Search

Numerous procedures have been proposed for the correction of symptomatic subclavian artery occlusive disease, none of which have been uniformly accepted by vascular surgeons. During the past 21 months we have successfully treated six patients with symptomatic subclavian artery occlusive disease by the construction of an axillary-axillary artery bypass. There were three complications in this small series, a wound hematoma, a case of median nerve parasthesias, and a late graft thrombosis, possibly caused by external pressure on the graft. These complications have not caused any serious morbidity. All patients have been followed to the present time, all have experienced symptomatic improvement and none has developed any symptoms of donor arm ischemia. Axillary-axillary artery bypass is currently our procedure of choice for the correction of symptomatic subclavian artery occlusive disease because of its effectiveness, absence of serious morbidity and ease of performance.

For many years, arterial reconstructive procedures designed to treat arterial occlusive disease involving the lower extremities were limited to the femoral and popliteal vessels. Arterial bypass procedures involving anastomoses below the knee were thought to be impossible because of the small size of the vessels involved and the limited runoff. However, as technics of vascular surgery have improved and as surgeons have become more familiar with the handling of smaller vessels, successful treatment of more distal arterial occlusions has been possible. Morris et al [I ] in 1959 described the first anastomosis of arterial grafts to the distal popliteal vessel below the knee. Two years later, McCaughan [2] described the first group of patients who had bypass grafts to vessels below the popliteal trifurcation. It soon became apparent that vessels distal to the popliteal artery would support inserted autogenous saphenous vein grafts [3-101. Thereafter, the frequency of arterial bypass grafting to the anterior tibial, posterior tibial, and peroneal arteries in the calf region increased rapidly. More recently, refinements in surgical technics for suturing vessels 2 mm in diameter have resulted in favorable patency rates for arterial anastomoses at the ankle and below [11-141. This report is an analysis of sixteen patients in whom the dorsalis pedis artery was utilized for the distal anastomosis in bypass grafting for arterial occlusive disease.

In order to evaluate the immediate effects of aortocoronary saphenous vein bypass graft surgery on myocardial contractility, studies were carried out in 24 patients with severe occlusive disease of the right or left coronary arteries or both. Myocardial contractility was expressed by the extrapolated maximal velocity of contractile elements shortening (Vmax) and peak (dP/dt)/KP (Vpm) as calculated from the left ventricular pressure and its rate of pressure rise, dP/dt by employment of a needle connected transducer. Studies were made with the patient in sinus rhythm and a stable circulation and no cardiac action drug administration before and after saphenous vein bypass surgery. The patients were divided into two groups: group 1 (12 patients) were those without LV aneurysm and satisfactory myocardial contractility (Vmax 1.40±0.07 and Vpm 1.08±0.06 muscle lengths per second), and group 2 consisted of 12 patients with poor initial myocardial contractility (Vmax±standard error 0.94±0.05 and Vpm 0.74±0.05 muscle lengths per second) and LV aneurysm. In group 1 patients there was a significant increase in Vmax and Vpm values from preoperative results (Vmax±standard error 1.84±0.09 and Vpm 1.39±0.07 muscle lengths per second (p Table 5 ). These preliminary data indicate that increased blood supply to the myocardium delivered by aortocoronary saphenous vein bypass graft surgery is beneficial and increase myocardial contractility in those patients with good preoperative contractility.

The variations and inter-relationships between the middle meningeal artery and the ophthalmic and internal carotid arteries are discussed in terms of embryogenesis, roentgen-anatomical correlation and pathological significance. The pathological conditions cited include arterial occlusive disease, regional neoplasms and extradural hematomata. When the ophthalmic artery connection with the middle meningeal artery results in a large meningeal vessel, it is best called the ophthalmic-middle meningeal artery as opposed to the conventional middle meningeal artery. A less frequent variation in the middle meningeal artery origin is one in which this vessel arises from the petrosal portion of the internal carotid artery; this seems best named the stapedial-middle meningeal artery and occurs infrequently when compared with the ophthalmic middle meningeal artery.

The 133xenon clearance test is an easy, noninvasive method to assess arterial blood flow and can distinguish a normal from an ischemic limb. In addition, the close correlation with clinical findings affords an objective method of evaluating the results of surgical revascularization. On the basis of these findings, we feel that this procedure should be employed in the evaluation of all patients with suspected or proved peripheral vascular insufficiency.

Multitechnical non-invasive procedures were used to assess the arteriolar effects of cinnarizine and its difluoroderivative, flunarizine, in 20 normal volun teers and in 43 elderly patients with occlusive disease of the extremities due to arteriosclerosis, 22 of whom had intermittent claudication. The trial involved six separate studies of which three were double-blind cross-over, one was a 6- month open study followed by a 6-month double-blind study and two were open studies. Significant drug-related effects were obtained by venous occlusion plethysmometry, differentiated pulse plethysmometry, oscillometry, claudicom eter, postexercise arm-ankle pressure gradients and exercise tolerance measure ments, but not by light plethysmometry and skin temperature measurements. The results indicated that cinnarizine and flunarizine improved vascular disten sion and blood flow in normal volunteers, as well as in patients with occlusive disease of the extremities due to arteriosclerosis. The patients also showed increased postexercise arm-ankle pressure gradients, improved arterial pulsa tions and better exercise performance and tolerance. The drugs were devoid of effects on sympathetic reflexes, resting blood pressure and pulse rate; they were devoid of side-effects and were well tolerated also by patients treated with antihypertensives and cardiac glycosides. Flunarizine was at least as effective as its parent compound at two to three times lower dose levels.

Our experience with 150 cases of femoropopliteal saphenous vein bypass grafting performed during the past nine years has been reviewed. A long-term patency rate of 84.6 per cent confirms our belief that the reversed autogenous vein bypass graft is the best operation in the treatment of occlusive disease of the femoropopliteal arteries. Our experience would seem to support the following conclusions: 1. 1. Long-term results do not appear to be significantly influenced by the clinical indications for surgery. 2. 2. It is impossible to determine the operability of any patient on clinical grounds alone. Patients with advanced gangrene may show an outflow tract ideally suited for grafting. 3. 3. There appears to be a poor correlation between the preoperative angiogram and the functional outflow tract found at surgery. 4. 4. Autogenous vein grafts appear to function well and remain patent for long periods of time despite limited outflow tracts such as an isolated popliteal segment or single vessel run-off. 5. 5. The long bypass graft from the common femoral artery to the distal popliteal artery below the knee is associated with the highest success rate. 6. 6. The success rate decreased significantly if the saphenous vein graft was less than 5 mm in diameter. 7. 7. The age of the patient alone does not appear to influence the success rate. 8. 8. Excellence in surgical technic is of utmost importance if a high degree of success is to be expected. Errors in technic probably account for most immediate failures and greatly influence the long-term results. 9. 9. Almost all patients facing immediate amputation because of gangrene should undergo femoral arteriography. When patients in this group were found suitable for venous bypass grafts, a success rate of 77.5 per cent was achieved with only a 5 per cent operative mortality.

Both organic occlusion and vasospasm are usually present in peripheral arterial vascular diseases. The degree of occlusion and the probable effectiveness of treatment designed to relax vasospasm can both be determined by measurement of the maximum increase in cutaneous blood flow produced by suitable vasodilator procedures. These studies included warming the torso and/or injections of tetraethylammonium chloride or benzylimidazoline, and administration of spinal anesthetic. The effects obtained with all three methods were closely comparable. Cutaneous blood flow was estimated from recordings of skin, room and body temperatures.

The most important cause of renal hypertension is actually an extrarenal disease, occlusive disease of the renal arteries. Arteriosclerosis is responsible for the majority of these lesions, and stenosing fibroplasia accounts for a smaller group. The renal arterial plaques that are now being recognized in middle-aged hypertensive patients have a grave potential in terms of loss of renal function.

A technic for intravenous thoracic angioaortography by catheterization of the inferior vena cava is presented. With this method, the procedure can be carried out in any hospital without using elaborate or expensive equipment. We have been able to demonstrate aortic aneurysms, brachiocephalic occlusive disease, pulmonary sequestration, and we could rule out aneurysm as a cause of abnormal mediastinal contour. The sequelae of arterial puncture are eliminated, and no complications have occurred in our series of twenty-two cases.

An angiographic method is introduced that permits detection and quantification of regional disorders of ventricular wall motion in man. The left ventricle is visualized as a muscular cone suspended freely from the atrioventricular ring. This ring, outlined partially by a coronary sinus catheter, serves as a fixed plane of reference for the motion of endocardial segments during systole. Regional motion of the left ventricle is analyzed by plotting the displacement of the apex and 6 hemiaxes during 4 sequential phases of systole. The nonischemic left ventricle (6 patients) revealed synchronous and symmetrical shortening of all segments. The middle and apical hemiaxes of the posterior wall shortened to a greater extent (62 and 70 percent, respectively) than the anterior wall segments (40 to 45 percent), and there was a slight angular displacement (5 °) of the apex toward the anterior wall. Of the ischemic hearts, 6 with predominant right coronary arterial lesions demonstrated posterior akinesis and dyskinesis during early systole and an exaggerated shortening, particularly in the posteroapical segment, during late systole. These findings were associated with a significant apical displacement (23 °) toward the wall opposite the ischemic zone. Six patients with major occlusive disease of the left anterior descending artery showed the same abnormal segmental pattern in an opposite direction. The study provides a simple technique for examining and quantitating localized disorders of wall motion, and the data indicate an association between the sites of major coronary occlusions and characteristic patterns of regional contraction.

Femorotibial bypass grafting is an effective means of salvaging limbs in selected patients. Broader applicability of this operation depends on the availability of whole limb serial femoral arteriography for case selection. A simple and readily adaptable method of whole limb arteriography is presented. Using this method of arteriography, a new clinical classification of occlusive disease of the femoral arterial system is proposed.

The authors report a case of bilateral internal carotid occlusive disease in a 10 year old girl exhibiting telangiectatic anastomoses between the external carotid system and the leptomeningeal vessels on the surface of the brain. It would appear that this patient is an example of an unusual form of progressive cerebral arterial occlusion.

Thirty patients over 35 years of age with one or more episodes of carotid TIA lasting less than one hour were studied. No patient had a history of brain disease and each had an EEG followed by an arteriogram. Arteriographical study showed 15 patients to have occlusive disease of the internal carotid artery, and four of these had intracranial occlusive arterial disease as well. An additional three patients had only intracranial occlusive arterial disease. Twelve patients had normal arteriographical studies. The EEGs of nine patients were diffusely or focally slow. Twenty-one patients had normal records. Six of the nine patients with abnormal EEGs had arteriographical evidence of intracranial occlusive arterial disease. Only one patient with extracranial carotid stenosis alone showed an EEG abnormality. In two patients with an abnormal EEG the arteriogram was completely normal or showed insignificant change. These data indicate that the EEG has the capacity to reflect changes in cerebral function not clinically evident in patients with carotid TIAs. Such changes were present in almost one-third of the patients in this study. Most commonly, generalized or focal EEG slowing in patients with the clinical syndrome of carotid TIA is associated with the presence of intracranial occlusive arterial disease. Alternatively, the finding of a normal EEG in such patients would suggest the absence of intracranial occlusive arterial disease, but occurs with equal frequency in patients with stenosis of neck vessels and in patients with no arteriographically demonstrable lesion.

Ten dogs underwent excision of a short segment of the diagonal branch of the left anterior descending coronary artery, the distal left circumflex coronary artery or one of its branches. Hemostasis was secured by suturing the overlying epicardium except in two animals in which the addition of a pericardial patch was necessary to control bleeding. Arterial sutures, prostheses, or adhesives were not used. Two animals died in the first 36 hr after surgery, one of massive pulmonary atelectasis, the other of bleeding. Arteriograms in the eight surviving animals showed healing of the divided coronary arteries with excellent distal filling in seven of them. Vascular union was noted as early as the fifth postoperative day and as late as the end of the 3-month follow-up period. The possibility of applying this simple surgical technique to certain instances of coronary arterial occlusive disease is discussed.

Extensive experience (more than 3,000 cases) with the operative treatment of cerebrovascular insufficiency has led to the recognition of definite patterns of extracranial arterial occlusive disease and the development of several concepts basic to the preoperative, operative and postoperative managment of these patients. Four case histories are presented, with detailed illustrations. Although in the geriatric patient there is a high incidence of associated arterial lesions (e.g., aneurysm of the abdominal aorta and peripheral arterial occlusive disease) and of disorders of other organ systems (particularly the heart, lungs and kidneys), careful management of these cases has resulted in a low operative mortality and a high rate of long-term relief of symptoms.

A CEREBROVASCULAR accident of extracranial occlusive origin is usually due to segmental involvement of an arterial channel. With demonstrable stenosis of one carotid, the contralateral carotid artery may also be involved some time in the future. When both carotid arteries manifest stenosis, the clinical symptoms may be ascribed to one artery which may be surgically treated, but the contralateral vessel also may be eventually further stenosed or occluded. Usually, three or more years elapse before the contralateral carotid becomes stenosed or occluded symptomatically. The vertebral vessels are implicated much sooner and, in such cases, there is probably multiple vascular occlusive disease from the time of the initial symptoms. In a group of 130 endarterectomy patients, eight developed new strokes from occlusive involvement of other than the endarterectomized or occluded vessel. The follow-up period was 2 to 11 years. In five cases with one carotid involved, the contralateral carotid artery became

29 patients with arterial disease of the limbs were examined by the pulse plethysmograph and a water-filled plethysmograph, to evaluate the ability of different plethysmographic parameters to discriminate between different degrees of arterial disease, classified by arteriography. The best pulse plethys mographic parameter had a discriminatory efficiency as good as, or better than, the best water plethysmographic one. Advantages and limitations of pulse plethysmography in routine diagnostics are discussed.

Plasma renin activity was measured in forty-eight hypertensive patients with angiographie evidence of unilateral or bilateral occlusive disease of a main stem renal artery. Increased plasma renin activity in patients with unilateral renal arterial lesions was almost always (96 per cent) predictive of a satisfactory response to subsequent and technically successful surgery. In contrast, when plasma renin activity was normal, technically successful surgical intervention was not associated with a postoperative reduction of blood pressure. These data demonstrate that measurements of plasma renin activity in hypertensive patients with unilateral renal arterial disease provide an excellent guide to the success or failure of subsequent surgical therapy. Further studies are required to determine whether measurements of plasma renin activity are similarly useful in hypertensive patients with bilateral renal arterial lesions.

The effects on peripheral cutaneous blood-flow of the alpha-receptor blocking drug thymoxamine were measured by strain-gauge plethysmography in 58 subjects. The intravenous drug produced a substantial, though often transient, vasodilatation in the feet of normal subjects, and in most instances increased pedal blood-flow in non-sympathectomized patients with lower-limb arterial occlusions and healthy feet. In patients previously sympathectomized for either non-occlusive or occlusive disease of the lower limbs the effect of the drug was variable, even bringing about a reduction in pedal blood-flow in a number of cases. Intravenous thymoxamine regularly though briefly produced vasodilatation in the hands of patients sympathectomized for primary Raynaud'S disease, but the oral drug had no such action in most instances. It is concluded that systemic thymoxamine is unlikely to be of therapeutic benefit to the sympathecromized patient.

AUTOPSY studies and the increasing use of arteriography have revealed an unsuspected frequency of occlusive disease of the aortocranial vessels as a cause of cerebral ischemia.1 2 3 4 5 On clinical grounds alone it has been practically impossible to differentiate intracerebral arterial insufficiency from stenosis or occlusion of the internal carotid or vertebral basilar system.6 The measurement of total cerebral blood flow and vascular resistance has not been considered to have clinical applicability because of the frequent lack of correlation with the functional status of the cerebrum.7 It is the purpose of this report to emphasize the fact that measurement of the cerebral . . .

Primary mesenteric venous occlusive disease occurs infrequently but the mortality rate is high. A review of the clinical records of twenty-two patients with this condition revealed an over-all mortality of 59 per cent and a surgical mortality of 52 per cent. Anticoagulation therapy seemed to be an important factor in reducing the mortality rate. A significant number of patients had a prodroma for many days before seeking medical care. Early active surgical treatment and careful postoperative observation provide the optimal therapy for the patient with primary mesenteric venous occlusive disease. A “second look” is indicated if the disease progresses or recurs.

The supply of blood to the papillary muscles is segmental in distribution, and reaches the muscle from large penetrating branches originating from epicardial vessels located radially outward from the muscle. The tip, mid-portion, and base generally receive their vascular supply from separate tributaries which have a radial arrangement. Fibrosis of the papillary muscles is most often associated with occlusive disease of the large coronary vessels. The vascular alteration accompanying this fibrosis is of two types: (1) a fine overgrowth of Class A vessels, without interruption of the Class B vessels, and (2) an interruption of all channels, with enlargement of subendocardial vessels, suggesting the utilization of these vessels in the formation of collaterals past the occluded area.

Sympathectomy and thrombo-endarterectomy have been largely unsatisfactory in the treatment of patients with arterial insufficiency of the lower extremities. In this paper the results are analyzed of a large experience with the use of lyophilized arterial homografts to bridge occlusive lesions below the aortic bifurcation. The criteria for selection of patients for operation, the simplified procedure of end-to-side by-pass of the obstruction, and the excellent results in 145 operations are presented.

Four cases of early venous filling in cerebrovascular occlusive disease are reported.Some criteria for differential diagnosis from neoplasm and arteriovenous malformations are presented.

Die A. fem. sup. ist der am haufigsten von der chronischen Verschluskrankheit befallene Gefasabschnitt. Im Spontanverlauf und ahnlich bei konservativer Therapie betragt die Amputationsquote um 300% und etwa zwei Drittel der Patienten sind nach 10 Jahren noch am Leben. Die Erfolge der rekonstruierenden Methoden sind deutlich besser: Von 189 Patienten mit 280 operierten Extremitaten, waren 56,4% im Stadium III und IV Fontaine. Durch TEA konnten bei einem durchschnittlichen Krankenhausaufenthalt von 33 Tagen 96,7 % der auswertbaren Extremitaten dem Stadium Fontaine 1 oder II zugeordnet werden. Die Fruhletalitat betrug 10,3%, die Amputationsquote 3,2%. Nach 5 Jahren waren von 179 auswertbaren Extremitaten 95,6% im Stadium I oder II Fontaine, 18,7 % der Patienten waren verstorben und die Amputationsquote betrug 4,9%. Von 42 Rezidivverschlussen wahrend der Nachuntersuchungsperiode, wurden annahernd 80% erfolgreich revidiert. Probleme der Indikationsstellung und der operativen Taktik werden diskutiert und die Bedeutung der rekonstruierenden Masnahmen bei Vorliegen von Kombinationsverschlussen in der Ausflusbahn betont.

The paper is a methodological study in which three diagnostic screening tests for carotid occlusive disease are discussed in detail: The carotid-compression tonographic test, the arm-to-retina fluorescein circulation time, and the dynamic tonometry method for corneal indentation pulse registration. In subsequent papers the systematic application of these tests to certain clinical groups will be presented.

The Doppler ultrasonic flowmeter is used routinely as a screening device to detect the presence of extracranial arterial occlusive lesions. Intraoperatively it is used to grade stenotic lesions in extracranial arterial vascular lesions and to objectively evaluate the efficacy of the surgical removal of the lesion by determining vascular patency in the immediate postoperative period. The instrument is also used to assure the surgeon that no compromise of the lumen has been made at arteriotomy closure. Postoperative follow-up study with the Doppler flowmeter in the clinic enables the surgeon to atraumatically evaluate patency of the extracranial vessels without the associated morbidity of angiography. The Doppler flowmeter is a relatively inexpensive electronic device which is portable and battery-operated. Use of the instrument in the clinical setting effects a saving of time and money to both the patient and hospital while providing an objective atraumatic evaluation of vascular patency.

Renovascular hypertension is the most common form of reversible hypertension. An analysis of 200 renal artery reconstructive procedures identified atherosclerosis as the arteriopathic lesion in 83 per cent of cases and fibromuscular hyperplasia in 13 per cent of cases. Bilateral renovascular disease was found in 31 per cent of cases. Renal arteriography is the most significant factor in the diagnostic evaluation of the hypertensive subject. Bypass graft and patch-graft angioplasty were the most commonly employed principles of renal artery reconstruction in this series. The occlusive process in the renal artery produced a pressure gradient exceeding 25 mm. Hg in 76 per cent of cases. The average period of observation following operation in these 200 patients was 1.6 years, ranging between 3 months and 5 years. Eighty per cent of patients are now normotensive. The primary goal of operation in 12 patients was reversal of renal failure due to severe bilateral renal artery occlusive disease. Disappearance of azotemia with improved renal function followed revascularization in 11 of 12 patients.

IN 1941 Kohlmeier1 described a twenty-one-year-old man with a papular skin eruption and multiple intestinal perforations. The intestinal process was interpreted as a thromboangiitis obliterans of the mesenteric vessels. Degos et al.,2 in 1942, presented a case with a similar skin eruption but considered the pathology to be quite distinct and suggested the name "atrophic papulosquamous dermatitis." When further observation of this case and that reported by Tzanck and his associates3 revealed early death from peritonitis, the name "malignant atrophic papulosis"4 was substituted to emphasize the fatal prognosis. As other cases have been described, it has become evident that this . . .

Coronary Arteries The most promising surgical approach to intractable angina from chronic coronary-artery occlusive disease appears to lie in restoration of continuity in the obstructed artery rath...

Seit 1966 wurden bei 136 Patienten mit chronischer Verschluskrank-heit der Unterschenkelarterien 147 Extremitaten operiert. Die Lokalisation und Ausdehnung der Verschlusprozesse im Unterschenkel sowie die hohe Quote von Kombinationsverschlussen erklaren die Tatsache, das 80% der Patienten amputationsbedrohte Extremitaten im Stadium III und IV hatten. Die angewandten rekonstruktiven Verfahren waren die direkte Desobliteration der Poplitea-Trifurcation oder langstreckige Umgehungen mit dem Vena saphena insitu by pass zu den Popliteasegmenten II und III oder einer der Unterschenkelarterien. Die Letalitat bis zur Klinikentlassung betrug 11%, die Amputations-quote 3,4%. Von den verbliebenen 127 auswertbaren Extremitaten waren bei der Klinikentlassung 93,7% funktionstuchtig. Im Spatergebnis bis zu 4 Jahren betrug die Erfolgsquote bei 98 auswertbaren Extremitaten 88,7%. Die gunstigen Erfahrungen lassen eine weniger zuruckhaltende Einstellung zur Rekonstruktion der A. popl. und der Unterschenkelarterien wunschenswert erscheinen.

Die vorliegende Arbeit beruht auf der Auswertung von 890 praoperativen und von 400 postoperativen Angiographien bei Kranken, die wegen Arterienverschlusse der unteren Gliedmasen operiert wurden. Es wird betont, das die postoperative Kontrollarteriographie zur Routineuntersuchungsmethode gehoren sollte, weil sie unentbehrlich fur die Fruhdiagnose der verschiedenen postoperativen Komplikationen ist. Sie ist weiter notwendig fur die Indikation zur Reoperation und fur die Wahl des Operationsverfahrens. Es hat sich auch gezeigt, das die postoperative Angiographie wichtig fur die Beurteilung der Funktion der rekonstruktiven Operationen, fur das Studium der Veranderungen des Kollateralkreislaufes und fur die Entdeckung der Ursachen der Spatthrombose ist. The present paper is based on data obtained from 890 pro-operative and 400 post-operative angiograms of patients who underwent surgery for arterial occlusive disease of the lower limbs. It is stressed that postoperative angiography should be used routinely, since it is essential for the early diagnosis of various postoperative complications. It is also necessary, if a decision has to be made, to re-operate, and for the choice of appropriate surgical techniques. Post-operative angiography has also been shown to be important for evaluating function of the reconstructed vessels, for a study of changes in the collateral circulation and in order to discover causes of late thrombosis.

Ankle blood pressures, easily obtained using the Doppler ultrasound flow detector and a traditional blood pressure cuff, offer the clinician new information to aid in his evaluation of the patient with a peripheral vascular problem. Experience with resting and exercise ankle pressures in a variety of vascular disorders is presented.

1. Selective renal arteriography permits visualization of the small intrarenal arteries to a degree approaching that obtained by opaque injection of anatomic specimens.2. The arteriographic features of benign and malignant hypertensive vascular disease, segmental arterial occlusion, pyelonephritis, hydronephrosis, tuberculosis, polycystic renal disease and unilateral renal vein thrombosis have been described.3. Emphasis has been placed on small vessel changes rather than main artery lesions in these disease entities. In some patients with occlusive disease of the main renal arteries, the status of the small intrarenal vessels may be of considerable importance.

Collateral circulation is of most concern in the pathologic process of the brain, particularly in the occlusive disease of the cervical and cerebral arteries. The collateral circulation to the brain exists in three main areas (Kaplan)1): (1) through extracranial arterial connections; (2) through developmental extracranial to intracranial persisting arteries; and (3) through intracranial cerebral arterial anastomoses. The author directed efforts toward an analysis of collateral circulation to the brain of the aged subjects with some degree of atherosclerosis in the cervical as well as in the cerebral arteries. The present study consists of three parts: (1) a study on atherosclerosis of the major cervical and cerebral arteries; (2) a demonstration of the collateral circulation between the internal carotid, external carotid, and vertebral arteries; as to the intracranial anastomoses, emphasis was laid on the variations of the basal cerebral arteries, including the circle of Willis; and (3) a clinical consideration of cases with severe stenosis of the cervical arteries, with regard to cerebral vascular insufficiency due to a drop of the systemic blood pressure.

1. 1. The femorofemoral graft operation for unilateral iliac artery obstruction has been performed in thirty-eight patients. Thirty-two of these operations were successful, and there have been no late failures in a follow-up period extending to approximately five years. Five patients are lost to follow-up study. 2. 2. Of twenty-two patients with rest pain, twenty-one were completely relieved and one partially relieved. Capacity for ambulation was greatly increased in eighteen of twenty patients and slightly increased in two. The operation did not limit the activities of any of the patients, and there was no objective evidence of injury to the opposite or donor limb. 3. 3. Several factors seem responsible for the success of the operation: (1) Hemodynamic changes imposed upon the donor iliac artery may arrest the progress of degenerative arterial disease which is present. (2) The short length of the prosthetic bypass favors patency. (3) The profunda femoris artery with its branches is usually patent even when extensive arterial occlusive disease is present in the limb.

The authors investigated the effect of repeated inunction with 2 per cent glyceryl trinitrate in lanolin on the blood flow and skin temperature of the extremities in 14 cases of Raynaud's disease and in 8 cases in which Raynaud's phenomenon was associated with such vascular diseases as acrosclerosis (3 cases), chronic occlusive disease of the arteries (3 cases), occupational disease of the arteries (1 case) and livedo reticularis (1 case). The inunction almost invariably caused an increase in the blood flow and in the skin temperature of the digits in the 14 cases of Raynaud's disease.