Based on the research and clinical work presented at the Fifth International Symposium, Vascular Surgery 1991, this book gathers forty contributions from renowned clinicians and researchers and outstanding young investigators around the world.

Nach den femorokruralen und aortoiliakalen VerschluBprozessen fruherer Bande wurde fur diesen Band der Oberschenkel-VerschluBtyp gewahlt. Schon morpholo- gisch weist diese Etage eine Besonderheit auf, denn sie besitzt mit der tiefen Ober- schenkelarterie eine Arterie, die Linton schon 1964 als besten korpereigenen Bypass bezeichnete. Urs Brunner nannte die Profunda gar die Konigin der Beinarterien. Dies beruht auf ihrer besonderen Kollateralisierungsbefahigung. Dem ist es zuzu- schreiben, daB das therapeutische Spektrum auf dieser Etage wesentlich breiter ist als in den beiden anderen VerschluBetagen. Andererseits ist dieser VerschluBtyp am haufigsten mit anderen VerschluBlokalisationen kombiniert, so daB eine ausschlieB- lich auf den Oberschenkel-ArterienverschluB gerichtete Betrachtung nicht moglich und naturlich auch nicht sinnvoll ist. Wie es in dieser Reihe ublich ist, wurde versucht, das Gebiet umfassend darzustel- len. Das erforderte eine umfangreiche interdisziplinare Bearbeitung, wozu auch namhafte Experten aller Bereiche gewonnen werden konnten. Diagnostik, physik ali- sche Therapie, konservative Behandlung, operative Verfahren und kombinierte MaBnahmen konnten so in einem Band zusammengefaBt werden. Zu betonen ist, daB die dargestellten Behandlungsverfahren nicht als konkurrierende Therapieprin- zipien sondern als sich sinnvoll erganzendes therapeutisches Spektrum in Abhangig- keit yom Stadium der DurchblutungsstOrung anzusehen und einzusetzen sind. Den Referenten ist es zu danken, daB dieser Band trotz vieler Schwierigkeiten doch noch relativ zeitgerecht erscheinen wird. Auch Frau Sabine Muller und ihrem Team yom Dr. D. Steinkopff-Verlag, mit der mich nun schon eine mehrjahrige ver- trauensvolle Kooperation verbindet, mochte ich fur ihre wertvollen Anregungen und ihre Unterstutzung danken.

The Surgeon as a Humanist Medicine is the most humane of the sciences and the most scientific of the humanities. Cardiac surgery today provides a most natural confluence for the high technology of medicine and the humanistic values traditional in the practice of medicine. The cardiac surgeon must, of necessity, be knowledgeable in physiology and cardio logy, and must also possess consummate surgical technical skill. The attainment of these skills over long years of training leads many of these surgeons to believe or per ceive this long struggle as an apotheosis of their position in life, rather than as an education in bringing the latest scientific advances to the care of patients. The problem lies not only with the cardiac surgeon; it is also contributed to by the patients' perception of heart surgery, heart disease, and the mystery of the science and physiology involved. The patient with heart disease expecting surgery may, for the first time, be facing the finiteness of his existence. The low risk of cardiac surgery to day not withstanding, the coronary surgery patients, most likely a type A personality, is faced with a perceived threat to his invulnerability, his self-image, his family, his independence, his control of situations, and his very existence."

Concise, recent data are presented on obstetric problems arising in patients with cardiovascular diseases (not only congenital and acquired valvular heart diseases and hypertension, but also uncommon heart lesions) and on cardiological complications encountered in pregnant women. The goal of the book is to provide obstetricians with necessary cardiological information and cardiologists with essential obstetric information to enable both specialists to make optimal decisions regarding the permissibility of pregnancy, management of pregnancy and labour, or termination of pregnancy, and selection of an adequate form of contraception in women with heart and vascular diseases. Along with recent scientific findings, the book contains practical recommendations for examination diagnosis and treatment that is effective for the mother and safe for the fetus.

A pioneering group of authors describes in this book, for the first time, the state of the art of spinal cord stimulation for chronic critical limb ischemia. This method, a progeny of pacemaking in cardiac rhythm disorders, is a promising, innovative procedure; it presents a modern challenge in treatment of endstage peripheral vascular disease or neuropathic pains. Spinal cord stimulation may have a tremendous future if it further develops to become a standard treatment in special indications.

Pediatric cardiology is celebrating in the 1990s the 50th anniversary of the beginnings of the age of therapy. This informal `history' describes how the discipline grew from the era of pathologic anatomy to the dawn of therapy, the beginnings of closed heart surgery between 1939 and 1945. That dawn ushered in a remarkable half century of change and growth, leading from clinicophysiologic correlations through the start of open heart surgery in the 1950s. The text celebrates some of the achievements of this vivid and heroic age, and describes how, in the mid 1970s, new surgical and medical approaches, including prostaglandins and Doppler echocardiography, led to successful cardiac treatment in infancy, the `infant era'. Interventional cardiology and the study of childhood arrhythmias began. Now, in the 1990s, a new era emphasising molecular biology and cardiac development is growing from the tools and concepts of the past. The four eras have focused on pathologic anatomy, clinicophysiologic correlations and surgery, heart problems in infancy, and now the developing heart. In each era there have been advances in the four domains of pediatric cardiology, the heart before birth, the normal heart, heart disease and defects, and preventive cardiology. Growth in knowledge has been both episodic and dramatic, yet not a picture of unalloyed achievement. The later chapters discuss some of the problems beginning to be recognised in the new and current `developmental era'. The pioneers of pediatric cardiology, both men and women, are more than eponyms, for each used in new and original ways the tools and concepts available in their era. The interaction of tools and concepts is a theme in this book. Just as the tool of the stethoscope was vital in delineating the clinical profile of ventricular septal defect and patent ductus, the fluoroscope played a role in developing the concept of the Blalock Taussig shunt. Pioneers also include patients and their families, and the book includes some discussion of what little is known of childhood and of the child with heart disease in the four different eras. This is a brief overview of the growth of knowledge of children's hearts from before William Harvey until our own time, and includes references to histories of cardiac surgery and to collections of classic cardiac papers. By its emphasis on the child as the central historic figure, and on the interaction of tools and concepts in the growth of knowledge, the text provides a celebratory approach to the 50th anniversary of modern pediatric cardiology.

Interstitial Fibrosis in Heart Failure, edited by Francisco J. Villarreal, M.D., Ph.D., provides a timely and integrative review of the basics of cardiac extracellular matrix structure. Topics covered include how cardiac remodeling influences its disposition, abundance and function; possible non-invasive techniques for diagnosis; and potential drug-based or molecular therapeutic strategies that may interrupt or even reverse the course of the development of cardiac fibrosis.

This resource for both clinicians and scientists aims to cover state-of-the-art findings relevant to cellular and molecular processes underlying cardiac fibrosis including basic elements of structure, function, diagnosis and treatment.

A major need of all cardiologists and surgeons involved with the application of allograft tissue to cardiac surgical reconstructions is met by this unique atlas. Step by step, it carefully describes the procedures involved in acquiring, sterilizing, and cryo-preserving allograft valves as well as the surgical technique used in left and right ventricular outflow tract reconstructions. All of the information needed to perform the reconstructions is given, including relevant references and applicable variations in method. Excellent illustrations accompany the description of surgical technique. All of the techniques are based on classic approaches, but assimilate the authors' modifications arrived at through vast experience. The wealth of references, illustrations and expertise in this volume make it a valuable asset for all cardiac surgeons.

"Prospects of Heart Surgery: Psychological Adjustment to " "Coronary Bypass Grafting" reports on a study of how patients and their spouses adjusted to the prospect, and then to the outcome, of coronary graft surgery. The focus upon patients' social relationships rather than upon individuals reveals that the way people bear their illness, and adapt to symptom removal, is part of a wider adjustment involving both the spouse and other individuals. The book offers, as one of its main contributions, a social-psychological approach to the study of illness in general. It sets out a new methodology which might be applied in a number of illness contexts. Using both qualitative and quantitative analyses, "Prospects " "of Heart Surgery" describes differences between smooth and problematic approaches to surgery as well as variations in the experience of rehabilitation afterwards.

Dr Rose honoured me with a request for a Foreword. I am delighted to oblige. The treatment of valvular heart disease has improved remarkably in the past 40 years. Many factors have contributed; not least being the introduction of artificial heart valves for treatment, more than 25 years ago. Their use has shown that they are good, but not an ideal substitute for native valves. A galaxy of pathological changes are associated with the insertion and malfunction of artificial heart valves. Each has to be defined, classified and related to clinical procedures or problems with a prosthesis; then a means sought to prevent them. Often, in understanding their cause, investigative procedures have/will improve patient care and broaden knowledge in other spheres. Dr Rose has been a student of this pathology for many years and has made many contributions. No doubt his interest in the area was whetted by colleagues in Cape Town, leaders in the field of cardiovascular medicine and surgery. This monograph provides a collected review of his experience. In it one finds lessons in geographic pathology, in considering the causes of valvular heart disease in Cape Town and valuable information regarding the identification of artificial heart valves and a means of examining a heart bearing one.

Over the past ten years, cardiac transplantation has evolved from an exper imental procedure performed in a handful of university centers to a viable therapeutic modality now performed in more than 150 centers worldwide. The complexity of the procedure, the changing immunosuppressive re gimes, and the follow-up care have necessitated a multidisciplinary ap proach involving a variety of medical, nursing, and social sciences special ties and subspecialties. In addition, health care trainees and referring physicians are increasingly becoming involved in the care of the cardiac transplant recipient. This book does not attempt to be a comprehensive treatise on cardiac transplantation; rather, we hope that it will serve as a manual and guideline for all health professionals involved in cardiac trans plantation. JEFFREY D. HOSENPUD, M.D. Contents Preface v Contributors IX 1. Cardiac Transplantation: An Overview JEFFREY D. HOSENPUD AND ALBERT STARR Immunogenetics and Immunologic Mechanisms of 2. Rejection 15 DOUGLAS J. NORMAN 3. Medical Therapy Tailored for Advanced Heart Failure 33 LYNNE WARNER STEVENSON 4. Ventricular Assistance as a Bridge to Cardiac Transplantation 53 D. GLENN PENNINGTON AND MARC T. SWARTZ Recipient Selection for Cardiac Transplantation 71 5. GEORGE A. PANTELY 6. Donor Selection and Management for Cardiac Transplantation 85 JEFFREY SWANSON AND ADNAN COBANOGLU 7. Operative Techniques and Early Postoperative Care in Cardiac Transplantation 95 ADNAN COBANOGLU Endomyocardial Biopsy: Techniques and Interpretation of 8."

This brilliant and highly practical book provides a case-based introduction and primer to the practice of ICD therapy. It contains a huge number of images and includes real-world patient histories. The reader is able to gain extensive practical knowledge of the practice of ICD therapy with the use of these case reports. These concentrate on the skills necessary to increase specialist knowledge of defibrillator therapy practice.

On the occasion of the inauguration of the Department of Heart Surgery at the Rehabilitation Center in Bad Krozingen, we held under the aus pices of the European Society of Cardiology an International Symposium on March 17 to 18, 1978 with the topic: . "Coronary Heart Surgery - a Rehabilitation Measure" This book contains the papers given at that time. The editors of this book, together with the other members of the sci entific committee - H. Denolin from Brussels, Ch. Hahn from Geneva, and F. Loogen from DUsseldorf - aimed at selecting controversial top ics as well as speakers representing different viewpoints. Thus avoid ing portrayal of an image of a world of coronary bypass surgery in which all problems have found a solution. In keeping with the topic of the meeting, special emphasis was drawn to the long-term functional results of aortocoronary bypass surgery; symptomatic imprQvement be ing, in most patients, significant enough and lasting for at least some years, thus allowing the patients to return to work. However, a combination of social, economic, and psychological factors may hamper optimal rehabilitation, as can be seen from some of the following papers. The incorporation of heart surgery into a rehabilitation center - being the motif of this symposium - may hopefully stimulate a global approach to cardiac rehabilitation which includes surgical, medical, psychological, vocational, and social rehabilitation mea sures. Bad Krozingen, January 1979 H. Roskamm M. Schmuziger Table of Contents 1."

This comprehensve review of scientific research supporting evidence of the relationship between cardiac disease and psychological condition offers practical suggestions for developing a clinical practice, and proposes directions for future research in the new field of "cardiac psychology." Every chapter is written by world-renowned researchers in the field. A theoretical and practical guide, it will interest physicians, clinical and health psychologists, and all professionals who seek to understand the mind-health link.

Cardiac surgery is performed on hundreds of thousands of patients a year, and can have an important beneficial impact on the outcomes of patients with coronary and valvular heart diseases. Despite the favorable recovery of most patients, some will have their post-operative period interrupted by the development of atrial fibrillation, with a host of potential complications including stroke. High risk subgroups may develop atrial fibrillation in more than half of cases, and often despite aggressive prophylactic measures. Treatment of atrial fibrillation and its aftermath can also add days to the hospital stay of the cardiac surgical patient. In an era of aggressive cost cutting and optimization of utilization of health care resources, the financial impact of this arrhythmic complication may be enormous. Experimental studies have led to a greater understanding of the mechanism of atrial fibrillation and potential precipitating factors in the cardiac surgical patient. Prophylactic efforts with beta-blockers, antiarrhythmic drugs and atrial pacing are being used, or are being investigated in clinical trials. New methods of achieving prompt cardioversion with minimal disruption of patient care, and prevention of the thromboembolic complications of atrial fibrillation, are also important therapeutic initiatives. This text is designed to aid health care professionals in the treatment of their patients in the recovery period after cardiac surgery, and to instigate additional research efforts to limit the occurrence of, and the complications following, this tenacious postoperative arrhythmia.

This book provides cardiologists with access to the wealth of imaging from the Royal Brompton Hospital and National Heart and Lung Institute in London to enable them to improve on their own skills and refine their imaging technique. The authors correlate this echocardiography experience with the pathological and surgical aspects of congenital heart defects. They include a review of the pathologic, physiologic and surgical observations of different congenital diseases to assist in understanding the various echocardiographic presentations. The book contains large numbers of echocardiographic images.

It is essential to know all of the intricate lymph pathways when performing surgery for esophageal cancer in order to determine the extent of lymph node metastasis. Professor Sato has undertaken, at the request of the TNM Research Committee of the International Society for Diseases of the Esophagus, to map out and classify the lymph nodes of the mediastinum and neck. The beautiful artwork in the Color Atlas of Surgical Anatomy for Esophageal Cancer edited by Professor Sato gives an excellent understanding of the lymph node pathways and their importance in surgical treatment. Minute dissections which represent real life situations, not just the superficial pathways, show the precise location and topographical arrangement of the lymphatics. Full-color schematics are given with the actual dissection illustrations and photographs. The atlas clearly presents the classification of four significant pathways and their communication, the relationship of these pathways en route to the venous angles and the definition and assessment of the most critical nodes. Thoracic surgeons especially will benefit from the excellent illustrations of surgical techniques and the methods for recording the dissected lymph nodes which are presented by Professor Kakegawa. Leading experts fighting esophageal cancer with surgical treatment can use the classification in this outstanding atlas for many years to come as a standard for international comparison. The careful dissection of the lymph nodes may be the best way to improve survival rates after surgery for cancer of the thoracic esophagus.

The sober explanation for this book is a call by the Springer-Verlag, London, to edit a publication on 'The functional relevance of the collateral circulation' of the heart. Alternatively, it could be 'sold' as the result of my intention to reduce entropy of 18 years of scientific work on the topic of the coronary circulation, which was itself meant to diminish the amount of 'useless' energy. Such a process of reducing disarray in a system with the aim of grasping it better is related to simplification, which carries the risk of introducing error. This can be exemplified by the historic view of angina pectoris, which used to be simplified as being always fatal, thus obscuring for nearly two centuries the view of a 'self-healing' mechanism such as the collateral circulation of the heart. It would be na?]ve, to assume the present work to be free of erroneous oversimplification, because the very nature of scientific work is related to generating (simple) hypotheses with their subsequent falsification. In that context and bluntly, my primary interest in the field of the collateral circulation was not initiated with a vision of eradicating the consequences of coronary artery disease (CAD) by promoting the growth of natural bypasses. The time for such sizeable ideas had passed in the 1970s with the start of the work by Wolfgang Schaper."

During the past three decades, Vascular Surgery has emerged as a specialty within general surgery. Fellowships are now available to equip surgeons with specialized skills for managing various vascular problems. Nev ertheless, the vascular surgical emergency, one of the greatest challenges in surgical management, may occur suddenly and at a time and place remote from the highly qualified vascular surgeon or a specialized center where complex vascular treatment is routine. The initial evaluation and treatment must be undertaken by a general surgeon who determines the extent, sever ity, and urgency of the problem at hand, and hopefully will arrange appro priate transfer to a specialized center if the patient's condition permits. Urgent problems, on the other hand, demand immediate surgical interven tion by the general surgeon if any hope for salvage is to occur. It is in this set ting that this volume offered by Professor Staudacher may be of assistance to the general surgeon whose experience in this type of emergency may be limited. This concise, well illustrated volume should serve as a guide to manage the peripheral vascular emergency involving either the arte rial or venous system."

Our common interest in surgery of the vertebral artery was born in 1976, when as residents in the same hospital, we attended an attempt by two senior surgeons to treat an aneurysm of the vertebral artery at the C 3 level. Long discussions had preceded this unsuccessful trial, to decide if surgery was indicated and to choose the surgical route. Finally a direct lateral approach was performed, but access was difficult and correct treatment was impossible, resulting in only partial reduction of the aneurysmal pouch. Following this experience, we decided to seek a regular and well defined approach for exposition of the vertebral artery. Review of the literature indicated some surgical attempts, but the descriptions did not give the impression of safety and reproducibility. No landmark on the described surgical route appeared sufficiently reliable. Henry's anatomical work (1917) gave the only accurate description on vertebral artery anatomy, and it became the basis for our work. When the same patient was referred again one year later, after a new stroke in the vertebro-basilar system, we had behind us repetitive experience on cadavers of an original approach to the distal vertebral artery.

Jean Natali The pathophysiology and management of chronic critical limb -ischaemia (CLI) has always been a problematic area, at least partly because it involves doc tors from a wide range of the traditional medical specialities including vascular surgery, angiology, diabetology, haematology and radiology. The treatment of these patients also varies largely with local circumstances and national traditions. CLI therefore seemed a particularly appropriate subject for a new type of European consensus approach. In 1988 a series of small workshops were held by the European Working Group on Critical Limb Ischaemia to discuss the definition, pathophysiology, in vestigation and management of this condition. The process culminated in a meet ing in Berlin in March, 1989 where 120 specialists from sixteen European countries, representing the basic sciences as well as a spectrum of clinical dis ciplines, met to evolve a Consensus Document on the subject with specific recom mendations. The Document, which is reproduced in the first section of this book, does not of course necessarily represent the unanimous view of all those who participated in its compilation; however it is agreed that it does represent a con sensus or majority view. It was also noted that the comments and recommenda tions in the document should be taken as a whole, and are not intended to dictate the only correct approach to individual treatment.

In patients with coronary artery disease, surgical revascu- larization with arterial or venous bypass grafts not only relieves symptoms, but also prolongs life. The result of such interventions, however, is frequently impaired by graft dysfunction and occlusion. This monograph highlights the clinical importance of coronary artery bypass graft disease and, in particular, the use of modern diagnostic techniques to assess graft structure and function. The molecular and cellular mechanisms of coronary bypass graft disease are ex- tensively discussed with several chapters devoted to prophy- lactic medical therapy. The indication, technique and results of reinterventions with balloon angioplasty, reope- ration or transplantation in patients with graft failure are also reviewed.

Surgery of tje Arteries to the Head provides residents and practicing surgeons with detailed descriptions and explanations of various surgical techniques. Written in essay style, it presents an opinionated discourse based on the collective experiences of leading vascular surgeons.

After 7 years of clinical use, percutaneous transluminal coronary angio plasty (PTCA) has now found worldwide acceptance, and its basic techniques are well standardized. A growing number of invasive cardi ologists are acquainting themselves with the procedure in order to be in a position to offer new therapeutic options to their patients. However, the transition from the diagnostic to the therapeutic intervention is not always easily accomplished. Certain prerequisites concerning technique, the physician, technical equipment, and program organization are necessary for safe and effective performance. The consequences of unsuccessful coronary angioplasty range from waste of time and money to severe complications for the patient; the decision to perform PTCA needs to be based on sound indications and techniques according to the best current scientific evidence. Techniques and technology for coronary angioplasty continue to evolve. Scientific evidence of its short-and long-term value continues to accumulate, and applications of the procedure are still being extended. This volume is obviously no substitute for well-guided hands-on experience with the procedure; it is intended rather to present current policies of patient selection and patient management; to describe standard techniques (femoral and brachial approaches) and potential applications; to point out problem areas and limitations of the proce dure; and to provide tips that may be useful even for the more experienced angioplasty operator."

"Duplex Sonography" is the first comprehensive text written about this modality. The book offers the reader detailed information about all major uses of duplex and is introduced by a brief chapter on the physical principles of doppler ultrasound as it relates to duplex scanning. "Duplex " "Sonography" is intended to provide relevant information on all aspects of the technique, ranging from the basics of performing the examination to the features of sometimes complex pathological states. The book is intended for anyone interested in non-invasive vascular diagnosis including radiologists, vascular surgeons and ultrasound/peripheral vascular technologists. Other groups may find individual chapters appealing: carotid/cardiac sonography for cardiologists, fetal sonography for obstetricians or carotid sonography for neurologists. Each chapter is not only a guide to duplex evaluation, but also provides valuable information about vascular dynamics of the organ system under discussion. Physicians or technologists reading this book should come away with a well-rounded background in state-of-the-art duplex sonography and will undoubtedly discover new possibilities for using this non-invasive vascular technique.