Premature cardiovascular disease is common in relatives of patients with premature peripheral atherosclerosis.

BACKGROUND: Numerous clinical conditions have been proposed to explain the premature onset of symptomatic peripheral vascular disease (PVD) in young adults, but the role of genetic factors has not been defined. This study was performed to determine the prevalence of cardiovascular disease among family members of patients with premature PVD. METHODS: The prevalence of early cardiovascular events occurring in first-degree relatives of 90 subjects with premature PVD (onset < or =49 years) was determined. The prevalence of occult atherosclerosis was determined by duplex ultrasonography in a cohort of 20 asymptomatic siblings. Reference groups included first-degree relatives of 80 subjects with premature coronary artery disease (CAD) and first-degree relatives of 48 healthy subjects. RESULTS: Cardiovascular events occurred at age 55 years or younger in 28% of the parents of PVD subjects, in 23% of parents of CAD subjects, and in 7% of the parents of healthy controls (P<.001). Cardiovascular events occurred in 24% of siblings of PVD subjects, in 14% of siblings of CAD subjects, and in 7% of siblings of healthy controls (P<.001). Duplex ultrasonography detected early plaques in the lower extremity circulation of 10 (50%) of the asymptomatic siblings of PVD subjects. CONCLUSIONS: Early, symptomatic cardiovascular disease is more common in first-degree relatives of individuals with premature PVD than in relatives of healthy individuals or of probands with premature CAD. Occult vascular disease in the lower extremity is prevalent among asymptomatic siblings of probands with premature PVD. These observations indicate that susceptibility to premature PVD has a familial basis.

Renovascular hypertension.

Renovascular hypertension is one of the more common causes of secondary hypertension. The true prevalence of this condition is not known, because only a selected few with hypertension are considered for thorough diagnostic work-up. The higher incidence figures come from centers with a special interest in this disease. The ability of a clinician to detect renovascular hypertension has improved substantially, thanks to the advances in radiology. The predominant mechanism of blood pressure elevation from renal ischemia is activation of the renin-angiotensin system. Clinically, the pathological lesions that cause renal artery stenosis are atherosclerosis and fibromuscular dysplasia; the former is typically seen in older men, and the latter is typically found in young women. Suspicion of the presence of renovascular disease should prompt the physician to obtain appropriate screening and confirmatory tests. Once diagnosed, the management of patients with renovascular hypertension requires a carefully planned multidisciplinary approach to offer the patient a best possible therapeutic option, with surgical revascularization or balloon angioplasty, or chronic medical therapy. However, these options are not mutually exclusive. The best long-term results are obtained with surgical therapy. Although balloon angioplasty is being increasingly used perhaps as the preferred initial therapeutic procedure for many patients with renal artery stenosis, long-term results comparable with surgery are not yet available. The ideal rational therapy for patients with renal artery stenosis is reperfusion of the ischemic kidney either by surgical correction or by balloon dilation. The aim is not only to improve the blood pressure control, but also to prevent and at times to reverse renal failure. Although effective antihypertensive drugs have become available, the role of medical management of renovascular hypertension is shrinking and should be limited to patients who have contraindications to or unwilling to undergo corrective procedures to relieve renal ischemia.

Alterations in serum creatine kinase and lactate dehydrogenase. Association with abdominal aortic surgery, myocardial infarction and bowel necrosis.

Experimental studies have shown that peripheral serum creatine kinase and lactate dehydrogenase change with bowel infarction. Some clinical reports have suggested that similar changes occur in patients. This prospective study documents the changes in these enzymes associated with acute myocardial infarction, acute bowel necrosis (MES INF), and uncomplicated abdominal aortic reconstruction. Analysis of 15 patients with AMI, 13 patients undergoing major AAS, and eight patients with MES INF has shown that these conditions may be differentiated by analysis of serum CK and LD isoenzymes. The study suggests that in the absence of electrocardiographic changes, a patient with epigastric distress with elevated levels of serum CK and either CK-MB or CK-BB bands present may well have a mesenteric rather than a myocardial infarction. Acute myocardial infarction can be ruled out further through analysis of serum LD1/LD2 ratios.

The Matas/Soubbotitch connection.

The Southern Association for Vascular Surgery, as one of the recently developed major regional vascular societies, has recognized the outstanding accomplishments of one of the vascular pioneers in the United States, Rudolph Matas, by including his profile in the Association logo. Although the contributions in vascular surgery by Matas are well known by all who have an interest in vascular surgery, the contributions of V. Soubbotitch have not been recognized widely in the English-speaking world. Matas proclaimed in an International Surgical Congress in London in 1913 that Soubbotitch had achieved clinical success that was unparalleled by repairing injured arteries and veins. Soubbotitch, Senior Surgeon, Belgrade State Hospital, Serbia (now part of Yugoslavia) and a Lieutenant Colonel in the Serbian Army Reserve during the Balkan Wars (Serbo-Turkish and Serbo-Bulgarian) initiated one of the first clinical programs that emphasized repair, rather than ligation, of injured arteries and veins. Surgeons from the capitals in Europe visited his clinic to assist in this effort, and the 1913 presentation in London included the experience of managing 77 injured large blood vessels, which resulted in 32 vascular repairs--19 arteriorrhaphies and 13 venorrhaphies. It is ironic that nearly 40 years passed before similar successful efforts were achieved during the latter part of the Korean Conflict (1952 to 1953). In this brief review we emphasize the connection between two outstanding surgical pioneers who shared mutual interest in the repair of injured vessels and in international surgical exchanges, Matas and Soubbotitch.

The influence of aspirin on postoperative platelet kinetics and venous thrombosis.

Several parameters of platelet kinetics were followed in 105 middle-aged and elderly postoperative patients, half of whom were randomly allocated to receive aspirin. A significantly lower incidence of venous thrombosis, as detected by 125I-fibrinogen scanning, was found among patients receiving aspirin when compared with the control group. Platelet survival was shortened in the postoperative state, an effect that was inhibited by aspirin. The development of deep vein thrombosis did not shorten platelet survival, nor did fibrinogen survival discriminate patients with venous thrombosis. Treatment with aspirin reduced urinary excretion of 5-hydroxy indole acetic acid--presumably by inhibiting in vivo platelet release of serotonin, reduced postoperative consumption of platelets, and reduced the mean corpuscular volume of the platelet population. These studies suggest that platelet function is important in the pathogenesis of postoperative venous thrombosis.

Nonvascular emergencies presenting as ruptured abdominal aortic aneurysms.

BACKGROUND: Patients may present with signs and symptoms of ruptured abdominal aortic aneurysm (RAA) but actually have other diseases mimicking RAA. The outcome of these patients has not been reported. METHODS: During the past 10 years, 16 patients presumed to have RAAs were found at operation to have other diseases accounting for the symptoms. Fifteen patients (94%) had abdominal pain, 9 (56%) had a pulsatile abdominal mass, and 7 (44%) were hypotensive on presentation. RESULTS: Ten of the 16 patients had intact aortic aneurysms at surgery; there were no reliable physical signs or diagnostic tests that could discern between RAAs and intact aneurysms with other intraabdominal diseases. Eight patients (50%) died in the perioperative period, including four with widespread metastases, three with overwhelming sepsis, and one with an acute myocardial infarction. None of the 10 patients with aneurysms suffered RAA after emergency laparotomy. Exploratory laparotomy was necessary to treat underlying disease in nine patients and was probably harmful only to the patient with a myocardial infarction. Two survivors with aneurysms underwent successful staged repairs. CONCLUSIONS: Mistaken diagnoses in patients who are suspected of having RAAs on the basis of physical findings are relatively uncommon. Exploratory laparotomies are required to correct the primary disease in most of these misdiagnosed patients. Few die as a direct result of laparotomy; true iatrogenic catastrophes associated with mistaken diagnoses are distinctly uncommon.

Role of physical examination in detection of abdominal aortic aneurysms.

BACKGROUND: Early detection of asymptomatic abdominal aortic aneurysms (AAAs) has been advocated to decrease the high mortality rate of ruptured AAAs. The purpose of this study was to document how AAAs were detected, whether AAAs not detected on physical examination (PE) were palpable, and what factors precluded detection by PE. METHODS: Two hundred forty-three patients undergoing elective infrarenal AAA repair at a Veterans Affairs, county, or university hospital during a 10-year period were analyzed retrospectively. The method of initial detection of the AAA, size of the AAA at initial detection and before repair, and whether the AAA was palpable on preoperative PE were recorded, and the body mass index [BMI; weight in kg/(height in meters)2] was calculated. Obese patients were defined with BMI of greater than 85th percentile. RESULTS: Only 93 (38%) patients had their AAAs initially detected by PE; the remainder (62%) were found incidentally on radiologic examinations performed for other indications. Patients with AAAs detected by PE had lower BMIs (PE, 23.7 +/- 3.6 kg/m2; incidental, 26.0 +/- 4.6 kg/m2, p < 0.001), but there was no difference in AAA size (PE, 5.8 +/- 1.6 cm; incidental, 5.5 +/- 1.9 cm, not significant). Forty-three percent of patients with AAAs detected on radiologic examination had palpable AAAs and should have been detected on PE. Overall, 55 (23%) AAAs were not palpable on preoperative PE, even when the diagnosis was known. Obese patients had only 15% of AAAs detected by PE, and only 33% were palpable. CONCLUSIONS: AAAs are underdiagnosed by PE, especially in obese persons. More widespread abdominal examination to detect a widened aortic pulse would improve detection of AAAs.

Late outcome of amputees with premature atherosclerosis.

BACKGROUND: Peripheral atherosclerosis in young adults has been associated with a high amputation rate. Our purpose was to examine the natural history of amputees with premature atherosclerosis. METHODS: We compared 50 consecutive young patients undergoing dysvascular amputation who were 49 years of age or younger (mean age +/- SEM, 43 +/- .7 years) with 75 consecutive men and women ranging in age from 60 to 75 years (mean age, 67 +/- .6 years) who were undergoing major amputations for atherosclerosis during the same period. RESULTS: Before undergoing amputation 46 (92%) patients in the study group underwent a mean of 3 +/- 0.3 vascular operations, and 49 (65%) older patients in the control group underwent a mean of 2 +/- 0.2 vascular operations (p = 0.003). The mean time from onset of symptoms to first amputation was not different in the study group versus the control group. Of those patients surviving until discharge, 20 (45%) patients in the study group and 21 (31%) patients in the control group became community or household ambulators, whereas 24 (55%) patients in the study group and 47 (69%) patients in the control group were confined to wheelchairs or were bedridden (p = 0.17). Seventeen (74%) patients in the study group who did not require contralateral amputations became community ambulators, as did 18 (38%) members of the control group (p = 0.01). Twenty (40%) patients in the study group and 39 (52%) patients in the control group died during the study period. The mean age at death was 48 +/- 1 years for the study group and 69 +/- .8 years for the control group (p < 0.001). Cumulative 5-year survival (62% patients in study group, 47% patients in control group) was not different between the two groups (p = 0.41, Kaplan-Meier). CONCLUSIONS: Compared with older counterparts, amputees with premature atherosclerosis have a higher number of failed bypasses before undergoing amputation and die at a younger age. However, both groups have a similar cumulative survival after amputation. Fewer than one half of young patients undergoing dysvascular amputation ultimately achieve ambulation, suggesting that major amputations are a harbinger of long-term disability and dependency in these patients. Because young patients had a higher potential for rehabilitation after unilateral amputation, these patients should be monitored closely for development of ischemia in the contralateral limb.

Differentiation of vascular prostheses in dogs with serial tests of in vivo platelet reactivity.

Three different vascular prostheses (standard weight knitted Dacron, double velour knitted Dacron, and expanded polytetrafluoroethylene) were implanted in the aortas of dogs, and serial determinations of platelet survival and platelet serotonin were monitored at 12-week intervals for 1 year. Prostheses were then removed and luminal coverage with endothelialized neointima and production of prostacyclin were measured. Changes in platelet survival were correlated with changes in platelet serotonin, and both measurements reflected in vivo platelet reactivity with the vascular prostheses. These changes were unique for each type of prosthesis and were dependent upon physical characteristics and the rate and degree of coverage of the prosthetic surface with endothelialized neointima that produced prostacyclin. Prostheses that reduced platelet survival and platelet serotonin the least as shown by serial evaluation were found at harvest to be the most completely paved with nonthrombogenic neointima. In dogs, these techniques allow differentiation of vascular prostheses and provide a useful animal model for their evaluation.

The antithrombotic nature of vascular prosthetic pseudointima.

Morphologic functional, and biochemical studies were performed on pseudointima obtained from woven Dacron aortic prostheses harvested from eight dogs 2 to 3 years after placement. In vivo platelet reactivity with prostheses was assessed by serial 51Cr-platelet survival measurements which documented that platelet survival returned towards normal but never attained preoperative levels. The extent of luminal coverage of prosthesis with pseudointima of the time of harvest was 60.3% +/- 2.4%. Morphologic techniques, including conventional light microscopy, immunoperoxidase light microscopy for endothelial factor VIII-related antigen, and scanning and transmission electron microscopy, demonstrated that pseudointima was composed of endothelial cells of varying maturity lining mesenchymal tissue. Areas of the prostheses with poorly formed pseudointima containing exposed Dacron fibers were covered with exuberant, platelet-rich thrombi. Ability of pseudointima to produce prostacyclin was assessed by bioassay of platelet antiaggregatory activity and radioimmunoassay of 6 keto PGF1 alpha, a metabolite of prostacyclin. These experiments confirmed that pseudointima produced abundant prostacyclin, although not as much as native aortic tissue. These studies document that vascular prosthetic pseudointima is nonreactive with platelets, presumably because of prostacyclin generation.

Dilation of knitted Dacron aortic prostheses and anastomotic false aneurysms: etiologic considerations.

Five patients with knitted Dacron aortic bifurcation prostheses developed prosthetic dilation and anastomotic false aneurysms. The interval between placement of prostheses and secondary presentation ranged from 4 to 10 years. Three patients presented with femoral false aneurysms (one ruptured) and two presented with aortic false aneurysms (one ruptured). In all cases, anastomotic sutures remained intact on the prosthesis and there was no evidence of infection. The mean (+/- SEM) increase in diameter of prostheses was 85.7 +/- 19.1% (range 76% to 137%). Dilated prostheses were removed in four cases and were tested for tensile strength and studied with scanning electron microscopy. These were compared to normal, nondilated knitted Dacron prosthetic fabric from the same manufacturer. There was no loss of breaking strength in dilated prostheses. Furthermore, on examination with scanning electron microscopy, there was no evidence of degeneration or fracturing of individual Dacron filaments. However, dilated prostheses were found to have a greatly expanded knit. The distance between loops was significantly increased and the number of fibers per 1000 microns was significantly less in comparison to normal knitted Dacron fabric. These studies confirm an association between prosthetic dilation and false aneurysm formation. Further, they suggest that the cause of prosthetic dilation is loss of compactness of the knit not associated with intrinsic Dacron fiber deterioration. A fabrication defect is most likely responsible.

Etiologic factors for recurrent carotid artery stenosis.

Since 1966, 29 patients with recurrent carotid artery stenosis have been encountered. The mean (+/- SEM) internal between initial carotid endarterectomy and secondary presentation was 67.5 +/- 9.2 months (range 6 to 180 months). There was a disproportionate number of women with recurrent stenosis. The mean age at initial endarterectomy in patients with recurrent stenosis, 54.6 +/- 1.4 years, was significantly less (P less than 0.001) than that of all patients who had endarterectomy. To define the etiologic factors for recurrence, 21 of these patients were matched with case-control patients of the same age and sex who had undergone endarterectomy the same year but did not develop recognized recurrent stenosis. There was no significant difference in the incidence of hypertension, diabetes mellitus, coronary artery disease, bilateral carotid disease, other vascular operations, or family history for atherosclerosis in patients with recurrent stenosis compared to control patients. The indications for primary endarterectomy, angiographic distribution of disease, and operative details were similar in both groups. There was no difference in the incidence of regular, therapeutic aspirin ingestion following initial endarterectomy (52.5% in both groups). There was a striking difference in smoking habits. Ninety-five percent of patients with recurrent stenosis continued to smoke following initial endarterectomy, compared to 23.8% of control patients (P less than 0.001). Lipid fractionation studies were performed in both groups, and there were no significant differences in levels of cholesterol, triglycerides, high-density lipoprotein (HDL)-cholesterol, and total cholesterol/HDL-cholesterol ratio. Dose-response platelet aggregometry detected no differences between groups in the sensitivity of platelets to adenosine diphosphate (ADP), collagen, and epinephrine. Reoperation in patients with recurrent stenosis was associated with minimal morbidity, no deaths, and generally excellent results.

Percutaneous transluminal balloon angioplasty of the iliac artery for contralateral ischemia.

The cases of three patients with lower extremity ischemia from ipsilateral iliac artery occlusion and contralateral iliac artery stenosis are presented. Planned treatment was percutaneous transluminal angioplasty (PTA) of the contralateral iliac artery, rendering it an adequate donor vessel for subsequent femorofemoral bypass. Because of adequate collateral vessels across the pelvis, cross-femoral bypass was unnecessary following PTA. Current technology allows simultaneous intraoperative PTA and femorofemoral bypass. We do not recommend this on the basis of our experience.

Asymptomatic cervical bruit and abnormal ocular pneumoplethysmography: a prospective study comparing two approaches to management.

Fifty-seven patients with cervical bruits and abnormal ocular pneumoplethysmography but without symptoms were followed prospectively. Mean follow-up was 32 months and all patients were followed for at least 1 year. Twenty-nine patients consented to join a randomized study comparing treatment with aspirin, close follow-up, and no intervention unless symptoms developed [( NI: ASA] n = 14) versus intervention with arteriography and prophylactic surgery [( I: A/S] n = 15). Among patients who refused randomization, 14 were treated with NI: ASA and 14 with I: A/S. Endpoints for analysis included all unfavorable outcomes related to both management plans and included stroke, death of stroke, major angiographic and perioperative complications, asymptomatic carotid occlusion, and recurrent carotid artery stenosis. In both the randomized and nonrandomized portions of the study unfavorable outcomes were more frequent in patients treated with I: A/S, and by combining the results of both studies a significant difference was observed (N: ASA - 3.6% versus I: A/S - 31%; X:2 = 4.78; p less than 0.05). Among patients treated with NI: ASA, a single minor stroke occurred without warning. In patients from all groups who underwent arteriography, advanced carotid stenosis was found in 78% (mean percent diameter stenosis = 72% +/- 2%; mean residual lumen = 1.3 +/- 0.1 mm). We conclude that, despite the probability of underlying severe carotid stenosis, most patients with cervical bruit and abnormal ocular pneumoplethysmography but without symptoms are appropriately managed without intervention unless symptoms develop.

Abdominal aortic aneurysms and malignant neoplasia: double jeopardy.

BACKGROUND: This study was performed to determine whether there is a significant association between abdominal aortic aneurysms (AAAs) and malignancy and to determine the impact of malignancy on late survival in patients with AAA. METHODS: We studied 126 men undergoing AAA repair and compared them with 99 men undergoing aortofemoral bypass (AFB) for occlusive disease and with 100 men undergoing herniorrhaphy during the same period. RESULTS: Fifty-one (40%) patients with AAA, 23 (23%) patients undergoing AFB, and 21 (21%) patients undergoing herniorrhaphy were diagnosed with cancer (p = 0.002). By life table analysis the proportion of subjects remaining cancer free at 5 years was 0.60 +/- 0.05 for AAA, 0.83 +/- 0.04 for AFB, and 0.81 +/- 0.04 for herniorrhaphy (p = 0.004). Multivariate analysis selected four independent risk factors for cancer: presence of AAA (p = 0.003, odds ratio 1.4, confidence interval [CI] 1.2 to 1.7), age (p = 0.001, odds ratio per year 1.1, CI 1.0 to 1.1), smoking (p = 0.04, odds ratio 1.5, CI 1.0 to 2.2), and hypertension (p = 0.04, odds ratio 0.73, CI 0.5 to 1.0). Cancer deaths accounted for 32% of late deaths in patients with AAA, which was not different compared with 26% of late deaths in patients undergoing AFB and 36% of late deaths in patients undergoing herniorrhaphy. Five-year cancer-free survival was 0.44 +/- 0.05 for patients with AAA, 0.64 +/- 0.05 for patients undergoing AFB, and 0.70 +/- 0.05 for patients undergoing herniorrhaphy (p < 0.001, AAA versus herniorrhaphy only). CONCLUSIONS: Cancer is more prevalent in men with AAA than in men undergoing AFB or herniorrhaphy. The presence of AAA appears to be an independent risk factor for cancer. Despite the higher cancer prevalence in patients with AAA, cardiovascular disease accounted for the largest number of late deaths in this series, minimizing differences in cancer-free survival between patients with AAA and patients undergoing AFB.

Age-related differences in the distribution of peripheral atherosclerosis: when is atherosclerosis truly premature?

BACKGROUND: The natural history of peripheral atherosclerosis in young adults appears to be unfavorable compared with that in older patients. No universally accepted definition of "premature" atherosclerosis exists, however, making comparison of clinical studies difficult. This study examined age-related differences in distribution of atherosclerotic lesions and determined an age threshold at which such differences became apparent. Such a threshold may provide a definition of premature atherosclerosis. METHODS: Arteriograms of all patients 49 years of age and younger undergoing evaluation of lower extremity ischemia during the past 5 years were reviewed and the findings were tabulated. Medical records were reviewed to obtain demographic data, assess risk factors, and confirm disease etiology. Exclusion criteria included normal arteriograms (three patients), history of acute or remote trauma (six patients), unclear cause of ischemic symptoms (three patients), arteritis (four patients), aneurysmal disease (one patient), and acute ischemia without prior chronic symptoms (12 patients). For comparison we also reviewed arteriograms performed during the same period in 140 patients older than 50 years of age who had chronic lower extremity ischemia caused by atherosclerosis. RESULTS: The mean age of the 59 study patients was 43.4 +/- 5.8 years (median age, 46 years; range, 25 to 49 years). Arteriograms were available in all cases; medical records were available in 54 (92%). Atherosclerosis involved only the aortoiliac segment in 25 patients (42%), the femoropopliteal-tibial arteries alone in 21 (36%), and both levels in 13 (22%). Patients with distal atherosclerosis had a higher prevalence of diabetes than those with proximal atherosclerosis (p = 0.004). Ninety-two (66%) of the 140 patients older than 50 years of age had atherosclerosis confined to a single arterial segment, which was not significantly different from the prevalence of single-level disease in the study group. However, 25 (54%) of the 46 study patients with single-level atherosclerosis had aortoiliac disease compared with only 15 (16%) of 92 patients older than 50 years of age with single-level disease (p < 0.001). CONCLUSIONS: In contrast to the pattern of disease in older adults, atherosclerosis in young, nondiabetic patients most commonly involves the aortoiliac segment. Differences in lesion distribution become increasingly apparent with age but are most striking between those 49 years of age and younger and those 50 years of age and older. Accordingly, we propose that premature peripheral atherosclerosis be defined as beginning at or before the age of 49 years.

Bright-light amaurosis fugax: an unusual symptom of retinal hypoperfusion corrected by external carotid revascularization.

The eye often serves as an important monitor of carotid artery disease by manifesting visual disturbances before cerebral events. The most typical ocular symptom complex is amaurosis fugax characterized by loss of vision in one eye that occurs suddenly and clears within seconds to minutes. This symptom is a hallmark of carotid artery disease and is usually caused by an embolic event. Although monocular visual disturbance on a hemodynamic basis is a more unusual manifestation of carotid artery disease, significant stenosis in combination with a low-flow state can cause transient, unilateral telescoping of vision. This report describes another visual disturbance associated with carotid artery disease in which unilateral visual loss occurred upon exposure to bright light. We term this syndrome bright-light amaurosis fugax and document successful treatment by external carotid artery revascularization in two patients.

Heparin. Efficacy and safety after arterial operations.

Hemorrhage is the most serious side effect of heparin sodium use. Under several circumstances, one may need to administer heparin to patients who have had recent peripheral vascular operations. Avoiding an inordinate number of hemorrhagic complications is mandatory after such operations. Side effects appear to be minimized by administering heparin by continuous intravenous (IV) infusion. Nineteen patients with recent peripheral vascular operations were given heparin by continuous IV infusion. A known hemorrhagic complication developed in only one. The degree of hemorrhage was mild and did not necessitate cessation of treatment with heparin. None of the patients whose mean activated partial thromboplastin times were in the therapeutic range experienced thrombotic complications while receiving heparin.

Focal motor seizures complicating carotid endarterectomy.

We studied four patients with focal motor seizures complicating carotid endarterectomy and compared them with 14 other cases reported previously. Seventeen of the 18 patients had high-grade carotid stenoses. A severe unilateral headache usually preceded seizure activity, which was followed by prolonged Todd's paralysis. Eight patients had histories of ipsilateral stroke. There was no association with perioperative hypertension. Two patients who were receiving heparin sodium had intracerebral hemorrhages that caused one of the two postoperative deaths. The patency of all endarterectomized carotid arteries was recorded by arteriography or noninvasive studies. These data suggest that patients who have severe unilateral headaches following ipsilateral carotid endarterectomy for high-grade stenoses are at risk for focal motor seizures. The roles of antithrombotic agents and anti-seizure medication in this setting are unclear.

Popliteal vascular entrapment. Its increasing interest.

In the past 20 years since the first clinical management of a patient with a congenital anomaly associated with an abnormal medial head of the gastrocnemius muscle causing external compression on the popliteal artery, approximately 100 similar lesions have been documented in the world's literature. This has been a lesion of international interest, with only approximately 25% of the cases from hospitals in the United States. This present series of 14 lesions from Walter Reed Army Medical Center, Washington, DC, during a 12 1/2-year period beginning in September 1966 emphasizes the increasing interest in this lesion. The young athletic male in whom intermittent claudication develops with strenuous exercise or the middle-aged patient with a popliteal aneurysm should be evaluated for the possibility of popliteal vascular entrapment. Medial deviation of the popliteal artery seen angiographically is a classic finding, however, there might also be segmental occlusion of the midpopliteal artery. This series outlines various types of popliteal vascular entrapment and documents successful surgical management.