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Reversed left internal mammary artery grafting with retrograde flow to the left anterior descending coronary branch was used in five of 500 consecutive bypass operations. The indications were significant stenosis in the left subclavian artery (3 patients) or the proximal left internal mammary artery (1) and proximal damage to the left internal mammary artery during dissection from the thoracic wall (1). The postoperative clinical course was smooth in all five patients, with no evidence of myocardial ischemia. In follow-up averaging 14 months four patients were asymptomatic. The reversed internal mammary artery graft was visualized with digital subtraction angiography in four cases. Radionuclide imaging during exercise confirmed graft patency in all but the symptomatic patient, who was found to have an area of reversible ischemia anteriorly in the left ventricle.

One hundred patients with high-risk unstable and medication-resistant angina pectoris underwent coronary artery by-pass grafting. In 35 cases the angina was of early post-infarction type, in 60 it was progressive after previous stability and in five it was of recent onset. All had abnormal ECG in association with anginal attacks (ST depression in 76, ST elevation in 5, T-wave inversion in 15 and left bundle branch block in 4). The left main coronary artery was stenosed in 33 patients, and the respective figures for three-vessel, two-vessel and one-vessel disease were 53, 9 and 5. The average number of inserted peripheral grafts/patient was 4.6. The perioperative mortality rate was 1%. Seven patients had confirmed or probable perioperative myocardial infarction and two had late infarction during the hospital stay, but none had angina pectoris on discharge. Of 60 patients re-examined after 1 year, 47 were angina-free. Five had NYHA class III angina, but all were improved. In refractory unstable angina pectoris there is severe coronary artery involvement, but bypass grafting can give good results.

Extracranial carotid aneurysms are uncommon, and in the past their management has not always been satisfactory. These aneurysms may be caused by arteriosclerosis, infection or trauma, or they may be congenital. Neurologic symptoms are common. Surgery is recommended for symptomatic aneurysms in patients of all ages. Non-growing aneurysms in old patients can be conservatively managed. Six cases of carotid and one case of vertebral artery aneurysm are reported. The mode of clinical presentation, etiologic factors, angiographic findings and methods of management are discussed.

Ruptured aneurysms of the aortic sinuses of Valsalva have been a surgical rarity at the Karolinska Hospital. Only nine such cases were operated on over a 13-year period (1968-1971). All nine aneurysms were of congenital type. They originated in the right coronary or the non-coronary sinus and drained into the right ventricle or the right atrium. All five ventricular entries were combined with a VSD in the membranous septum. No patient was in critical condition, despite significant left-to-right shunt and reduced aortic diastolic pressure. Aortic root angiography conclusively demonstrated the rupture per se, but even complete invasive examination failed to reveal two VSD's which were detected at surgery. Coexistent cardiac defects (5 VSD's, one ASD and one infundibular pulmonic stricture) were corrected in conjunction with the aneurysmal repair. The aneurysm was closed at its base. Isolated patched mattress sutures were always used. If tension-free approximation seemed unlikely, a patch was instead stitched to the margin of the defect. Reoperation was required in two cases because of recurrent fistulation. No patient died and the prognosis after repair appeared to be good. The transaortic supravalvular approach is preferred as the anatomically safest way to obtain closure at the aneurysmal base. A probe passed through the defect may help to identify the chamber of entry. A VSD is most likely to be present if the rupture drains into the right ventricle. These coexistent VSD's are often located in the membranous septum and they may be amenable to transaortic or transatrial repair.(ABSTRACT TRUNCATED AT 250 WORDS)