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Simultaneous compression of the celiac axis and superior mesenteric artery by the median arcuate ligament of the diaphragm is likewise uncommon. Only 2 patients have been reported in literature. Description of four patients with severe abdominal angina caused by this condition. All patients were cured by division of the arcuate ligament.

Three approaches are considered: the left thoracoabdominal approach, the right-sided retro- or supracolic route and the transabdominal access. Aorto-common hepatic venous bypass grafting is the preferred procedure in singular occlusions of the celiac axis. Reimplantation and aorto-mesenteric venous bypass are the treatments of choice in singular occlusions of the mesenteric artery. Occlusions of both upper intestinal arteries can be treated with a venous bridge bypass graft or by transaortic end-arterectomy. Operative mortality is low (0.9%). Remaining occlusion and recurrent symptoms occurred in 12 of 92 patients.

The treatment of infection after vascular operations depends on the severity and extent of this complication. In infections of low virulence an attempt to prevent progression of the infectious involvement should be made with the help of antibiotics and immobilization. Suppurating infection involving a vascular graft but not yet causing bleeding can be treated successfully by drainage and antibiotic irrigation. In case of bleeding at the site of an infected anastomosis it is sometimes possible to prevent further bleeding and to cure the infection by wrapping omentum round the anastomactic lines. Severe infection and repeated hemorrhage require sacrifice of the reconstructed vessel to prevent loss of limb and even life: arteries reconstructed with the use of autogenous material must be ligated; any implanted synthetic material has to be removed. In these cases limb salvage can be accomplished using a remote bypass (axillo-femoral bypass, obturator-bypass, crossed bypass, etc.).

Renovascular hypertension caused by renal artery stenosis was a coincidental discovery in 5 of the 6 patients presented. They did not have any comlaint and it was by routine bloodpressure measurement that hypertension was diagnosed. In one patient without hypertension stenosis of both renal arteries was seen on the aortography for an infrarenal aortic occlusion. Depending on the extent and localisation of the stenosis unilateral renal artery stenosis was treated by a saphenous vein graft interposition, or by an aortorenal vein patch. In a man with bilateral renal artery stenosis a venous bridge was constructed. Once an unilateral nephrectomy was necessary, the kidney being atrophic and a vascular correction impossible.

Proximal involvement of the innervation of the arm is a well recognised cause of hand symptoms; a proximal vascular abnormality is rarely responsible. This case report describes such a rare cause, namely, a post-stenotic aneurysm of the subclavian artery due to an abnormal first rib but in the absence of a cervical rib or scalene bands.

Thirteen patients with proximal malignant obstruction of the biliary tract secondary to primary cholangiocarcinoma are presented. Seven of these patients had bilateral involvement of the major vessels of the porta hepatis, and 12 had bilateral involvement of the main hepatic ducts up to the level of segmental bifurcation. Resection of the tumor was carried out in all of the patients. Extensive resection of the liver with resection of the regional vascular structures was done in six. Another six underwent resection of the liver without resection of the regional vascular structures. The remaining patient underwent resection of the tumor and of the regional revascular structures alone. Vascular resection included resection and reconstruction of both the portal vein and hepatic artery in four patients or only of the portal vein in three. Biliary drainage was carried out by intrahepatic cholangiojejunostomies between segmental hepatic ducts and a Roux-en-Y loop. Two patients died and ten are alive. The quality of postoperative life is satisfactory and the patients are free of sequelae and symptoms secondary to operation or disease. This approach is recommended for the management of a number of patients with bilateral vascular or biliary involvement secondary to primary cholangiocarcinoma of the porta hepatis. For those patients, this approach offers a promising alternative.

Optimal protection of the brain during carotid endarterectomy is of great importance and is guaranteed by general anaesthesia with maintenance of normal blood-pressure and a normal CO2-level, routine use of internal shunts and heparinization. Operation of "asymptomatic" patients has to be seriously considered. Patients with acute occlusions of the carotid artery should not have surgery as emergency procedures, unless the operation can be done immediately after the onset of symptoms. In chronic occlusion of the internal carotid artery endarterectomy may be considered if the shiphon is patent and in good condition.

Based on the own experience and on an intesive study of the literature with a total of 52 patients with an aortic aneurysm and a horseshoe kidney the problems of operative treatment are discussed. The conclusion is made, that the treatment of this rare combination has its special difficulties in nearly 2/3 of all cases, but the same results as conventional surgery of aortic aneurysms, when the renal artery abnormalities are respected and treated with adequate vascular surgical skill.

For this second panel by correspondence, we have asked 3 distinguished experts to answer 7 questions and to comment on 3 case histories concerning vascular surgery. Although a direct discussion between the participants was not possible an impressive degree of agreement is here being demonstrated.

Neurogenic and vasculogenic impotence after aortoiliac reconstruction is an unpleasant problem in vascular surgery. The importance of maintaining or restoring intraoperatively a sufficient hypogastric artery blood flow is emphasized. Postoperative neurogenic sexual disabilities are irreversible and are due to interruption of sympathetic nerve fibers supplying the genital system. Dissecting the terminal aorta and the iliac arteries the hypogastric sympathetic plexus--which descends across the bifurcation--can be easily damaged. This is the cause of the high incidence of failure of ejaculation after aortoiliac surgery. In order to avoid this neurogenic sexual dysfunction a retromesenteric approach to the aortoiliac region is anatomically suggested by A. v. Hochstetter. It enables the exposure of the abdominal aorta and the iliac arteries without disrupting the superior hypogastric plexus and its variants. Respecting the integrity of the sympathetic plexus and a sufficient flow in the internal iliac artery the frequency of postoperative disturbances of erection was reduced from 17% (1199 patients) to 12.3% (570 patients). The incidence of postoperative loss of ejaculation in the same groups of patients decreased from 81% to 20%.

Based on experience with about 1,000 patients with operable aortoiliofemoral occlusive disease, the factors influencing the operative procedure are discussed. These include the angiographic picture, the severity of ischemia, general risks, accessibility of the operating field, and availability of reconstructive material. It is concluded that, in discussing the operative procedure in aortoiliofemoral occlusive disease, the central question must be, which procedure is best for this patient, in view of his special circumstances, and not, which procedure is technically possible.

The costoclavicular compression syndrome and the cervical rib syndrome can cause arterial complications of the subclavian artery: mural thrombosis, occlusion and aneurysma. These complications can result in peripheral emboli or cerebrovascular insufficiency. Such sequelae can be avoided by timely surgical treatment of these compression syndromes. The therapy of choice is transaxillary rib resection. The same axillary approach can also be used for directly reconstructing the subclavian artery.

Based on the experience with 243 patients with chronic occlusive disease of the visceral arteries, the different symptoms of intestinal angina are described. Problems concerning diagnostic procedures, especially angiography, and indication for reconstructive arterial surgery are discussed.