evidence of deep vein thrombosis in another 15% of patients (14 of 94), three of which caused death. From August 1988 until July 1992, of 67 other patients with an ISS > 16, 13% (nine of 67) developed deep vein thrombosis and 1% (one of 67) had a pulmonary embolism; this was not statistically significant (P > 0.25). Of these 67 patients who were considered to be at high risk of pulmonary embolism, because of a contraindication to anticoagulation or physical impediment to sequential compression boots, 29 had prophylactic placement of a Greenfield filter. No pulmonary emboli occurred in these patients. During long-term follow-up (mean 32.8 (range 4-58) months), 84% of the surviving patients (21 of 25) underwent duplex ultrasonography of the inferior vena cava; patency of the vessel was confirmed in all patients.

A 10 year retrospective study of 103 patients with amaurosis fugax was done. Sixty-two patients with symptoms of amaurosis fugax underwent arteriography, which demonstrated ulcerated carotid plaque in 36 and hemodynamically significant stenoses (greater than 75% diameter reduction) in 26. These 62 patients underwent carotid endarterectomy. The other 41 patients who had proven ulcerated plaque (33 patients) or hemodynamic stenoses (eight patients) were not treated surgically and served as a control series. No strokes or deaths occurred in the immediate postoperative period. Follow-up of the 62 operated patients extending to 10 years (mean 4.2 years), revealed one (1.6%) patient with recurrent amaurosis fugax symptoms, two (3.2%) with transient ischemic attacks, and one (1.6%) with a stroke in the operated hemisphere. In the nonoperated group, despite aspirin or warfarin treatment, four (9.7%) patients had ongoing amaurosis fugax symptoms, and two (4.8%) developed transient ischemic attacks that led to carotid endarterectomy. One (2.4%) other patient developed sudden, permanent monocular blindness, and two (4.8%) suffered hemispheric strokes, one of which was fatal. The cumulative morbidity (ongoing ocular or transient ischemic attack symptoms, perioperative and late stroke) in the operated group was 6.4% (four patients), while the cumulative morbidity in the nonoperated group was significantly higher at 21.9% (nine patients) (p = 0.02). When patients present with symptoms of amaurosis fugax and have demonstrable carotid bifurcation disease, carotid endarterectomy is recommended. Amaurosis fugax should be regarded as a harbinger of monocular blindness and stroke.

Laser assisted balloon angioplasty with a laser heated metallic capped fiberoptic catheter may be effective in the treatment of femoral and iliac artery occlusive disease. In order to avoid the inherent trauma of balloon angioplasty, yet at the same time "debulk" atheroma, 75 patients underwent laser angioplasty of the superficial femoral and iliac arteries as "sole therapy". Laser angioplasty was performed using an Nd:YAG laser coupled to a 600 micron fiber and a 3.5 mm probe (22-28 watts), 4.2 mm or 5.0 probe (32-40 watts). Fifty-nine patients had laser angioplasty for claudication and 16 for limb salvage. The initial angiographic success rate was 84% (41/49) (lesion length 2-14 cm) for the superficial femoral and 69% (18/26) (lesion length 2-14 cm) for the iliac arteries. In follow-up extending to 21 months (mean 14.4 months) 73% (30/41) of the superficial femoral artery and 76% (14/18) of the initially recanalized iliac arteries remain patent. When initial failures are included, this represents an overall intermediate-term patency rate of 52% (32/49) for superficial femoral and 49% (14/26) for iliac arteries respectively. By avoiding the disruptive effect on the arterial wall architecture caused by balloon angioplasty, while at the same time ablating and vaporizing more atheromatous material with larger laser probes, the long-term patency rates of laser angioplasty as "sole therapy" may prove to be superior to those of laser assisted balloon angioplasty.

To determine the benefit of carotid patch angioplasty, a retrospective study of 1000 consecutive carotid endarterectomies was done. Based on the type of carotid endarterectomy closure, patients were divided into four groups: 250 had primary closure, 250 had expanded polytetrafluoroethylene patch, 250 had Dacron patch, and 250 had saphenous vein patch. On the basis of operative technique or type of carotid artery closure, no statistical difference was found in the incidence of postoperative stroke (p greater than 0.25): primary closure 1.6% (4), expanded polytetrafluoroethylene 2.0% (5), Dacron patch 1.6% (4), and saphenous vein patch (0). Postoperative carotid patency was determined by B-mode ultrasonography, and 717 patients were evaluated in follow-up extending to 6 years (mean 37.8 months). Based on the method of carotid endarterectomy closure, no significant difference (p greater than 0.25) was found in the incidence of significant restenosis (greater than 50% diameter reduction): primary closure 4.0% (7), expanded polytetrafluoroethylene 4.0% (6), Dacron 5.4% (9), and saphenous vein 1.0% (2). Significant restenosis was most frequent in habitual smokers (93%, 25/28) and females (78%, 22/28) despite the method of carotid endarterectomy closure. No statistical difference was found in the incidence of late ipsilateral stroke either (p greater than 0.25): primary closure 2.9% (5), expanded polytetrafluoroethylene 2% (3), Dacron 5% (3), and saphenous vein 0%. These results indicate that the incidence of postoperative stroke, regardless of method of arterial closure, was not statistically different. The method of carotid closure did not appear to affect the occurrence of late ipsilateral stroke or restenosis; however, patch angioplasty with saphenous vein appears appropriate in habitual smokers, and likely in patients with small internal carotid arteries.

There is no consensus about the most appropriate management of the patient with intermittent claudication due to a superficial femoral artery occlusion. To evaluate the natural history of prosthetic above-knee femoropopliteal (AKFP) bypass, 200 operations for intermittent claudication were reviewed. One hundred AKFP bypasses were done with PTFE and 100 with dacron. In the 30 day postoperative period, four PTFE and three dacron grafts occluded without consequence and only one patient died. Analysis of results by the life-table method demonstrated statistically similar primary graft patency rates at five years (PTFE 65% SE +/- 6.5, dacron 57% +/- 6.2) and ten years (PTFE 31% +/- 18/9, dacron 32% +/- 13.2) (p greater than 0.10). Redo procedures (e.g., thrombectomy, angioplasty) were necessary on 21 grafts (12 PTFE, 9 dacron) and "secondary" patency rates at five years were 76% PTFE and 62% dacron; no grafts which required a redo procedure were patent at ten year follow-up. Major amputations during ten year follow-up were necessary in 16 (8%) patients; all amputations were in diabetic patients. Survival rates were 79% at five and 42% at ten years. An anticipated, the leading cause of death was cardiac related (25 patients); 28 (14%) patients underwent aortocoronary bypass during follow-up. A prosthetic AKFP bypass graft is a safe and durable operation which provides relief from the symptoms of intermittent claudication while allowing for the preservation of the saphenous vein for use later in the coronary or infrapopliteal circulations, should the need arise. These results indicate that the risk of amputation after AKFP is no greater than the natural history of untreated claudication; however, AKFP offers a significant improvement in life-style.

The hemodynamic significance of the kinked internal carotid artery and cerebrovascular insufficiency are demonstrated. Several procedures have been devised to correct a carotid kink, but these involve resection or excision of the internal, external or common carotid artery. We currently prefer a reimplantation technique whereby preservation of the external carotid is maintained, resection of the internal carotid artery is avoided and, when necessary, endarterectomy may be safely employed.

During a 7-year period, 818 patients underwent carotid endarterectomy (CE) and were evaluated for postoperative neurologic deficits. Three hundred and eighteen had CE performed with a shunt; transient deficits occurred in 2.9% (nine patients) and permanent deficits occurred in 1.6% (five patients). CE was performed without a shunt in 274 patients; transient deficits occurred in 2.9% (eight patients), while permanent deficits occurred in 2.2% (six patients). CE was monitored by surveillance in 226 patients; transient deficits were found in 2.2% (five patients), while permanent deficits occurred in 1.6% (four patients). There was no significant difference in the incidence of postoperative neurologic deficits between the groups (P greater than 0.25). The concept of inadequate collateral cerebral flow during endarterectomy could not, therefore, be indicted as the cause of the postoperative neurologic complications. Technical errors that caused carotid thrombosis or cerebral emboli, and not inadequate collateral cerebral flow, accounted for most of the neurologic deficits after CE. Deficits occurred most frequently in neurologically unstable patients, those who were first seen with stroke in evolution or with postreversible ischemic neurologic deficit and poststroke symptoms. Twenty-two patients awoke from CE with minor transient deficits, and neurologic function rapidly returned. Fifteen patients with profound postoperative deficits had reoperations immediately; intracranial emboli were identified in three patients, while a thrombosed CE site was demonstrated in seven. Three late (greater than 6 hours) postoperative deficits were due to thrombosis of the CE site. Patients with minimal postoperative deficits will improve without intervention, but reoperation is mandatory if a major deficit occurs in the immediate postoperative period. A protocol for the management of the post-CE neurologic deficit is presented.

Rupture of an abdominal aortic aneurysm is readily diagnosed when the triad of abdominal or back pain, shock and a pulsatile abdominal mass are present. Clinical diagnosis can be difficult, however, when patients present with chronic pain and an aneurysm which is not readily palpable. In these patients with confusing abdominal symptoms, CT scan provides a rapid, noninvasive diagnosis. The acute leaking AAA has been documented, but only rarely. This report identifies two patients who ruptured an aortic aneurysm several "months" prior to operation--a "contained chronic" rupture.

A case of fibromuscular dysplasia of the external iliac arteries treated by graduated internal dilatation is presented. At follow-up extending to 7 years, the external iliac arteries are patent with no evidence of recurrent disease by arteriography, and the patient remains asymptomatic. The recently reported successes with percutaneous balloon catheter angioplasty offers a nonsurgical alternative in the treatment of external iliac fibromuscular disease. A consideration of balloon catheter angioplasty in future similar cases is suggested. If balloon catheter angioplasty is unsuccessful, the option of operation remains available.

This study was done to evaluate the effect of aspirin (ASA), dipyridamole (DIP), and warfarin on 406 patients who had femoropopliteal-tibial operations with saphenous vein (SV), umbilical vein (UV), polytetrafluoroethylene (PTFE) and Dacron (DuPont, Wilmington, DE). Above-knee bypasses were performed in 181 patients: 77 were taking ASA and DIP at the time of operation, 41 were placed on postoperative "low-dose" warfarin, whereas 63 did not receive adjunctive medications. Late patency demonstrated no significant difference among the groups based on graft material used (SV 71%, UV 68%, PTFE 66%, and Dacron 65%) (P less than .25). Below-knee femoro-popliteal bypasses were performed in 183 patients: 82 were taking ASA and DIP at the time of operation, 40 were placed on warfarin postoperatively and no medications were given to 41 patients. Late patency rates (39 months) demonstrated that SV (62%) was superior to UV (51%), PTFE (30%), and Dacron (18%) (P less than .01). Femorotibial-peroneal bypasses were done in 42 patients: 13 patients were taking ASA and DIP at operation, 21 were placed on warfarin postoperatively and 8 received no medication. SV late patency (33 months) was again superior (43%) to UV (31%); no PTFE or Dacron grafts functioned after 24 months. Patients who took warfarin and ASA had the best early (16 months) patency results. Above-knee prosthetic grafts achieved late patency rates similar to SV while reducing operative time, shortening recuperation, and sparing the saphenous vein for use in the coronary or infrapopliteal vessels. In below-knee bypasses SV was superior to prosthetic grafts, with or without the use of ASA and DIP or warfarin.(ABSTRACT TRUNCATED AT 250 WORDS)

Splanchnic arteriosclerosis is common among the elderly population, but intestinal angina is distinctly a rare entity. Extensive and efficient mesenteric collateral pathways make development of intestinal angina unlikely unless at least two major vessels exhibit hemodynamically important stenoses. Herein we describe the surgical management of 17 patients with chronic intestinal ischemia. The patients most commonly had postprandial pain and lost significant weight; angiography, including lateral aortography, confirmed the diagnosis. An average of 2.5 vessels in these 17 patients were arteriosclerotically involved. These 17 patients underwent 20 major splanchnic artery reconstructions altogether (average, 1.2 vessels per patient) for relief of symptomatic intestinal ischemia. Arterial reconstructions (16 bypass procedures and 4 endarterectomies) were undertaken with either autogenous saphenous vein (10 vessels) or Dacron prosthetics (6 vessels). Revascularizations involved the superior mesenteric artery (six patients), hepatic artery (three patients), splenic artery (seven patients), and inferior mesenteric artery (four patients). Five deaths occurred after operation, two early and three late, all from myocardial infarctions. All patients who survived have been relieved of their pain, and there has been no recurrence. The average length of follow-up has been 60.9 months and repeat angiography in six patients at intervals of up to 5 years has shown no evidence of revascularization occlusion.

Although kinking of the internal carotid artery has been recognized for many years, the surgical significance of this lesion has remained controversial. The present study was designed to identify hemodynamic significance of kinking of the internal carotid artery using a positional testing technique with preoperative and postoperative noninvasive data that were correlated with intraoperative electromagnetic flow measurements to establish operative criteria. A fluid-filled oculoplethysmograph (OPG) was used to assess carotid artery flow in 26 patients with cerebral ischemic symptoms who had angiographic documentation of kinking of the internal carotid artery. OPG testing was done with the patient's head positioned first in the neutral, then in the right and left rotations, and then in extension-flexion positions. Sixteen patients underwent angioplasty. At operation electromagnetic flow measurements of the internal carotid artery were determined in these 16 patients with similar positional maneuvers. A reduction of flow from 30% to 80% was found on positional testing during operation in 14 of these 16, and all 14 of these patients also had abnormal preoperative OPG testing. After angioplasty, effects of position on internal carotid artery flow were eliminated, as proved by electromagnetic flowmeter measurements and by follow-up OPG studies in all 14 patients. The other two patients who had been subjected to surgical correction had no positional effects as documented by electromagnetic flowmeter testing. A high correlation between noninvasive data and operative flow measurements suggests that positional OPG testing is helpful in identifying hemodynamically significant kinking. Symptomatic patients with kinking of the internal carotid artery and abnormal OPG testing may be candidates for corrective surgery.

Our recent experience in reconstruction of late thrombosis of Dacron aortic-femoral graft is presented along with initial evaluation and treatment. It is suggested that a particular patient population is prone to this complication, and that aggressive restoration of limb flow is essential. This frequently involves ingenious techniques of deep femoral artery reconstruction done concomitantly with various inflow procedures as illustrated.

Between 1978 and 1983, 103 patients underwent operations for infrarenal abdominal aortic aneurysms (AAA). Fifty-seven patients (group I) had elective procedures without a death and with a morbidity of 19 per cent. Thirty-three patients (group II) had symptomatic but nonruptured AAA, while 13 patients (group III) had ruptured AAA. In group II, the mortality was 6 per cent and in group III, 37 per cent, while the morbidity was 33 and 100 per cent, respectively. There was no morbidity or mortality from pulmonary emboli, as all patients had prophylactic inferior vena cava interruption at the time of operation for their AAA. These results substantiate the necessity for early and aggressive treatment in patients with AAA, as the mortality and morbidity, once symptoms develop, remain prohibitive.

In many patients undergoing femoropopliteal bypass, an occluded superficial femoral artery may reconstitute at the adductor canal and the popliteal artery will be patent. For these patients, uncertainty exists as to whether the preferred site for the distal anastomosis is an above-knee (AK) or below-knee (BK) bypass graft. Operation is, therefore, often based on personal preference rather than fact. To evaluate this problem, we undertook a 6-year review of the cases of 90 patients who had femoropopliteal bypass to a patent popliteal artery. Seventy AK bypass grafts were performed: 20 with autogenous vein, 25 with Dacron, and 25 with polytetrafluoroethylene (PTFE). Based on the life table analysis method, the late patency rate was 70% for vein, 68% for PTFE, and 64% for Dacron. These results were compared against results in 25 patients who had BK femoropopliteal bypass with autogenous vein, in whom the late patency rate was 65%. There was no statistical difference between these groups (P less than 0.25). An AK femoropopliteal bypass with a prosthesis yielded long-term patency rates that were similar to those of AK or BK vein grafts. When the popliteal artery is patent and the distal anastomosis can be done proximal to the knee joint, a prosthetic graft should be used. A prosthetic graft will reduce operative time, shorten recuperation time, and spare the saphenous vein for use in the coronary or infrapopliteal vessels if the need arises.

To evaluate the efficacy and long-term patency results of axilloaxillary bypass, a review of 32 patients with follow-up extending to 11 years was done. Twenty-two bypasses were performed for vertebrobasilar symptoms or subclavian steal and 10 for upper extremity claudication and/or ischemia. The mean age of the operative group was 66 years, 94% of patients had more than one atherosclerotic risk factor (hypertension, diabetes, coronary artery disease, smoking), and 75% had undergone a previous arterial reconstruction operation. There were no operative deaths, and the only postoperative complication was a sterile seroma which responded to aspiration. At late follow-up extending to 11 years, three grafts had thrombosed while another became infected and had to be removed; no limb loss resulted from these graft failures and the actual late patency rate was 87%. Carotid-subclavian bypass, intrathoracic bypasses, and endarterectomy at the site of occlusion have all been suggested for the treatment of symptomatic proximal subclavian artery disease. With axilloaxillary bypass, however, the hazards associated with carotid artery manipulation, operation on the notoriously treacherous subclavian artery, and the morbidity related to thoracotomy in this older, high-risk patient population can be avoided. The axilloaxillary bypass is safe and simple, and the excellent long-term patency rates make it the procedure of choice for symptomatic subclavian artery disease.

Many patients who suffer a massive pulmonary embolus die despite emergent therapy. In these desperately ill patients an aggressive, combined method of management was initiated to improve their chances and quality of survival. During a 5-year period 10 patients were treated with (1) low-dose topical, intrapulmonary thrombolytic therapy to dissolve thrombus, (streptokinase or urokinase); (2) anticoagulation to prevent thrombus propagation (heparin); and (3) the simultaneous insertion of a Greenfield filter to prevent the early, recurrent, and therefore potentially fatal pulmonary embolus--"triple-armed therapy." Thrombolytic therapy was administered through a Swan-Ganz catheter wedged against the pulmonary embolus. During the same interval 10 other patients also sustained massive pulmonary emboli but were treated only with systemic heparin. Serial pulmonary arteriography was performed daily. The patients treated by triple-armed therapy responded favorably with a rapid (less than 6 hours), significant improvement in PaO2, pulmonary artery pressure, cardiac output, pulmonary vascular resistance, and blood pressure, compared with patients treated with continuous heparin alone. Nine patients in the triple-armed therapy group survived whereas only six in the heparin group survived. Two additional patients were treated by triple-armed therapy and had thrombolysis with triple-armed therapy with tissue plasminogen activator; these patients demonstrated the most rapid improvement in cardiorespiratory dynamics and arteriographic clearance of emboli. This management protocol shows promise for patients who sustain a massive pulmonary embolus, because it reduces the morbidity associated with pulmonary embolectomy while avoiding the hazards associated with systemic thrombolytic therapy.

The recent utilization of the axillo-axillary bypass graft for revascularization of proximal subclavian or innominate artery occlusions has proved to be a successful operation, technically simple with a low operative morbidity. We have reviewed the reported experience to date and have added our experience of nine additional cases. The procedure has produced excellent results in all patients, with no evidence of postoperative "steal" from the donor limb. Preoperative hemodynamic defects were corrected. Our experience has led us to the conclusion that this simpler and safer extrathoracic approach should be considered as the procedure of choice when arterial lesions allow for its selection and use.

Penetrating arterial injuries can result in the formation of a traumatic false aneurysm or an arteriovenous fistula. Traumatic arteriovenous fistulas of the mesenteric circulation are extremely rare, with only 15 operated cases reported in the English language literature that involved the superior mesenteric artery and vein. Although surgical intervention has been considered the most successful method to treat traumatic mesenteric arteriovenous fistulas, percutaneous transcatheter embolization has been occasionally advocated in the management of small iatrogenic fistulas. We report a case of a gunshot wound patient who had an 8 cm abdominal aortic false aneurysm, as well as a high-flow arteriovenous communication between the superior mesenteric artery and vein, which were successfully treated by a combination of aorto-superior mesenteric bypass and postoperative percutaneous transcatheter embolization. A review of the literature is also included.

Carotid body tumor or chemodectoma is a slow-growing lesion; it should be diagnosed early to facilitate the technical surgical resection. When these lesions are large, the routine use of a carotid internal bypass shunt is advocated for their safe removal. With the newer vascular approaches, specifically the carotid internal bypass shunt, resection can be performed with acceptable risks. A patient with large bilateral carotid body tumors had successful resection of both these lesions.

Aspirin (ASA) and dipyridamole (DIP) have been shown to reduce the incidence of transient ischemic attacks (TIAs), but aspirin's ability to reduce the incidence of postoperative neurologic deficits in patients who require carotid endarterectomy (CE) is controversial. To evaluate the role of adjunctive ASA/DIP in conjunction with CE, 908 CE cases were reviewed. Four hundred sixty-seven patients took ASA (650 mg/day) and DIP (150 mg/day) preoperatively, while 381 received no ASA/DIP. There was no statistical difference in the distribution of postoperative neurologic deficits. Twenty-six transient deficits occurred: 14 (53%) patients were taking ASA/DIP, whereas 12 (47%) were not. Seventeen permanent deficits occurred: ten (58%) patients were taking ASA/DIP and seven (42%) were not. ASA/DIP are useful medications in combating ischemic cerebrovascular disease, but ASA/DIP cannot replace precise operative technique which affords unequaled protection against a postendarterectomy neurologic deficit.

Five hundred and fifty-eight patients have been evaluated at the peripheral vascularocular pulse blood flow laboratory over a year. The accurate correlations with angiography in the peripheral arterial investigation has been 100%, the cerebrovascular investigation has been 75% and the venous correlation has been 86 2/3%. Even though the results from ocular testing are slightly lower than reported by Kartchner and McRae, we believe that the results emphasize the delicacy of instrumentation and the degree of refinement necessary in reading of the tests. We do think, however, that a 75% accuracy does indicate this method to be of significant benefit as a noninvasive stroke screening procedure.

The ideal management of the patient with an asymptomatic stenosis of the extracranial internal carotid artery remains controversial. The purpose of this article was to evaluate the effects of prophylactic carotid endarterectomy (CE) done to treat asymptomatic carotid stenosis (greater than 50% diameter reduction by angiography) 10 years later. In 1976, 42 prophylactic CEs were performed. There were no postoperative deaths or strokes. During 10-year follow-up two strokes occurred in the operated hemisphere; one stroke was fatal and was due to an intracranial hemorrhage, whereas the other stroke was thromboembolic in origin. Two other patients suffered strokes in the contralateral hemisphere and seven patients had transient ischemic attacks in the contralateral hemisphere, which necessitated CE. The survival rate at the end of the study period by life-table analysis was 57% (mean 8.7 years). Sixteen late deaths occurred, with coronary artery-related disease the most common cause of death. This review with actual 10-year follow-up demonstrated that prophylactic CE may be performed with minimal risk, that late stroke in the operated hemisphere was negligible, and that long-term survival was similar to that of a comparable age-matched population, possibly because late deaths attributed to stroke were reduced. On the basis of long-term follow-up, CE to treat asymptomatic high-grade carotid stenoses appears to be indicated in appropriate patients.

In hypertensive emergencies the physician is obligated to reduce arterial pressure immediately. This is best done with intravenous antihypertensive agents. If renal artery occlusion is demonstrated and the patient is refractory to appropriate medications, renal artery reconstruction may be necessary. In the poor risk patient, an attempt at transcatheter thromboembolectomy may be worthwhile. If this maneuver is unsuccessful, emergent aorto-renal reconstruction is indicated. A case of bilateral renal artery thromboses causing a hypertensive crisis which was successfully managed by aorto-renal bypass grafting is reported.