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OBJECTIVE AND IMPORTANCE: Mycotic aneurysms of the extracranial carotid artery are rare and difficult to diagnose. A search of the world literature published since 1966 reveals at least six cases of mycotic carotid aneurysms due to a Salmonella septicemia. We present an exceptional case of mycotic pseudoaneurysm of the bifurcation of the carotid artery due to Salmonella septicemia and discuss the pathogenesis as well as various aspects of the diagnosis and surgical management. CLINICAL PRESENTATION: A 68-year-old man presented in Poland with Salmonella sepsis; 1 month later, he was admitted to the emergency department of the Sir Mortimer B. Davis-Jewish General Hospital in Montreal with a bulky and pulsatile right cervical mass. An angiogram and a computed tomographic scan revealed a voluminous and partially thrombosed aneurysm the size of a tangerine originating from the posterior aspect of the carotid junction. INTERVENTION: Balloon trapping was attempted at the Montreal Neurological Hospital. Subsequently, the patient developed a significant neurological deficit, which was quickly reversed by the administration of hypertensive, hypervolemic, and hemodilution therapy. Thereafter, the pseudoaneurysm was resected surgically, and the internal and external carotid arteries were sacrificed. Pathological examination of the excised specimen of the carotid junction revealed a pseudoaneurysm. Bacterial culture of the lesion showed growth of Salmonella. CONCLUSION: The postoperative course was satisfactory except for laryngeal paralysis due to involvement of the vagus nerve. Four months later, a computed tomographic scan showed only small lacunae in both centra semiovale.

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There have previously been only rare reported survivors of an aortoesophageal fistula resulting from a traumatic pseudoaneurysm. We report a case of a young man with a dramatic presentation who was successfully managed by immediate operative repair. A prosthetic graft was sewn within the sac of the aneurysm, with the aneurysm wall being used to protect the graft, and the esophagus was resected. Staged reconstruction of the esophagus was subsequently performed successfully. The patient is now alive and well 2 1/2 years later.

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BACKGROUND: The purpose of this study was to look at the clinical behavior of bronchial carcinoids and clarify a surgical approach. METHODS: Eighty-four patients resected for bronchial carcinoids were retrospectively reviewed for clinicopathologic variables, surgical management, and outcome. Tumors were considered "typical" or "atypical" based on histologic features. "Conservative" surgery signified lung parenchyma-sparing procedures. Survival analysis was performed using standard statistical methods. RESULTS: Most patients presented with an abnormal routine chest x-ray. One patient had the carcinoid syndrome. Computed tomography scan reliably predicted lymph node status and bronchoscopic biopsy diagnosed carcinoids with 70% success. Fifteen "conservative" procedures were performed. Fifteen percent of patients had atypical carcinoids, 12% presented with lymph node metastases, and 6 patients had tumorlets associated with the primary tumor. Overall survival rates were 93% and 82% at 5 and 10 years, respectively. Significantly decreased disease-free survival was found with atypical histology (p < 0.0001) and the presence of tumorlets (p = 0.02); lymph node involvement strongly tended toward poorer outcome. CONCLUSIONS: Bronchial carcinoids have a definite malignant potential predicted by atypical histology, presence of tumorlets, and lymph node involvement. These features can be identified with routine bronchoscopic biopsy, computed tomography scanning, and intraoperative assessment including frozen section. In the select group of patients without negative features, strong consideration should be given to performing a conservative resection.

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This study was designed to compare duplex scanning with contrast venography for the diagnosis of acute deep vein thrombosis of the lower extremity, both at the femoropopliteal (above-knee) and tibioperoneal (below-knee) levels. A total of 216 patients with 220 limbs suspected of acute deep vein thrombosis underwent duplex scanning followed within 24 h by ascending venography. The two studies were interpreted independently by two physicians who were blinded to the results of the corresponding alternative study. Venography was positive for deep vein thrombosis in 44.5% of cases (98/220). Duplex scanning was inadequate at the above-knee level in two cases (0.9%) and at the below-knee level in 17 cases (7.7%). Sensitivity and specificity of duplex scanning at above-knee level were 98.7% and 100% respectively while corresponding values were 85.2% and 99.2% at below-knee level. By excluding technically inadequate duplex studies, the sensitivity at below-knee level was clearly improved (93.8%). It is concluded that with meticulous technique, duplex scanning is highly accurate in diagnosing acute deep vein thrombosis of symptomatic lower extremities, avoiding contrast venography in over 90% of the cases, even at the tibioperoneal level.

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A 67-year-old woman underwent an esophagogastrectomy and esophagogastrostomy for carcinoma of the distal esophagus. She died of massive hematemesis and exsanguination on the 14th postoperative day. An acute peptic ulcer-induced aortoenteric fistula was present at the anastomotic line. The literature on peptic ulcer-induced aortoenteric fistulas after esophagogastroplasty is reviewed.

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A patient with Bean's blue rubber bleb nevus syndrome presented with a hemothorax, and 18 years earlier had presented with "idiopathic" hemopercardium and tamponade. Typical hemangiomas were found in the pleura and skin. This is the first report of intrathoracic bleeding with this disorder.

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The management of patients with metastatic disease from primary carcinoma of the colon and rectum is still controversial. To evaluate the results of resection of pulmonary metastases from patients with colorectal primaries, a retrospective study of all patients who underwent such resection was carried out at the teaching hospitals of McGill University and Université de Montréal. A total of 345 patients admitted with pulmonary metastases; 27 of them underwent pulmonary resection with the extent of the resection varying from wedge excision of the metastatic nodule to pneumonectomy. In 25 of the 27 patients the resection was considered curative. Eight of the 27 patients had resection of two metastatic lesions while the remaining 19 patients had resection of solitary lesions. The interval between resection of the primary colorectal malignancy and the resection of the metastatic lesion (disease-free interval) varied from 2 to 77 months with a median interval of 35 months. The five-year survival following resection of pulmonary metastases was 21 percent. A prolonged interval between treatment of the primary and resection of the pulmonary metastasis was associated with a longer survival. This retrospective study demonstrates that prolonged survival can be achieved following resection of pulmonary metastases from colorectal carcinoma.

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Ninety-seven patients presenting with isolated Raynaud's phenomenon were evaluated clinically and immunologically. Three patients developed progressive systemic sclerosis in a 3-5-year follow-up. Nineteen patients had positive antinuclear antibody, 32 depressed serum complement, and 31 elevated serum immune complexes. None of the immunologic abnormalities had obvious diagnostic significance.

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Two patients considered to be examples of the Type IV or "arterial" variety of the Ehlers-Danlos Syndrome (EDS) are presented. In case 1 there seems to be little doubt about the diagnosis. Case 2, which is currently under treatment also appears to be an example of EDS, Type IV. The multiple arterial aneurysms and the findings on the skin biopsy appear to substantiate the diagnosis. These two cases demonstrate some of the features of the Type IV variety of EDS. In the first case visceral artery aneurysms dominated the clinical picture and in the second case peripheral arterial aneurysms were dominant. In neither case were the classical manifestations of the disorder, skin hyperelasticity and joint hypermobility, prominent.

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During the past decade, resection of abdominal aortic aneurysms has become common. The technical aspects of the operation are now relatively standardized and simplified. With concomitant improvements in anesthesia and intensive care, the operative mortality for elective resection of these aneurysms has declined progressively; several centres report an operative mortality of less than 5%. The author considers the following principles important in managing patients with abdominal aortic aneurysms: (a) simplicity and limited dissection are critical features of the operative technique; (b) tubular grafts should be used whenever possible; (c) selected patients should be transferred to the intensive care unit preoperatively for "fine-tuning" of the cardiovascular system; (d) patients should be monitored intraoperatively and postoperatively; (e) the surgeon should be aware of special problems such as horseshoe kidney, venous anomalies, adherent duodenum and the presence of major arteries arising from the aneurysm; (f) ruptured aneurysms should be diagnosed promptly and the patient operated upon without delay. Using these principles, the author's group achieved an operative mortality of only 1.8% in 168 patients with abdominal aortic aneurysms resected electively. However, the operative mortality for their patients with ruptured aortic aneurysms was 50%, a rate that has not changed appreciably over the years.

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In summary, definitive answers to the many questions regarding femoropopliteal and femorodistal bypass grafting are not available. The results vary widely for many reasons. Although many aspects of vascular surgery do not lend themselves to scientific investigation by randomized, controlled, prospective studies, some of these questions can be answered by such studies. Since large numbers of patients may be required for prolonged follow-up, multicentre cooperative studies can provide meaningful data. There is also a need for standardization of follow-up techniques. The classification of vascular disease by symptoms and presentation such as claudication, rest pain, ischemic ulcers pregangrene and gangrene is inadequate and highly subjective. A more objective classification is essential, perhaps using the current techniques of the vascular laboratory or newer techniques that are sure to be developed. The national and regional vascular societies must be the leaders in these efforts. A start has already been made and it is hoped that progress will be rapid.

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The introduction of the Fogarty catheter heralded a new era in the management of patients with arterial embolism. In the 15 years from 1966 to 1980, the authors managed, operatively, 148 separate episodes of arterial embolization in 134 patients. Excluded from the series were patients who had visceral emboli and those who were managed nonoperatively. The emboli occurred in the upper extremities in 22 patients who had 24 embolic episodes and in the lower extremities in 112 patients who had 124 separate embolic episodes. The source of the embolus was the heart in 106 patients and in the remaining 28 patients a proximal aneurysm or atherosclerotic artery, a prosthetic graft or an unknown source. Most operative procedures were performed under local anesthesia using a transverse arteriotomy. The limb was saved in all 24 episodes of upper extremity embolism and in 115 (87%) of 132 lower limbs at risk (seven patients had emboli in both lower extremities simultaneously and one had emboli in an upper extremity and lower extremity simultaneously). The mortality for the 148 embolectomies was 20% an included all deaths occurring within 30 days after operation or during the same hospital admission. An analysis of our results indicates that embolectomy may not be successful when the delay between the occurrence of the embolus and its removal is excessively prolonged (more than 48 hours), when the patient is elderly and when the source of the embolus is unknown.

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Because of reports that negative mammographic findings have resulted in a delay of treatment in patients with breast cancer, the authors reviewed their experience with mammography in 160 patients, admitted to the Sir Mortimer B. Davis-Jewish General Hospital in Montreal over a 28-month period, who had histologically verified carcinoma of the breast. Of these patients 153 had clinically palpable masses and 7 had occult carcinomas. The mammogram was considered to be positive for carcinoma in 112 (73.2%) and negative in 41 (26.8%). In 44 patients under the age of 50 years the mammogram was positive in 26 (59.1%) and negative in 18 (40.9%), a significant difference (P less than 0.05). There was no significant difference between the findings of mammograms read by the hospital radiologists and those read by community radiologists. This study confirms the findings of others that mammography is not a reliable technique for evaluating the clinically suspicious breast lesion and must not be used as a substitute for biopsy of such lesions.

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Communications between the esophagus and the tracheobronchial tree in adults are usually acquired and are generally caused by tumour, trauma or infection. Congenital fistulas persisting to adult life are uncommon. The authors present the case of a 72-year-old woman with a congenital fistula between the esophagus and the posterior segmental bronchus of the lower lobe of the left lung. The relative lack of symptoms in this patient for so many years is a well recognized feature of such fistulas. The fistula and lower lobe of the left lung were excised. Some of the reported cases of congenital esophagobronchial fistulas in adults are reviewed and the clinical, radiologic and histologic features of this entity are described.

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Between Jan. 1, 1970 and June 30, 1977, 50 men and 23 women underwent femorofemoral bypass grafting. The average age of the group was 64.7 years. The procedure was performed for disabling claudication in 50 patients and for limb threatening ischemia in 23. Knitted Dacron grafts were used in all but two patients. The operative mortality was 4.1% and the late mortality 21.9%. There were six complications related to the prostheses, three infected grafts and three false aneurysms. Thrombosis of the graft occurred in 15 patients; the graft was successfully revised in 2. The cumulative 5-year patency rate determined by life-table methods was 73.4%. The causes of failure appeared to be well defined and unilateral iliac artery disease. The donor iliac artery, poor runoff through a diseases deep femoral artery on the recipient side and infection of the graft. This study indicates that femoro-femoral bypass has a definite place in the management of patients with unilateral iliac artery disease. The procedure can be performed on selected patients with a low operative mortality and an acceptable patency rate.

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