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Ischemia in children deserves some specific considerations. It is not as rare as it is commonly thought (Barnes et al. 2004; Amlie-Lefond et al. 2008, 2009) with a frequency reported to be 2–6/100,000 children per year. Unlike in adults, it is rarely linked to factors related to atherosclerosis. Instead, it is associated with a variety of pathological processes, including cardiac diseases and other non-atherosclerotic arteriopathies which are listed in Table 17.1 (Chap. 17). In some cases, a precise etiology can be identified; in many others, however, it may only be suspected or remain unknown (Barnes et al. 2004; Jones et al. 2010).

The incidence of occlusive disease affecting the innominate artery is unknown because severe atherosclerotic lesions remain undetected by commonly employed screening modalities such as duplex ultrasound. Furthermore, symptoms are frequently minimal and clinical examination findings are subtle. However, abnormalities of the aortic arch branch vessels are increasingly encountered in patients with severe peripheral vascular disorders (Ballard 2001; Chang et al. 1997; Owens et al. 1995; Sakopoulos et al. 2000; Twena and Ballard 2000). In addition, the atherosclerotic process tends to occur in the proximal one-third of these arteries. This makes upper mediastinal access ideal for surgical reconstruction of innominate artery occlusive disease (Owens et al. 1995; Twena and Ballard 2000). The mini-sternotomy technique described in this chapter maximizes direct surgical reconstruction options such as aorto-in-nominate artery bypass and, less commonly, innominate artery endarterectomy. Alternatively, extrathoracic bypass procedures utilizing the subclavian and/ or axillary arteries may be advisable for prohibitive surgical risk patients or if the planned sternotomy would be a complex re-do procedure.

Deep vein thrombosis (DVT) is a common medical condition that can affect both the upper and lower torso and extremities. DVT is associated with high mortality and morbidity rates, and substantial immediate and long-term costs to society. Short-term complications for both upper and lower body DVT include pulmonary embolism (PE) and venous ischemia, while delayed complications include a spectrum of debilitating symptoms referred to as the post-thrombotic syndrome (Carpentier and Priollet 1994).

The application of endarterectomy, or direct removal of a lesion from within an artery, was the first operation performed to restore flow in arterial occlusive disease. Dos Santos performed the first endarterectomy in a superficial femoral artery and termed the operation “disobliteration” and noted the critical role that the anticoagulant heparin had in his success. Jack Wylie at the University of California at San Francisco (UCSF) performed the first successful endarterectomy in the United States for occlusive disease of the abdominal aorta soon thereafter, and went on to report a significant series of these pioneering operations. This established a tradition of endarterectomy at UCSF which has evolved to treat occlusive lesions throughout the arterial system.

Operative treatment of patients with renovascular occlusive disease has become somewhat standardized. Although newer diagnostic tests and refined indications for therapeutic interventions have contributed to better surgical results, salutary outcomes have been influenced most by the proficient performance of properly chosen primary procedures by experienced surgeons. The procedures are tailored to the subgroups of renal artery disease.

Manifestations of arteriosclerosis such as cardiovascular and arterial occlusive disease are among the major causes of death in the western world. Besides age, sex and genetic disposition, other common risk factors for arterial occlusive disease include diabetes, nicotine, high blood pressure and lipid metabolic disturbances.1

Disorders of the vascular system are the leading causes of death and disability in the western world. One of the most debilitating forms of vascular disease is peripheral arterial occlusive disease when it is manifested as critical limb ischaemia. Patients with limbs threatened by distal tibioperoneal occlusive disease present an ongoing chal- lenge to the vascular surgeon.

Unlike the lower extremity, the upper extremity is less likely to be affected with occlusive disease (10%) [17]. Di- agnosis and treatment of upper limb occlusive disease is often difficult for the following reasons: Most of the lesions are asymptomatic until the appear- ance of trophic lesions. Only 2.8%of all vascular reconstructive techniques are applied to the upper extremity. One-third of the lesions are proximal and accessible to reconstructive or endovascular techniques while two- thirds are distal lesions, where treatment is considered to be a therapeutic challenge [18]. Ischaemic problems in the upper extremity have many causes.Local,regional and systemic causes have been recognized.A precise aetiology is often difficult to es- tablish.

Ischaemic stroke represents a major health problem and an important cause of morbidity and mortality in several western countries [12]. Mortality from stroke ranges be- tween 10% and 30% [61] and its survivors remain at a high annual risk of recurrent ischaemic events and mor- tality both from myocardial infarct and repeated stroke [76]. Atherosclerosis from supra-aortic vessels, especially from the common carotid bifurcation, is the major single aetiology of ischaemic stroke in developed countries as opposed to intracranial occlusive disease and cardioem- bolization.

Our goal is to establish the utility of multi-detector row CT angiography (MDCTA) for evaluating arterial stenosis in patients with arterial occlusive disease of lower extremities.

The term “arterial occlusive disease” is applied chiefly to limb arteries and generally characterizes pulse deficits in arteries located distal to the site of the flow obstruction. It is defined as the occlusion or high-grade narrowing of one or more arteries, leading to more or less pronounced clinical manifestations of functional disability in the affected limb.

The most common locations of arterial occlusive disease in the upper extremities include: 1. In the aortic arch arteries, directly at the ostium (Fig. 35.1) 2. Distal of the latter, before the branching of the vertebral artery (Figs. 35.2 and Fig 35.3) 3. Distal of the vertebral artery, close to the costoclavicular narrowing (Fig. 35.4).

In radiological interventions, complex pathophysiological changes may occur. Appropriate premedication can prevent or weaken these mechanisms. Moreover, the examination can be carried out more rapidly, presents less risks and is less unpleasant for the patient (Cunningham et al. 1984). Patients with peripheral vascular disease often present with further manifestations of arterial occlusive disease, usually have more than one type of disease, and are frequently also receiving several different drugs simultaneously, which need to be taken into consideration when administering premedication.

Renal revascularization is part of the procedure when repairing pararenal abdominal aortic aneurysms (AAAs). This combined approach may also be indicated for juxtarenal AAA or when infrarenal aortic aneurysmal or occlusive disease coexists with renal artery stenosis (RAS).

The treatment of polyinfected lesions in arterial occlusive disease is based on a multimodal approach, in which several procedures are applied in concert to avert the impending loss of a limb. In addition to the various techniques for improving blood perfusion in the ischemic areas, combating infections plays a major role. Initial measures comprise local surgical treatment with necrectomy, lancing of abscesses, border zone amputation and local antiseptic treatment. This local treatment must be supplemented by systemic control of infections using a potent antibiotic with the broadest possible spectrum of activity. The efficacy of this antibiotic therapy depends above all on the concentration of active drug at the site of infection which can be considerably increased by administering the antibiotic by intraarterial, instead of intravenous, route (Amendt and Hild 1990; Gottlob and Hugeneck 1982; Widmer and Hurlimann 1966).

The first step in assessing patients with chronic venous insufficiency with or without ulceration is a full clinical history and examination. It is important to look for arterial occlusive disease or complaints of orthopedic or neurological character. A sign for a former pelvic vein thrombosis is given in the case of varicose veins in the mons pubis region.

In 2 years 47 patients with occlusive disease of the iliac and femoral arteries were treated by a transfemoral approach: In 18 cases endarteriectomy of the common femoral artery or of the profunda was performed. In 14 cases endarteriectomy and in two cases angioplasty of the iliac artery, seven disobliterations of the superficial femoral artery, five angioplasties and one “Rotax” procedure were done. All operations except the Rotax maneuver were successful; intraoperative control was done by angiography in all angioplasties, and endarteriectomy was controlled by angioscopy. The transfemoral approach to the iliac and femoral vessels is a minor invasive procedure with good results in elderly patients.

This chapter is concerned mainly with “major” and life-threatening ischemic strokes in the posterior circulation. There is a rough correlation between the clinical severity of brain-stem strokes and the presence of large artery occlusive disease in the vertebrobasilar system. Small penetrating vessel or branch arterial disease results in restricted brain-stem and cerebellar infarcts with a relatively good functional prognosis and will not be the main focus of this discussion.

Although rules are not always correct, life would surely be chaotic and unstructured without them. In The Cider House Rules by John Irving, each year a list of rules was posted for the itinerant, often illiterate, undisciplined, and frequently intoxicated workers who processed the apple harvest into cider. Despite the fact that the rules often went unread and mostly unheeded, their mere presence lent some order to the workday. Rules serve as a baseline, a place mark for future change and improvement. Herein I share my present rules for topographic brain-stem and cerebellar correlation with vascular lesions. I am not much troubled that some, if not many, of the rules will be proven wrong, or at least imprecise and partially incorrect. They are a start.

The optimal treatment of calcaneal fractures remains controversial [2–4, 6–11, 14, 18, 19, 23, 24]. During the last few years an increasing number of surgeons have reported encouraging results of internal fixation for displaced intra-articular fractures of the calcaneus [2, 6, 12, 15, 17, 20, 22, 26–28]. The prerequisites for open reduction and internal fixation are: good general condition, good soft tissues, an interval of less than 3 weeks after injury, no arterial occlusive disease, and a reliable patient. In contrast functional treatment is indicated for patients in bad general condition, for unreliable patients, those with severe arterial occlusive disease or with severe soft tissue problems, when there has been an interval of more than 3 weeks since the injury, and in cases of undisplaced or completely “smashed” fractures.

The functional effects of coronary occlusive disease (COD) in cardiac transplant patients on small-resistance coronary vessels are unclear. We investigated the changes in coronary flow reserve (CFR) in response to the non-specific smooth muscle vasodilator papaverine. A 3F Doppler probe was inserted into the left anterior descending (LAD) coronary artery in 61 patients following orthotopic heart transplantation. Studies were performed in 57 males and 4 females with a mean age of 46 years (range 20–61 years). The median time from operation was 4 years (range 3 months to 10 years). Coronary blood velocity was measured at rest (RFV) and maximum hyper-aemia (PFV) produced by intracoronary papaverine. Coronary flow reserve (CFR) was defined as the ratio of PFV to RFV. Minor lesions in epicardial vessels were found in 23 transplant patients. The mean percentage diameter of the most severe lesion in the coronary tree was 23% SD 3% including 12 lesions in the LAD coronary artery itself (mean 24% SD 4%). Patients with COD had an impaired CFR (2.6 SEM 0.2) compared with normals (3.9 SEM 0.2, P= 0.0003), adjusting for year after operation. Mean resting flow velocity was similar in both groups (minor COD, 6.8 cm/s SEM 1.2; normals, 7.1 cm/s SEM 0.6), but mean peak flow velocity response to pap-verine was reduced (16.5 cm/s SEM 2.5 versus 27.3 cm/s SEM 2.6; P= 0.007). In the presence of minor epicardial disease, coronary flow reserve in resistance vessels was reduced due to impairment of peak flow. This demonstrates that non-endothelial-dependent coronary resistance vessel vasodilatation is abnormal and may be caused by a defect in vascular smooth muscle function.

MRI is discussed in three children with the Moyamoya syndrome. MR angiography (MRA) was obtained in two of them. The superiority of MRI over CT is well known, as it detects the vascular anomalies (stenosis of major cerbral arteries as well as the hypertrophic collateral circulation) in addition to the ischaemic pathological changes. MRA, although not as detailed as conventional angiography, is very useful for diagnosis and follow-up of this syndrome. Conventional angiography should remain indicated only as preoperative examination.

The femoropopliteal segment consists of the caudal portion of the external iliac artery, the common femoral artery with its division into the profunda femoris artery and superficial femoral artery, and the popliteal artery down to the trifurcation in the lower leg.

Combined aortoiliac and femoropopliteal lesions are more commonly encountered and indicate in most of the cases an advanced stage of arterial occlusive disease (4, 8, 10). The majority of the involved cases are old and to a relatively high percentage, they present with rest pain and tissue necroses (10, 11). Total reconstructions in both regions with these patients carry a high operative risk. The purpose of this study is to demonstrate the possibility of resubstituting such major procedures with more simple ones.

In this section we would like to describe one specific area where agents for the prevention of thrombosis and embolism may be important: cerebrovascular disease. This can be the result of a variety of disturbances and though there is rarely only one factor responsible (Yates and Hutchinson, 1961; Zulch, 1967), it is most frequently caused by local factors such as arteriosclerotic changes of the vessel wall, leading to stenosis, thrombotic occlusion of the lumen, or embolism. The latter usually occurs as macroembolism, mainly of cardiac origin, or as microembolism originating probably from ulcerated atherosclerotic neck arteries. Microemboli are at present considered as a frequent cause of Transient Ischemic Attacks, however, they play only a minor role in the pathogenesis of longer duration ischemic lesions (Fisher, 1961). The reported frequencies of embolism vary widely between 5% and 46% (Glynn, 1956; Jorgensen and Torvik, 1966). Kurtzke (1969), in reviewing several clinical, postmortem, and epidemiologic studies, suggested that about 10% of thromboembolic occlusive disease was due to embolism.

Significant arteriosclerotic lesions of aortoiliac and femoropopliteal arteries are frequently found. Complete revascularization would seem to be the ideal anatomic and physiological result to relieve the occlusive disease involving the lower extremities. The importance of the profunda femoris artery was emphasized by Morris et al. (12). Since then, many authors have cited the importance of this artery as a collateral vessel for revascularizing ischemic limbs with combined segmental occlusive disease (5, 6, 10, 11, 15). In some patients, proximal revascularization alone will not improve symptoms. In others, an initial good result from proximal revascularization may be followed by sudden or gradual deterioration. Hemodynamic tests have been proved to evaluate or distinguish between aortoiliac and femoropopliteal disease, but no one can demonstrate with certainty which of the patients will need a distal revascularization. Most of the authors have advocated and done staged revascularization (2, 4, 7), and bypass of multiple lesions by one-stage aortofemoropopliteal reconstruction has not been widely practiced, mainly because it was a longer and more formidable procedure with higher mortality and graft failure rates (2, 11). Continued improvements in the care of the patients and the surgical procedures for revascularization has allowed performance of extensive vascular surgery when revascularization of the profunda femoris is not sufficient (8, 14).

The walking distance, type of pain and ulcer healing were constantly monitored in 25 patients who were not suitable candidates for vascular surgery. Pyruvate, lactate, citrate, oxoglutarate, β-hydroxybutyrate, acetoacetate, proteolytic activity, protease-binding capacity, elastase, cathepsin B, α1-antitrypsin, α2-macro-globulin, inorganic phosphates, ATIII, plasminogen, antiplasminogen and factor XIII were monitored for 10 days and there was found to be an objective metabolic correlation. The patients were given daily one dose of prostaglandin E1 of on average 0.3–0.6 ng/kg body weight · min by intra-arterial infusion lasting 10 hours. Individual dose-response curves were plotted by means of an impedance device. Twenty patients treated with naftidrofuryl served as the control group. With the aid of the impedance measurements and clinical chemistry parameters, the responders could be clearly distinguished from non-responders. In the responders the blood flow increased by 33%, α1-antitrypsin rose from 108 ± 36% to 156 ± 19%, α2-macroglobulin remained constant, elastase fell from 144 ± 73 to 111 ± 46 ng/ml. The concentrations of organic acids in venous blood also tended to fall. AT Ill-uptake showed a modest decline from 86 ± 14% to 73 + 12%.

The blood flow in capillaries is essential for the nutrition of the tissue and the transport of the waste products. It is very useful to distinguish between micro- and macro-circulation, and therefore it is necessary to measure the microcirculation directly at the site of interest.

The oxygen pressure of the healthy skin fluctuates between 0 and 4 mm Hg [5]. The application of hyperemizating ointment or heat causes skin oxygen pressure to rise; maximum hyperemia results at temperatures above 40 °C, while the blood flow remains constant [8]. A further increase in blood flow, such as one induced by drugs, cannot be expected, just as a reactive hyperemia cannot be measured. In earlier investigations, a uniform decline in tcPO2 was observed when an electrode was used at 44 °C in patients with arterial occlusive disease under an intra-arterial infusion of various drugs. This we interpreted as a steal phenomenon [2]. If, however, electrode core temperatures between 37 °C and 39 °C are selected, changes in the cutaneous blood flow can be detected [6]. In the following, the results of tcPO2 investigations using an electrode core temperature of 37 °C are reported.

The evaluation of patency during extra-intracranial bypass procedures depends on the personal experience of the surgeon. Postoperatively the rate of patent anastomoses is demonstrated angiographically, although, as pointed out by Fox and Allock (1978) and Reisner et al. (1980), this investigation has a high risk for patients with cerebrovascular occlusive disease, especially after extra-intracranial bypass operations. Therefore the need for noninvasive methods is obvious.

Combined disease of the aortoiliac and femoropopliteal arteries generally results in more severe ischemia of the lower limb than isolated disease of either segment. Furthermore, two-segment disease often reflects generalized arteriosclerotic morbidity, most significantly involving the coronary and cerebral artery system. Therefore, in this group of patients an urgent therapy is required more often and the operative risk is markedly increased.

Since January 1978, we have been using prostaglandin (Pg) E1 in our department as a last attempt in advanced inoperable arterial occlusive disease in stage IV. We were able to report about first encouraging results with this substance at the 27th International Congress of Cardiovascular Surgery in June 1978 in Lyon, at the annual meeting of the German Society of Angiology in September 1978 in Heidelberg, as well as at the 11 th Congress of the Austrian Society of Vascular Surgery in October 1979 in Graz. We have learned the latter described technique from Shionoya in Nagoya who has been successfully employing this substance in Buerger’s disease since 1976 (5, 6). Apart from one report by Carlson and Erikson (1) from 1973, there are — as far as we know — no publications about the administration of Pg E1 in vascular diseases in the European and Anglo-American literature. Only recently have there been first reports about treatments with Pg E1, e.g. Sethi (4).

Arteriosclerosis of the coronary, cerebral, or peripheral vessels is one of the most frequent causes of increased perioperative morbidity and mortality in Western Europe and North America. The exact cause of arterial occlusive disease still remains unclear. However, there is no doubt that certain risk factors are of decisive significance for the development and progression of the underlying disease (see Table 11.1).