Establishment Of Collateral Circulation Research Articles

Preliminary application of ulnar cortex transverse transport technique in treatment of upper extremity thromboangiitis obliterans

To investigate the feasibility and effectiveness of ulnar cortex transverse transport technique in treating upper extremity thromboangiitis obliterans (TAO). A retrospective analysis was conducted on the clinical data of 7 male patients with upper extremity TAO who were admitted and met the inclusion criteria between January 2019 and July 2022. The patients ranged in age from 32 to 50 years, with a mean age of 40.1 years. The disease duration ranged from 6 to 24 months, averaging 13.6 months. The smoking history ranged from 8 to 31 years, with a mean of 18.4 years. All patients presented with finger ulcers or gangrene, including 1 case affecting the thumb and index finger, 1 case affecting the index and middle fingers, 1 case affecting the middle and ring fingers, 1 case affecting only the ring finger, and 3 cases affecting the ring and little fingers. The preoperative visual analogue scale (VAS) score was 9.1±0.7. All patients underwent treatment with the ulnar cortext transverse transport technique. The wound healing time and the disappearance time of rest pain were recorded. The VAS score was used to assess the degree of hand pain before and after operation. Serum interleukin 6 (IL-6) levels were measured before operation and at 1 month after operation. Computed tomography angiography (CTA) of the affected limb was performed before operation and at 3 months after operation to evaluate changes in blood vessels. The clinical outcomes were evaluated at 1 year after operation based on the Patwa and Krishnan grading system. All 7 patients were followed up 12-17 months, with an average of 13.7 months. All patients experienced successful healing of ulcers, with wound healing time ranging from 14 to 21 days, averaging 17.3 days. During the follow-up, no complication occurred, and there was no recurrence of ulcers. The disappearance time of rest pain ranged from 8 to 15 days, averaging 12.1 days. The pre- and post-operative (1-month) serum IL-6 levels were (25.1±5.9) pg/mL and (11.9±2.9) pg/mL, respectively, with a significant difference ( t=5.363, P=0.002). CTA examination at 3 months after operation revealed partial revascularization of upper extremity arteries and establishment of collateral circulation, showing significant improvement compared to preoperative status. The VAS scores at 1, 7, 28 days, and 6 months postoperatively were 6.4±0.8, 3.7±0.8, 0.6±0.8, and 0.1±0.4, respectively, all of which significantly improved compared to preoperative scores ( P<0.05). Furthermore, the VAS scores gradually decreased over time, with significant differences observed between postoperative time points ( P<0.05). At 1 year after operation, the effectiveness of all 7 patients were evaluated as excellent based on the Patwa and Krishnan grading system. The ulnar cortex transverse transport technique can improve blood circulation in the upper limb of patients with TAO, reconstruct microcirculation, inhibit inflammation, promote ulcer healing, and alleviate limb pain.

Effects of asymptomatic cerebral artery stenosis of anterior circulation and establishment of collateral circulation on cognition

ObjectiveThe purpose of this study is to investigate how cognition is affected by asymptomatic cerebral artery stenosis (CAS) of the anterior circulation and its related collateral circulation. Methods102 patients with CAS of the anterior circulation and 52 controls were enrolled from January 1, 2019 to June 30, 2022. Patients with CAS of anterior circulation were further divided into different subgroups according to the degree of stenosis, cerebral perfusion, and collateral circulation. A series of neuropsychological scales were used to evaluate the participant’s cognitive function, activities of daily living, and neuropsychiatric symptoms (such as memory, execution, psychomotor speed, etc.). The data were analyzed using T-test, F-test, chi-square test, rank sum test, and other statistical methods, moreover, the quantitative data were further examined for trends. The relationship between the degree of CAS, cerebral perfusion, collateral circulation, and the outcome of the cognitive test was investigated using Spearman correlation analysis. ResultsCompared to controls, there were severe impairments of global cognition, psychomotor speed/execution, memory, attention, activities of daily living, and more neuropsychiatric symptoms in patients with anterior circulation CAS (p < 0.05), and these impairments got worsened with the aggravation of CAS (p < 0.05). The global cognition, psychomotor speed / executive function, memory function, and daily living ability were impaired both in the cerebral perfusion-compensated group and decompensated group(p < 0.05), while there was no statistically significant difference between the two groups (p > 0.05). With the aggravation of CAS, the proportion of poor collateral formation increased, and this difference was statistically significant (P < 0.01). The degree of stenosis, cerebral perfusion, and collateral circulation establishment of anterior circulation CAS was correlated with global cognition, memory, psychomotor speed, execution, attention, activities of daily living, and neuropsychiatric symptoms (all p < 0.01). ConclusionCognitive impairment and the percentage of inadequate collateral circulation development rise as stenosis progresses in patients with anterior circulation CAS. The decline in global cognitive function was accompanied by impairments in psychomotor speed / executive function, memory function, attention, and daily living skills, as well as the aggravation of neuropsychiatric symptoms, especially in patients with impaired cerebral perfusion and poor collateral circulation formation.

Retracted: The Effect of Long‐Term External Counterpulsation Combined with Exercise Therapy on the Establishment of Collateral Circulation in Patients with Coronary Artery Occlusive Disease

Retracted: The Effect of Long‐Term External Counterpulsation Combined with Exercise Therapy on the Establishment of Collateral Circulation in Patients with Coronary Artery Occlusive Disease

The Effect of Long-Term External Counterpulsation Combined with Exercise Therapy on the Establishment of Collateral Circulation in Patients with Coronary Artery Occlusive Disease.

Objective By detecting the levels of external counterpulsation combined with exercise therapy on the levels of moesin, angiopoietin-like protein2 (Angptl 2), angiopoietin-like protein (Angptl 3), hypoxia inducible factor-1α (HIF-1α), and RNA-34a (miR-34a) in patients with coronary artery occlusive disease, the effect of external counterpulsation combined with exercise therapy on the establishment of occluded coronary collateral circulation was studied. Methods A retrospective analysis of 166 patients with coronary heart disease was confirmed by coronary angiography results that at least one coronary artery (anterior descending branch, circumflex branch, and right coronary artery) was completely occluded and was classified into the control group (routine medication) and the treatment group (routine drug therapy plus exercise therapy and external counterpulsation) according to the treatment plan of the patient. The serum levels of moesin, Angptl 2, Angptl 3, and HIF-1α were detected by enzyme-linked immunosorbent assay (ELISA) test. The index of microcirculatory resistance (IMR) and coronary flow reserve (CFR) of the two groups of patients were measured before and after 2 weeks of treatment. The formation of collateral circulation was analyzed according to the Rentrop classification method. Results After treatment, the IMR levels of the two groups were significantly decreased, and the CFR levels were significantly increased. The decrease of IMR level and the increase of CFR level in the experimental group were better than those in the control group (P < 0.05). There was no significant difference in the positive detection rate of moesin antibody between the two groups, but the OD detection value of the treatment group decreased significantly (P < 0.05). The levels of Angptl 2, Angptl 3, and miR-34a in the treatment group were lower than those in the control group, while the relative expression of HIF-1α was higher than that in the control group. The difference was statistically significant (P < 0.05). External counterpulsation combined with exercise therapy improved the formation rate of collateral circulation (P < 0.05). Conclusions External counterpulsation combined with exercise therapy can reduce moesin antibody, Angptl 2, Angptl 3, and miR-34a levels increase HIF-1α levels, and promote the establishment of occluded coronary collateral circulation.

Analysis of the Value of GE1.5HDX MRI Information Imaging Technology in the Clinical Diagnosis of Patients with Hemorrhagic Cerebral Infarction

Objective: To analyze the imaging characteristics of hemorrhagic cerebral infarction (HI). Methods: The cases were selected from 220 patients with new cerebral infarction who were hospitalized in our hospital from March 2015 to February 2018, of which 34 cases were found with hemorrhagic cerebral infarction. All the selected cases met the criteria for "Diagnosis Points of Various Cerebrovascular Diseases" adopted by the Fourth National Cerebrovascular Diseases Academic Conference of the Chinese Medical Association in 1995, and were confirmed by cranial CT and/or GE1.5HDX MRI scans as Hemorrhagic cerebral infarction. Retrospectively analyze the clinical data, clinical manifestations, brain CT, GE1.5HDX magnetic resonance examination, and clinical data of 34 patients with HI, and analyze their short-term prognosis, HI occurrence time, type of bleeding, infarct area, incidence site, arteries The blood supply and imaging performance were analyzed by statistical X2 test to analyze the imaging characteristics of hemorrhagic cerebral infarction. Results: 1. 34 patients with HI in this group accounted for 15.45% of the cerebral infarction in the same period, including 16 males and 18 females. The ages ranged from 45 to 86 years, with an average of 68.09 ± 10.41 years. 2.34 cases of HI included cerebral embolism in 26 cases (76.47%), cerebral thrombosis in 7 cases (20.58%), lacunar infarction in 1 case (2.94%), cardiogenic cerebral embolism in 22 cases (64.71%), and history of atrial fibrillation. Fourteen patients (41.18%) and 24 patients with large infarction (70.59%). Conclusions: Embolization, occlusion, recanalization, and establishment of collateral circulation are closely related to the occurrence of HI. For patients with cardiogenic cerebral embolism and large-scale cerebral infarction, regardless of whether the clinical symptoms are exacerbated, attention should be paid to cerebral infarction.

Expression and significance of malonaldehyde, superoxide dismutase and endotoxin in liver injury model of Budd-Chiari syndrome in rats

Objective To investigate the expression and significance of malonaldehyde (MDA), superoxide dismutase (SOD) and endotoxin (ET) in liver injury model of Budd-Chiari syndrome (BCS) in rats. Methods The animal model of BCS was established by partially ligating the inferior vena cava of the posterior segment of liver in rats. The experimental animals were divided into three groups: control group (12 rats), model group (48 rats) and sham operation group (48 rats). The model group and sham operation group were divided into four subgroups (1, 3, 6, 12 weeks) of 12 rats each. After the success of modeling, being confirmed by digital subtraction angiography (DSA), nine rats in each group were sacrificed at random respectively, where their serums and liver tissues was collected. The levels of MDA, SOD and ET in both liver homogenate and serum were examined respectively. ANOVA was used to compare the total difference between groups and within group of each measurement data. The LSD method was used to do multiple comparison within group and between groups. Pearson method was used to do correlation analysis of hypoxia markers. Results The levels of MDA, SOD and ET in liver homogenate and serum at different time points in model group were significantly different from those in control group and sham operation group (MDA: liver homogenate (F=52.906, 219.016), serum (F=21.573, 43.878);SOD: liver homogenate (F=22.927, 19.317), serum (F=10.841, 31.643);ET: liver homogenate (F= 33.588, 105.515), serum (F= 40.832, 46.323);P<0.05). The total difference of the MDA level in serum at each time point after the operation was not statistically significant in model group(F=1.965, P=0.139), but that of liver homogenate in the model group was statistically significant (F=7.716, P=0.001). The SOD and ET levels in both liver homogenate and serum of model group were compared within groups at different time points after operation respectively, and the overall difference was statistically significant (SOD: F=17.053, 7.903;ET: F=19.870, 39.372;P<0.05). The time-varying curves of MDA and ET in liver homogenate and serum in model group were similar, which both increased from 1 week after operation,peaked at 6th week and slightly decreased at 12th week. The increase levels of MDA and ET in liver homogenate were significantly higher than those in serum. There was a negative correlation between MDA and SOD in liver homogenate and serum (r=-0.814,-0.591;P=0.001, 0.001), a positive correlation between MDA and ET (r=0.761, 0.422;P=0.004, 0.001), and a negative correlation between SOD and ET (r=-0.726,-0.490;P=0.001, 0.001). Conclusions The levels of hypoxia related markers, such as MDA, SOD and ET in liver and serum of BCS animal model, change to varying degrees in the early stage, and will be aggravated as the disease continues to advance. In the later stage, with the establishment of collateral circulation, hypoxia will be slightly eased, but is still significantly higher than normal, which indicates that congestion and hypoxia run through the whole process of BCS, and could be the key and initiating factors. Key words: Anoxia; Endotoxins; Reactive oxygen species; Budd-Chiari syndrome

Basic Science Liver

Basic Science Liver

Establishment of collateral circulation in patients with moyamoya disease after combined revascularization

Objective To observe the establishment of postoperative collateral circulation and its types after the combined revascularization for the treatment of patients with moyamoya disease. Methods From January 2010 to January 2015, 57 patients with moyamoya disease (67 hemispheres) treated with direct vascular reconstruction (superficial temporal artery-middle cerebral artery anastomosis, STA-MCA) combined with indirect vascular reconstruction (encephalo-duro-myo-synangiosis, EDMS) at the Department of Neurosurgery, Brain Hospital Affiliated to Nanjing Medical University were analyzed retrospectively. Head CT or MR perfusion imaging was use to evaluate cerebral blood flow. According to the digital subtraction angiography (DSA) images, the establishment of collateral circulation after procedure (the cerebral hemisphere blood supply range) was evaluated. The blood supply range of revascularization of 2 surgical methods after procedure was compared. Results The postoperative follow-up was 6-60 months (mean, 23±12 months). At 6 months after procedure, 60 (89.6%) of 67 hemispheres showed increased cerebral blood flow perfusion on the operated sides. The direct vascular anastomosis was patent in 65 sides (97.0%). DSA showed that the feeding range of neovascularization in patients ≥1/3 of the middle cerebral artery (MCA) blood supply region accounted for 97.0% (65 sides), among them, in patients >2/3 blood supply region accounted for 82.1% (55 sides). The neovascularization was sparse only in 2 sides, and the blood supply range the indirect one; and 23 sides (34.3%) were < the indirect revascularization blood supply range; and 25 sides (37.3%) were equal to the indirect revascularization blood supply range. At 6 months after procedure, there was no significant difference in the establishment of collateral circulation between the patients with ischemic and hemorrhagic moyamoya disease. Conclusions The effect of the direct revascularization combined with the indirect revascularization for the treatment of revascularization of moyamoya disease is better. The direct revascularization may immediately improve the cerebral perfusion in ischemic area, while the indirect revascularization may provide a more lasting effect of revascularization. Key words: Moyamoya disease; Cerebral revascularization; Collateral circulation

Influence of thoracic duct ligation on the lipid metabolism of patients with esophageal carcinoma after esophagectomy

The aim of this study was to determine the influence of thoracic duct ligation on the lipid metabolism of patients with esophageal carcinoma after esophagectomy. A total of 74 patients with esophageal carcinoma who underwent esophagectomy were divided into 2 groups according to whether or not their thoracic duct was ligated. Thirty-nine patients were in the thoracic duct ligation group and the other 35 assigned to the control group. Enteral feeding was through a nasojejunal tube from the 1st day to the 8th day after operation, and liquid diet was provided starting on the 6th day. We compared the plasma concentrations of cholesterol (CHOL), triglycerides (TG), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) at different time points. There were no statistically significant differences between the two groups in CHOL, TG and HDL levels at different times. However, LDL levels in the thoracic duct ligation group were significantly lower at different times compared to the other group (P < 0.05), where they were the lowest at the end of the 1st month and then gradually recovered 3 months later. Thoracic duct ligation can effectively prevent chylomicrons from being transferred to the blood, reducing the generation of LDL. The establishment of collateral circulation was slow after the ligation of the thoracic duct, which had a negative effect on early postoperative nutrition of patients.

Influence of thoracic duct ligation on lipid metabolism after esophagectomy

Objective To explore influence of thoracic duct ligation on lipid metabolism after esophagectomy. Methods Seventy-four patients with esophageal cancer received esophagectomy were divided into two groups by their thoracic duct ligation, 39 in ligation group and 35 in non-ligation group. All the patients were fed with nutrients through nasal-duodenal tube placed during operation from the 1 st day to the 8th day after surgery, and started taking liquid diet on the 6th day. Blood specimens were collected from the patients on the 1st day after admission, the 9th day, one month and three months after surgery,respectively for biochemical analysis,including determinations of total cholesterol(TC),triglyeeride(TG),high-density lipoprotein-cholesterol ( HDL-C) and low-density lipoprotein-cholesterol ( LDL-C) . Databetween the two groups were compared with statistical analysis. Results No significant difference in plasma levels of TC, TG and HDI.-C was found between the two groups at varied time points. Plasma level of LDL-C in the ligation group significantly decreased on the 9th day after surgery, as compared with that in the nonligation group ( P ＜ 0. 05), and went down to the lowest level one month after surgery. Conclusions Chylomicron was blocked to enter blood stream and production of LDL-C decreased by thoracic duct ligation,which affect lipid absorption and metabolism leading to poor early nutrition in patients with esophagealsurgery due to slower establishment of collateral circulation. Key words: Thoracic duct; Esophageal neoplasms; Lipid metabolism disorders; Lateralcirculation

Peritoneoatrial Shunting for Intractable Chylous Ascites Complicating Thoracic Duct Ligation

Thoracic duct ligation for chylothorax is considered a safe and efficient procedure. However, we observed two cases that were complicated by intractable chylous ascites. Refractory chylous ascites are usually cured by surgical peritoneovenous shunting, but in both patients successful treatment required peritoneoatrial shunting. Actually, a peritoneovenous shunt was impossible because of extensive venous thrombosis in jugular and superior vena cava in one patient and failed because of constrictive pericarditis requiring pericardectomy in the other, both underlying diseases also accounting for the thoracic duct ligation complications.

Biogenesis of Short Intronic Repeat 27-Nucleotide Small RNA from Endothelial Nitric-oxide Synthase Gene

Endothelial nitric-oxide synthase (eNOS) is a constitutively expressed gene in endothelium that produces NO and is critical for vascular integrity. Previously, we reported that the 27-nucleotide (nt) repeat polymorphism in eNOS intron 4, a source of 27-nt small RNA, which inhibits eNOS expression, were associated with cardiovascular risk and expression of the eNOS gene. In the current study, we investigated the biogenesis of the intron 4-derived 27-nt small RNA. Using Northern blot, we showed that the eNOS-derived 27-nt short intronic repeat RNA (sir-RNA) expressed only in the eNOS expressing endothelial cells. Cells containing 10 x 27- or 5 x 27-nt repeats produced higher levels of 27nt sir-RNA and lower levels of eNOS mRNA than the cells with 4 x 27-nt repeats. The 27nt sir-RNA was mostly present within the endothelial nuclei. When the splicing junctions of the 27-nt repeat containing intron 4 in the full-length eNOS cDNA vector were mutated, 27nt sir-RNA biogenesis was abolished. Suppression of Drosha or Dicer diminished the biogenesis of the 27nt sir-RNA. Our study suggests that the 27nt sir-RNA derived through eNOS pre-mRNA splicing may represent a new class of small RNA. The more eNOS is transcribed or higher number of the 27-nt repeats, the more 27nt sir-RNA is produced, which functions as a negative feedback self-regulator by specifically inhibiting the host gene eNOS expression. This novel molecular model may be responsible for quantitative differences between individuals carrying different numbers of the polymorphic repeats hence the cardiovascular risk.

Significance of establishing collateral circulation by leptomeningeal anastomoses in the occlusion of arteriae cerebri mediae

We have investigated establishment of collateral circulation in patients with cerebral circulation disorder. Thirty angiograms of patients treated at Neurological Department of Hospital Centre in Sarajevo suffering from arteriae cerebri mediae occlusion were used for this study. Cerebral anastomoses that included connections between arteriae cerebri anterior and arteriae cerebri mediae over leptomeningeal anastomoses occurred in some patients suffering from occlusion of this arteriae. It was concluded that the majority of anastomoses existed between big leptomeningeal branches of postcommunicant segment of a. cerebri anterior and branches of cerebri mediae. These collaterals are of great significance as their functional ability is sometimes of a high degree in cases of occlusion of one or the other artery. It can be concluded that anastomosing of the blood vessels increases their volume in the whole and therefore more blood can be provided, although physiological factors should not be neglected, as functional effectiveness of collateral circulation in postocclusive states depends also on the state of the whole cerebrovascular system, then on the speed of creation of occlusion (thrombosis or embolism), systemic arterial pressure, volume and viscosity of the blood.

Influence of transarterial chemoembolization on angiogenesis and expression of vascular endothelial growth factor and basic fibroblast growth factor in rat with Walker-256 transplanted hepatoma: an experimental study.

After transarterial chemoembolization (TACE), the residual cancer cells are under extensive hypoxic or even anoxic environment. Hypoxia can lead to adaptive responses. For example, angiogenesis will help these cells survive. In this study, we examined the effect of TACE on angiogenesis and expression of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (b-FGF) and to assess their relevance to Walker-256 transplanted hepatoma. Male Wistar rats were inoculated with Walker-256 tumor in the left lobe of liver. Angiography and transarterial chemoembolization were performed at d14 after transplantation. Sixty rats bearing walker-256 transplanted hepatoma were randomly divided into control group, arterial infusion group and TACE group. Each group consisted of twenty rats. Normal saline, 5-Fu, 5-Fu and lipiodol were infused through hepatic artery respectively. Two weeks after the infusion, staining of factor VIII, VEGF and b-FGF was performed by immunohistochemistry method in routine paraffin-embedded sections. Microvessel density (MVD) was counted in endothelial cells with positive factor VIII. Their expression levels were analyzed in conjunction with the pathologic features. While a smaller tumor volume was found in TACE group (F=37.818, P<0.001), no statistical differences between MVD and expression of VEGF and b-FGF were found among the 3 groups. MVD of the control group, chemotherapy group and chemoemoblization group was 80.84+/-24.24, 83.05+/-20.29 and 85.20+/-23.91 (F=0.193, P=0.873), respectively. The positive expression of VEGF and b-FGF was 75%, 75%, 85% (chi2=0.449, P=0.799) and 30%, 25%, 30% (chi2=0.141, P=0.922), respectively. Statistical analysis revealed a positive correlation between the expression of VEGF and MVD (r=0.552, P<0.001). There has been little influence of lipiodol chemoembolization on the formation of tumor angiogenesis, but the development of neovascularization and expression of VEGF play important roles in establishment of collateral circulation and reconstruction of blood supply of residual cancer tissue.

Ischemia of the left colon associated with abdominal aortic aneurysms and their treatment.

Since the advent of resectional therapy for abdominal aneurysms, 1,2 it has become evident that the inferior mesenteric artery can generally be divided close to the aorta with impunity. This fact was anticipated in many of the earlier reports of extirpation of aneurysms. 2-8 The hindgut derivatives usually remain viable under these circumstances because of the adequacy of collateral blood flow through the middle colic artery via the marginal artery of Drummond 9 and by a similar, but less effective and constant, flow through the middle hemorrhoidal arteries from below. This latter avenue of collateral blood supply presupposes that one hypogastric artery remains open. When the hypogastrics are occluded or must be sacrificed, such flow depends upon collateral channels through the inferior hemorrhoidal artery. The dimension of time may also play an ill-defined, and possibly not too important, role in the establishment of collateral circulation by these channels. Since many

Surgical treatment of coarctation of the aorta; report of a case: Shick, R. M.: Proc. Staff Meet., Mayo Clin. 22:127 (April 2), 1947

This condition is found two to three times more frequently in females than in males. It is usually a congenital anomaly, though the adult type has been reported as a result of Streptococcus viridans infection. The lesion itself is a narrowing or constriction of the aorta in the region of the insertion of the ductus arteriosus or its vestige. In 25 per cent of these cases, the aortic valve is bicuspid. This gives rise to a narrowing of the lumen and thinning of the walls of a part or all of the aorta with a consequent reduction of the volume of blood flowing through it. This same thinning of the walls is evident in the cerebral vessels. Survival and capacity for work in such patients depend upon the establishment of collateral circulation through the anastomoses between aorta and subclavian, intercostal, and epigastric arteries. Its diagnosis rests upon symptoms and signs developing along this collateral circulation. These are in the order of their frequency and importance: 1.1. Hypertension and high pulse pressure in the upper extremities both as compared to normal and to that of the lower extremities.2.2. Notching and erosion of the lower rib margins as seen in the x-ray3.3. Pulsations, thrills, bruits, and other sounds along the course of the collateral circulation.4.4. Gradually diminishing pulse volume as the terminal arteries of the lower extremities are approached.The greatest danger of pregnancy, and particularly labor, in these patients is sudden rupture of the thinned-out aorta or cerebral vessels. It is therefore usually advised that pregnancy be avoided by contraceptive devices, or if pregnancy has occurred despite these, interruption be done early. If the patient has been carried to near term, she should be delivered by cesarean section with tubal sterilization.

Résumé of cardiac disease in pregnancy for a five-year period: With report of a case of coarctation of the aorta

This condition is found two to three times more frequently in females than in males. It is usually a congenital anomaly, though the adult type has been reported as a result of Streptococcus viridans infection. The lesion itself is a narrowing or constriction of the aorta in the region of the insertion of the ductus arteriosus or its vestige. In 25 per cent of these cases, the aortic valve is bicuspid. This gives rise to a narrowing of the lumen and thinning of the walls of a part or all of the aorta with a consequent reduction of the volume of blood flowing through it. This same thinning of the walls is evident in the cerebral vessels. Survival and capacity for work in such patients depend upon the establishment of collateral circulation through the anastomoses between aorta and subclavian, intercostal, and epigastric arteries. Its diagnosis rests upon symptoms and signs developing along this collateral circulation. These are in the order of their frequency and importance: 1.1. Hypertension and high pulse pressure in the upper extremities both as compared to normal and to that of the lower extremities.2.2. Notching and erosion of the lower rib margins as seen in the x-ray3.3. Pulsations, thrills, bruits, and other sounds along the course of the collateral circulation.4.4. Gradually diminishing pulse volume as the terminal arteries of the lower extremities are approached.The greatest danger of pregnancy, and particularly labor, in these patients is sudden rupture of the thinned-out aorta or cerebral vessels. It is therefore usually advised that pregnancy be avoided by contraceptive devices, or if pregnancy has occurred despite these, interruption be done early. If the patient has been carried to near term, she should be delivered by cesarean section with tubal sterilization.

Simultaneous ligation of vein in ligation of large arteries: Experimental study

Consideration of the problem of simultaneous ligation of the companion vein when it is necessary to ligate a large artery has led to a review of the clinical and experimental literature and the presentation of our own experimental results. Review of the clinical literature leads us to believe that: (1) Most surgeons consider the incidence of gangrene of a limb following ligation of its main artery to be very high. Halsted did not concur in this view and made an elaborate analysis of all reported cases to prove his stand. Our own experience with dogs indicates that the incidence of gangrene in this animal following the uncomplicated ligation of the external iliac artery is rare. (2) Previous to 1916 every effort was made to preserve the accompanying vein in the belief that its occlusion increased the danger of gangrene. Since 1916 and the experience gained in the World War, this policy has completely changed, and many surgeons advocate the simultaneous occlusion of the accompanying vein when an artery is ligated to prevent gangrene and to aid in the establishment of collateral circulation. There are some discrepancies in the clinical statistics on which the advocacy of this procedure is based. We have already considered the experimental data with which various authors attempt to establish the procedure on a sound physiological basis. In the light of our experiments here presented, and the previous experiments of Harvey and Ferris 33 in 1925, the earlier temperature experiments of Brooks and Martin 30 would seem to have been of too short duration to give an adequate idea of the effect of simultaneous vein ligation. Their experimental results on the incidence of gangrene in rabbits, however, are not disproved. On the other hand, Brooks 36 has questioned the conclusions of Holman and Edwards 34 based on the increased flow of blood from the distal end of the divided femoral artery, and we agree with him in this. Again, Holman and Edwards' comparison of their results on the incidence of gangrene in rabbits with those of Brooks and Martin is not conclusive because of differences in the methods of ligation. The contradictory results of Pearse 37 and Theis 38 in regard to roentgen findings after ligation and injection will need further rechecking. So it would seem that the experimental literature does not provide any sound physiological proof that the procedure of simultaneous ligation of the accompanying vein either decreases the incidence of gangrene or aids in the establishment of collateral circulation when a large artery is ligated. Our previously reported experiments 1 on establishment of the collateral circulation in the dog, lead us to believe that the incidence of gangrene following the ligation of the external iliac artery, at least in this animal, is small. Consideration of the statistics from reported cases in the literature from 1900 to 1930 of ligations of the iliac and femoral arteries strengthens the opinion that the incidence of gangrene in the human following the uncomplicated ligation of these vessels either with or without ligation of the companion vein is smaller than generally supposed. Finally the results of our experiments here reported indicate that in seven dogs, the temperature curve showing the return of collateral circulation was no different whether or not the accompanying vein was ligated with the artery. Furthermore, there was no gangrene in either leg of any of these dogs.

A REPORT OF A CASE OF THROMBOSIS OF THE INFERIOR VENA CAVA

The report of the following single case seems warranted on account of the infrequency of ante-mortem diagnosis, and because of the favorable outcome through the establishment of collateral circulation. We claim no credit whatever for the recovery course, and very little for the diagnosis, which we realize was the result of unusually favorable circumstances: Patient. —A woman, American-born, aged 30, weighing about 125 pounds, and presenting a somewhat under-nourished and anemic appearnce. Family history good. History. —No infectious or chronic diseases are reported, and no vaginal discharge, swelling of legs, or ascites up to the last pregnancy. Menses began at 14 and are of the regular twenty-eight-day type. Patient has four living children, the youngest born Dec. 20, 1912, and has had two miscarriages; one a pregnancy of a month's duration, between the second and third child, the other of three months' duration, between the third and the last.

Results of Experiments on Kidneys with Special Reference to Decapsulation and Establishment of Collateral Circulation

Results of Experiments on Kidneys with Special Reference to Decapsulation and Establishment of Collateral Circulation