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Thoracic outlet syndrome (TOS) embodies a constellation of symptoms arising from compression of the nerves, arteries, and veins at the base of the neck. Symptoms may vary in distribution and intensity, depending on which of the three structures in the neurovascular bundle are involved. The majority of patients benefit from nonsurgical management; however, when surgery is indicated, transaxillary first rib resection has a high degree of acceptance from patients and surgeons. Length of hospital stay for surgery is brief and long-term results appear to be excellent. This article reviews the fundamentals of recognition and management of TOS and describes recent Suburban Hospital experience.

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Inflammatory aneurysms are an uncommon disorder that represent between 5% and 10% of abdominal aortic aneurysms. Their presentation is often variable and may include pain and obstruction of adjacent anatomic structures. This report describes a 68-year-old man who sought treatment after insidious onset of progressive bilateral lower extremity edema over a 6-month period. Noninvasive studies were suggestive of bilateral iliac vein occlusion, and a venogram showed a nearly obstructed vena cava from external compression. A CT scan showed a thick-walled infrarenal abdominal aneurysm. At exploration an inflammatory abdominal aortic aneurysm was found. Because of the presence of dense inflammatory changes surrounding the aneurysm and extending into the pelvis, the surgical procedure of choice was an aortobifemoral bypass graft done with Dacron. The aneurysmal wall was debrided from the vena cava. His postoperative course was uneventful, his edema resolved, and follow-up noninvasive studies were normal. Postoperative venography showed resolution of the extrinsic compression of the vena cava.

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Chronic lower-leg edema in patients with venous disorders was studied by means of lymphoscintigraphy. Lymphatic patterns of flow were evaluated prospectively in 26 patients with technetium 99m antimony trisulfide colloid injected subcutaneously in the interdigital web spaces on the feet. Most patients in this study had postphlebitic syndrome, and all of these patients had abnormal lymphoscintigraphic flow patterns. Nine had evidence of lymphatic obstruction, and one had an enhanced flow pattern. Three patients had veins used for distal arterial bypass, and all these veins showed decreased lymphatic flow. Two patients with Klippel-Trenaunay syndrome (congenital varicose veins associated with limb elongation, a capillary nevus, and an abnormal deep venous system) had obstruction to lymphatic flow, and two others had normal and enhanced patterns. Normal studies were seen in four of five patients who had veins used for coronary artery bypass grafting. The finding of decreased lymphatic flow in patients appears to be the result of the length of time from an episode of deep venous thrombosis, the occurrence and number of episodes of cellulitis and lymphangitis, and mobilization of the vein for use in distal arterial bypass surgery. This study shows that the edema attributed previously to primary venous disorders may have a significant lymphatic component. The degree of lymphatic obstruction can be determined by lymphoscintigraphy with technetium-labeled antimony trisulfide colloid.

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Eleven of 14 survivors who sustained trauma to the abdominal aorta have been evaluated 16 to 18 years after injury through personal interview, physical examination, and abdominal contrast computerized tomography (CCT). The average age of survivors was 39 years (range, 37-47). All patients had minimal debridement of the aortic injury with lateral arteriorrhaphy. No patients had symptoms of arterial insufficiency. However, five patients had abnormal ankle/brachial indices (ABI). In four patients, ABI was less than 1.00 at rest and a fifth patient's ABI decreased significantly: 0.60 left and 0.65 right from an average of 1.00 bilaterally after standardized exercise treadmill. CCT evaluation revealed aortic calcification in five patients in the area of aortic injury. Aortic calcification occurred only in the patients with abnormal ABI's. This long-term followup identifies no evidence for late compromise in the aorta; however, there is a suggestion that injury and repair may contribute to the accelerated development of atherosclerosis.

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The incidence of coronary artery disease in patients coming to aortic surgery and the impact of aggressive preoperative cardiac catheterization and myocardial revascularization was prospectively analyzed in 59 patients. Seventy-five percent of patients had at least one-vessel involvement, and 32% had three-vessel or left main involvement. Patients with electrocardiographic evidence of coronary artery disease had at least one-vessel involvement 84% of the time and three-vessel, left main involvement 36% of the time. Sixty-four percent of patients with no preoperative indications of coronary artery disease had at least one-vessel involvement and 29% had three-vessel, left main involvement. Resting (39 patients) and exercise multiple-gated acquisition scans (22 patients) did not predict the presence of coronary artery disease in patients without a history or electrocardiographic evidence of coronary artery disease. Myocardial revascularization was performed prior to aortic surgery in 17 patients (29%). The operative mortality was 3.7% with two patients dying from noncardiac-related complications. There were two additional deaths prior to aortic surgery with one patient dying during coronary artery bypass grafting, and one dying of aneurysm rupture prior to repair, making the overall mortality associated with this approach 7.4%. Preoperative cardiac catheterization and an aggressive approach toward coronary artery bypass grafting reduces the risk of cardiac complications in aortic surgery.

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There were 85 patients in this series. The overall mortality was 17.6%. Gunshot wounds were responsible for 51 injuries, with a 21% mortality. There were three stabbings and three shotgun blasts, with a mortality of 10% and 33%, respectively. There were 127 intra-abdominal vascular injuries. The majority were to the SMA and its branches: 34. The highest mortality occurred with protal vein and combined aortic and vena caval injuries (80%). Fatalities averaged twice as many vascular injuries as survivors. There were 194 organ injuries. A liver injury predicted the highest mortality as did injuries to the spleen, lung, and pancreas. The presence of shock and the ability to rapidly control the source were the major predictors of survival. Fatalities averaged a Trauma Score of 7.5; survivors averaged a score of 14.0. There were 12 deaths which occurred intra-operatively and three postoperatively, for a total of 15 deaths. Once the patients made their way from surgery, their survival was 96% assured. Early suspicion of an intra-abdominal vascular injury followed by rapid exposure and control of hemorrhage are the keys to successful management.

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Blast injury remains an important source of trauma in both civilian and military settings. We have studied a recently developed blast wave generator to evaluate its effectiveness for laboratory study of blast injury. In order to determine the reliability of the device and the pathology of the lesions caused by the short duration (0.5-1.0 msec), and high intensity (60-375 psi) pressure wave, laboratory rats were exposed to the pressure waves generated by the machine. The animals were divided into three groups: the first exposed to midthoracic blasts, the second to abdominal blasts, and a group of controls exposed to a gentle stream of gas. Group I showed gross and microscopic evidence of lung blast injury of "rib imprint" hemorrhages, intra-alveolar hemorrhage, marked increase in lung weight, prolonged apnea, and bradycardia. Group II showed typical blunt abdominal trauma at the closest ranges, but characteristic submucosal hemorrhages up to 4.0 cm from the blast nozzle. In both groups, a protective effect was seen in heavier animals. The blast wave generator permits reproducible blast injury in the laboratory that is safer and faster than current methods. The lung and bowel lesions induced are grossly and microscopically similar to injuries of blast exposure seen in clinical patients.

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One hundred patients undergoing carotid endarterectomy under general anesthesia were prospectively randomized to receive either a local anesthetic injection of their carotid sinus nerve with bupivacaine (Marcaine) or no injection. Systolic blood pressure and pulse rate were recorded before injection and at 5 and 30 minutes after injection. The need for intraoperative and postoperative use of systemic vasopressor and vasodilator medications was recorded for each group as was the incidence of arrhythmias, neurologic complications, and myocardial infarctions. Intraoperative local anesthetic injection of the carotid sinus nerve did not significantly influence the intraoperative pulse rate or incidence of hypotension. It did, however, significantly increase the incidence of intraoperative hypertension and the need for systemic vasodilator medications intraoperatively. The incidence of postoperative hypotension (6 percent of patients), hypertension (34 percent), arrhythmias (6 percent), cerebrovascular accidents (1 percent), transient ischemic attacks (3.1 percent), and myocardial infarctions (2 percent) were not significantly influenced by intraoperative local anesthetic injection of the carotid sinus nerve. Intraoperative and postoperative hypotension did not cause morbidity in this series, however, local anesthetic injection was associated with a significant incidence of perioperative hypertension. Routine prophylactic local anesthetic injection of the carotid sinus nerve cannot be recommended in view of its detrimental effects in relation to the development of hypertension.

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One hundred eleven impotent men and 25 potent men were prospectively evaluated with a standardized exercise treadmill test (SETT) used to noninvasively define their pelvic hemodynamics. Fifty-six men had vasculogenic impotence, whereas the remaining 55 had erectile dysfunction resulting from undetermined causes (31), psychogenic factors (10), or other identifiable reasons (14). Arteriography was performed on 40 (71%) of the patients with vasculogenic impotence without false positive results, as well as in 11 (44%) of the potent control patients and in six (11%) of the patients with nonvasculogenic impotence without false negative results, confirming the validity of the SETT. The distinction between vasculogenic and nonvasculogenic impotence can be accurately made with the SETT. Patients with vasculogenic impotence had a resting penile-brachial index (PBI) equal to 0.60 +/- 0.022 (mean +/- SEM) and a PBI after exercise equal to 0.45 +/- 0.019 with a fall in the mean PBI of -0.15 (p less than 0.001). Patients with nonvasculogenic impotence had a resting PBI equal to 0.80 +/- 0.024 and a PBI after exercise equal to 0.88 +/- 0.019 with a rise in mean PBI of 0.08 (p less than 0.001). This response was not significantly different between the control group and the nonvasculogenic impotence patients. The addition of PBI determinations after treadmill exercise revealed that 18% of the patients with vasculogenic impotence would have been incorrectly diagnosed, because their resting PBI was greater than the traditional standard of 0.70. Furthermore, 18% of the patients with nonvasculogenic impotence would have been incorrectly diagnosed as having vasculogenic impotence because their resting PBI was less than 0.70.(ABSTRACT TRUNCATED AT 250 WORDS)

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The case of a patient with renovascular hypertension related to an arterial kink is reported. The arterial kink was caused by a renal artery aneurysm and was not apparent with angiography. This is the first reported case in which renin-mediated hypertension was clearly related to a correctable mechanical problem from a saccular renal artery aneurysm. Indications for surgical repair of renal artery aneurysms and angiographic findings indicative of a functionally significant renal artery stenosis are reviewed.

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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.

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This report summarizes the Walter Reed Army Medical Center experience with six patients operated on from 1949 through 1982 for vascular injury related to lumbar disk surgery. All had common iliac artery injuries generated by L4-5 disk operations. Four patients had isolated arterial injuries and two had combined arteriovenous injuries. Three underwent vascular repair acutely, two with shock and one with a false aneurysm. Delay in diagnosis occurred in two patients who presented 6 weeks and 3 years postinjury with minimally symptomatic arteriovenous fistulae. A sixth patient had a known arterial injury and was operated on after a 1-month delay. All patients survived. Two patients had had repeated back operations, suggesting that this may be a risk factor for perforation of the anterior spinal ligament by an operative rongeur.

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Eighty-three femoral anastomotic false aneurysms occurring in 51 patients were diagnosed from 1972 through 1982. Twenty-two (27%) presented with acute events. Seventy (84%) were confirmed by sonography and/or arteriography. Bilaterality (29%), recurrence (18%), and associated aortic false aneurysms (8%) were significant problems. Eight-one were repaired with a six per cent complication rate, including one death related to preoperative rupture. The 51 patients were evaluated for associated illnesses, risk factors, and etiologies of their false aneurysms. The most common single cause (61%) was host vessel degeneration with an intact suture line remaining attached to a disrupted Dacron limb. Twenty-three patients with host vessel degeneration were matched with case controls not developing false aneurysms. These two groups were matched for gender, age, and year of AFB and compared for associated illnesses and risk factors. Incidences of cigarette smoking, hypertension, cerebrovascular disease, coronary artery disease, diabetes mellitus, previous femoral endarterectomy, outflow disease, other aneurysmal disease, multiple groin operations, wound complications, and training levels of surgeons performing initial AFBs were similar for both groups. Factors observed significantly more often in patients who developed false aneurysms included serum lipid abnormalities (p less than 0.05), braided synthetic suture material as opposed to monofilament polypropylene (p less than 0.05), and continued abuse of tobacco following AFB (p less than 0.005).

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Experience with 11 cases of thromboembolectomy of leg arteries explored at the ankle is presented. Patency was established in 19 of 23 arteries (83%), resulting in salvage of 11 of 14 limbs (79%). This experience documents success of this technique with follow-up ranging from 2 to 70 months (mean followup, 24.7 months). Current indications for the procedure include 1) incomplete extraction of thrombus via the popliteal trifurcation, 2) incomplete transfemoral extraction of thrombus with restoration of a popliteal pulse, and 3) thromboembolus initially confined to the infrapopliteal arteries.

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One-hundred nineteen patients with 125 iatrogenic vascular injuries requiring surgical intervention were treated at Walter Reed Army Medical Center from 1974 through 1982. This experience was compared with that from 1966 through 1973 [1]. A decrease in the proportion of cases resulting from cardiac catheterization was partially offset by an increase in injuries from invasive monitoring and injuries from percutaneous transluminal dilation procedures. A threefold increase in cases resulting from urologic surgery was related to the evolution of an aggressive approach toward retroperitoneal metastatic tumor. Over half of the arterial injuries are now iliofemoral in location because of the routine use of the femoral approach for angiographic and cardiac catheterization procedures. The need for complex reconstruction in addition to thrombectomy increased fourfold. Delayed surgical intervention was a factor in 9 of the 12 patients with permanent disability. There was no death attributable to vascular reconstruction.

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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.

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