Extracranial arterial reconstruction for chronic cerebral ischaemia. An audit of experience in the Durban Teaching Hospitals.

Experience with 147 operations for extracranial cerebral arterial reconstruction in 122 patients over a 36-month period is presented. The commonest condition in white, black and indian patients was atherosclerosis, although 8 of the 23 black patients had nonspecific aorto-arteritis (Takayasu's disease). Operations within the mediastinum included bypass from the ascending aorta to major arterial branches (14), brachiocephalic endarterectomy (1), and replacement grafts of carotid (1) and subclavian (1) arteries. Cervical procedures included carotid endarterectomy or reconstruction (115), carotid-subclavian artery bypass (13) and axillary-to-axillary artery crossover (2). Both early and longer-term results are comparable with those reported in the surgical literature.

Operative treatment of nonspecific aortoarteritis (Takayasu's arteritis).

Operative treatment of nonspecific aortoarteritis remains controversial and little information is available on the results of reconstruction of extracranial cerebral vasculature in this disease. Our experience with 25 patients with histologically proven symptomatic disease treated during a 4-year period is presented. The aortic arch and its branches were involved in 12 patients and 13 had disease affecting the descending aorta and its tributaries. Patients with cerebrovascular disease had aneurysms, minor stroke, or intermittent neurologic dysfunction. Descending aortic involvement resulted either in symptomatic or ruptured aneurysm and renovascular hypertension. Operative treatment of cerebrovascular disease comprised aortic arch (three patients), carotid (three patients), or subclavian artery reconstruction (six patients). Descending aortic reconstruction comprised thoracoabdominal (four patients) or infrarenal (five patients) aneurysmorrhaphy, abdominal aortic replacement with bilateral renal artery reconstruction (two patients), and nephrectomy (two patients). One early postoperative death occurred because of stroke. Twenty-four survivors have been observed between 3 and 42 months. No deaths or further neurologic episodes have occurred during this period and three of five hypertensive patients were cured. We conclude that symptomatic aortoarteritis, including cerebrovascular disease, may be treated by standard operative techniques with rewarding results.

Bypass versus primary major amputation in patients with femoropopliteal distal disease and a threatened limb.

Over a 36-month period 201 patients came to the Vascular Service, King Edward VIII Hospital, with atherosclerotic occlusive disease involving the femoropopliteal or femoro-infrapopliteal segments. On the basis of angiographic and clinical assessment 113 patients underwent bypass procedures and in 88 amputation was performed. The two groups were well matched as regards age and clinical condition. In-hospital mortality was 3,5% and 2,3% in the bypass and amputation groups respectively and the time spent in hospital was 5-6 weeks. In the longer term the desired achievement was limb salvage or ambulation on a prosthesis. Cumulative life-table analysis showed that more patients in the limb-salvage group than amputees were ambulant over any given time interval, although at 36 months after operation there was only an 8-10% difference. The results suggest that it is worth while attempting limb salvage in these cases, certainly as far as the first 3 years after operation are concerned.

Neurological deficit and injuries involving the neck arteries.

The management of 85 patients with penetrating injuries involving the external (n = 19), internal (n = 6) and common carotid (n = 46), vertebral (n = 10) and brachiocephalic (n = 4) arteries over a 5-year period in one hospital is reviewed. Sixty-three patients had no peroperative neurological deficit; 22 presented with localizing neurological signs. Where there was no deficit, the external carotid (n = 19) and vertebral (n = 10) arteries were ligated without adverse sequelae. Arterial reconstruction was performed of the internal carotid (n = 2) which resulted in a temporary neurological deficit in 7 patients and death in 3. Among the 22 patients with a preoperative neurological deficit, arterial reconstruction was performed in 18, which involved the common carotid in 17 patients and the internal, carotid in 1 patient. There was complete neurological recovery in 11 patients and 2 patients died. Four comatose patients had cerebral revascularization performed without fatality and with complete recovery in 3 of them. CT head scanning was not routinely employed for logistic reasons but has proved of limited value. No intraluminal arterial shunts were used in this series. It would seem that arterial reconstruction is not harmful and may well be beneficial to the young patient with extracranial cerebral arterial injury associated with a neurological deficit. Shunts are probably unnecessary for routine use.

Surgery for aneurysms involving the thoraco-abdominal aorta. Report on 2 patients.

The surgical management of 2 patients presenting with symptomatic thoraco-abdominal aneurysms is reported. In the first patient a technique which utilized multiple side-arm grafts to the visceral arteries is described. In the second patient we used the simpler and more expeditious technique of anastomosing the visceral artery orifices to "windows" in the aortic replacement graft from within the opened aneurysm. The merits and demerits of the different techniques and their hazards are discussed. It would seem that few aneurysms can be regarded as inoperable.

Cervicomediastinal arterial injuries. A surgical challenge.

The initial clinical observations and methods and results of treatment in 104 patients with subclavian (48), vertebral (four), and carotid (52) artery injuries are reported. Delayed hemorrhage ten days after misdiagnosed subclavian artery injuries resulted in false aneurysms causing compressive brachial plexus palsies. A conservative approach to penetrating cervicomediastinal wounds was adopted with selective use of arch aortography when arterial injury was suspected by defined criteria. This proved safe, accurate, and invaluable for planning operative approach. Partial median sternotomy without entering the pleura proved optimal for superior mediastinal access; simple clavicle transection provided adequate distal subclavian exposure. External carotid and vertebral arteries were ligated. No shunts were employed for common and internal carotid repair. None of the 14 patients revascularized in the presence of a neurologic deficit died and none was made worse by carotid reconstruction.