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."

The papers presented in this book were held at the International Sym posium on "Prognosis of Coronary Heart Disease - Progression of Cor onary Arteriosclerosis" on October 22 and 23, 1982 in Bad Krozingen, FRG on the occasion of the 10th anniversary of the Rehabilitationszen trum Bad Krozingen. The symposium was sponsored and supported by the European So ciety of Cardiology and the Pharma Schwarz Co. The scientific com mittee was composed of F. Loogen (Dusseldorf), P. G. Hugenholtz (Rotterdam), and the editor of this book. To all of these and to my co-workers many thanks. Bad Krozingen, August 1983 H. Roskamm Table of Contents W. Steinbrunn and P. R. Lichtlen Prognosis of Patients with Coronary Heart Disease Evaluated Using Data Obtained by Invasive Methods . . . . . . . . . . . . . . . . . . . . . . . . 1 R. A. Bruce Prognosis of Coronary Heart Disease Patients Evaluated by Data Obtained by Noninvasive Methods . . . . . . . . . . . . . . . . . . 16 K. Bachmann, W. Niederer, H. Fuchs, and H. Holzberger Prognosis of Coronary Heart Disease Patients Evaluated by Data Obtained by Invasive and Noninvasive Methods . . . . . . . . . . . . . . 24 R. Balcon, M. Cattell, and K. Wong Prognosis of Coronary Heart Disease Patients Evaluated by Data Obtained by Angiography and Exercise Testing . . . . . . . . . . . 36 M. Kaltenbach and W. -D. Bussmann Prognostic Relevance of Findings from Invasive and Noninvasive Investigations in Coronary Heart Disease Patients . . . . . . . . . . . . . 44 H. Gohlke, L. Samek, P. Betz, and H. Roskamm Prognostic Relevance of Invasive and Noninvasive Data in Angiographically Defined Subgroups of Coronary Heart Disease Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 v. F."

This atlas offers a collection of EEG spectral analyses and their corresponding conventional recordings under anes thesio10gical procedures. The EEGs presented here were re corded on general surgical and gynecological patients during the last few years. Premedication, induction and maintenance of anesthesia, recovery the immediate postoperative period, and intensive care are covered. Techniques for operating the necessary equipment and artefacts relevant to the routine clinical use of EEG are briefly outlined. Typical examples of characteristic EEGs are presented at the beginning of each chapter, followed by illustrations of deviations from the norm showing the great variety of anesthesiologically induced changes of cerebral function. The description of each EEG course is assessed in relation to clinical parameters. Sometimes no satisfactory interpreta tion can be made, because many physiological and patho physiological causes of alterations in cerebral function are unknown. Time and again it proves impossible to estimate wether deviations from the norm have their origin in cerebral changes or are secondary to extracerebra1 disturbances. The atlas comprises a complete survey in itself, but it can also be seen as a supplement to the book The Electroenceph alogram in Anesthesia by I. Pich1mayr, U. Lips, and H. Kunkel (Springer, 1983), in which detailed lists of references are quoted that are omitted here."

Assisted Circulation 4 is an authoritative review of the progress which has been achieved in the last 5 years since the publication of "Assisted Circulation 3" in 1989. The present book highlights the work of well-known experts on indications for assisted circulation, cardiac support devices such as bridges, devices for transplantation, devices for chronic mechanical support, biological energy sources, cardiomyoplasty, extracorporeal membraneoxygenation and an overview of cardiac devices support with a specific emphasis on xenotransplantation. Assisted Circulation 4 is the latest product of an ongoing effort by the editors to keep readers regularly informed of recent developments in the field. Assisted Circulation is a standard technology in cardiac surgery and especially in cardiac transplantation.

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.

In textbooks on anatomy, radiology and stead of the normal one. An "accessory ar- surgery only the "normal" arterial blood tery" is a second artery ip addition to the one normally present, without any specifi- supply is usually described. This "nor- mality", however, is sometimes found in cation of size being made. However, there less than 30% of all cases for some arteries, is no general agreement on whether minute but in over 95% for others. Rarely men- vessels with very small diameters and hard- tioned are deviations in the individual ar- ly any significant blood flow should also be tery's origin, topographical localization and considered. the area it supplies. They can be classified The aims of this book were twofold: first, to into two groups: malformations and vari- extract the frequency of arterial anomalies from the literature (often published in inac- ations. Malformations often have a nega- tive influence on the function of the organ cessible journals) and second, to classity under normal circumstances, e.g. if both these arteries by schematic outlines of the basic types.

Use of the implantable cardioverter/defibrillator is the most significant advance in the management of patients with life- botn threatening cardiac arrhythmias. This device represents an important practical as well as conceptual breakthrough in arrhythmia management. It places on firm footing use of non-pharmacologic tools for clinicians. The text, Implan- table Cardioverter/Defibrillator, represents contributions by the leading clinicians in this field from both sides of the Atlantic and is a welcome addition to the library of clinical electrophysiologists as well as cardiac surgeons. The editors have well collated the critical issues related to current use of device therapy in a meaningful and practical fashion. The text amply reminds us that we are in the early growth phases of a technology that promises to completely change our approach to the cure of patients with actual or potentially life-threatening ventricular dysrhythmias. It also reminds us that Dr. Mirwoski's dream continues to live and remains as a perpetual challenge to clinicians and engineers alike to bet- ter perfect and utilize device therapy for our patients. I com- mend the authors and editors for a superb and timely effort. San Francisco, CA, USA Melvin M. Scheinman, M. D. Preface 1teatment of patients with ventricular tachycardia and pre- vention of sudden arrhythmic death is one of the most challenging tasks of modem cardiology. 'len years ago anti- arrhythmic drug therapy was the medical tool used most fre- quently in the management of patients with life-threatening ventricular tachyarrhythmias.

"Rate Adaptive Cardiac Pacing" provides a comprehensive overview of this most advanced form of stimulating the heart by means of cardiac pacemakers that vary the pacing rate according to the needs of the patients. The heart rate is controlled by one or several sensors that detect various parameters such as respiration, blood temperature, oxygen saturation, intracardiac pressure, QT interval, stroke volume andbody activity. Besides describing the clinical and functional characteristics of these various sensors, the book also gives a clear understanding of hemodynamic aspects and in particular, all clinical issues of importance such as indications for rate adaptive pacing and selection of the appropriate patients for rate adaptive pacemakers, with many ECG samples. The book also covers new concepts in rate adaptive pacing such as single lead atrial synchronous pacing and the combination of various sensors, which are among the most recent developments in the field. With contributions from the most wellknown experts in the field from allover the world, this book is the first publication to cover all the hemodynamic, clinical and technical aspects of rate adaptive cardiac pacing.

Major epidemiologists from the UK, USA and Europe contribute to the first ever, much needed comprehensive review of the epidemiology of peripheral vascular disease in the lower limbs.

La pathologie vasculaire a ete tres marquee par les progres biologiques de ces vingt demieres annees. Le systeme arteriel est main tenant considere comme un organe a part entiere. Modelee au cours de l'organogenese par les facteurs hemodynamiques, Ie paroi arterielle maintient une structure hautement organisee et des proprietes mecaniques qui dependent directement des conditions de pression et de debit. La monocouche endotheliale developpe 2 une surface de plusieurs centaines de m a l'interface sang-tissu; elle est a la fois un organe endocrine complexe synthetisant de nombreuses proteines qui participent a l'hemostase, une surface thromboresistante et hemocompatible, une barriere de permeabilite contr6lant les echanges sang-tissus. Les cellules musculaires lisses constituent un tissu multifonctionnel, contractile, assurant la synthese des composants structuraux responsables des proprietes mecaniques de la paroi arterielle, la transmission de la force contractile, et une etonnante activite reparatrice en reponse aux agressions. Tout ceci est soumis a un ensemble complexe de communications cellulaires qui font de l'endothelium un veritable systeme recepteur pour la paroi vasculaire. Parallelement, ou a la suite de ces progres, l'angeiologie s'est progressivement affirmee comme une specialite clinique. Debordant Ie cadre de la chirurgie vasculaire, elle integre les concepts physiopathologiques au diagnostic et au traitement des maladies arterielles. De cet effort d'integration est ne cet ouvrage, cherchant a concilier les connaissances fondamentales es plus recentes et la demarche clinique.

Spinal Cord Stimulation II (SCS) contains the state of the art of this innovative method in the treatment of peripheral vascular disease.
The volume presents such topics as: Spinal Cord Stimulation for Chronic Pain.- Management of Critical Limb Ischemia.- Spinal Cord Stimulation for Angina Pectoris.- Buerger's Disease.- Miscellaneous.

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.

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.

Circulation through the deep femoral artery and its branches is critical to patients with aortoiliac and infrainguinal arteriosclerosis. It is, accordingly, essential that all physicians who are seriously interested in treating patients with lower extremity ischemia have a good working knowledge of this crucial artery's anatomy and func tion. It is equally essential that they be aware of arteriosclerotic disease patterns that involve this important artery, how these patterns can be Clccurately defined, and, most importantly, what therapeutic options are available and when they should be used. All this important information relating to the deep femoral artery and its surgical significance is included in Dr. Merlini's fine volume. Eighteen authors have contributed 11 well-edited and nicely illustrated chapters that provide all the facts that the com mitted vascular surgeon would ever want to know about the deep femoral artery and how it should be managed in patients with lower limb ischemia. Although some of the chapters overlap in some areas, this adds to the value of the book since the different authors are' all acknowledged experts and their varying perspectives. are beneficial to a reader seeking to formulate his own unbiased views.

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.

Reconstructive microvascular surgery is now in its teens. At first many thought this new child was a whim and would fail to thrive. Some were un certain, others with vision either supported or became actively involved in this new area of surgical endeavour. Although initial interest was focused on the replantation of amputated parts, it has been the one stage free trans fer of living tissue to a distant site which has launched microsurgery into the surgical spotlight. From its humble beginnings we have witnessed a revolution in this branch of plastic surgery; many of the long established methods of recon struction have, like barricades, fallen before the advances made in this field. In its infancy there were relatively few procedures available. There was a tendency to make the patient's problem fit the operation, rather than the reverse, and this frequently led to an inferior result. The then known flaps, such as the groin flap and the deltopectoral flap, were employed. Unfortunately they were sites which posed many technical problems; namely those of vascular anomaly, a short pedicle and vessels of small cal ibre. Long operations were the norm, and vascular thrombosis was not un common. Hospital routine often was disrupted and there was a danger that these new techniques would fall into disrepute. Over the last decade this state of affairs has changed dramatically.

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."

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."

The history of electric cardiac stimulation is long and fascinating. The grow- ing clinical importance has been recognized and renewed as Zoll in 1952 described a successful resusciation in cardiac standstill by external stimula- tion. Meanwhile, patients with disorders of cardiac rhythm have been treated all over the world for about 15 years. Recently the technical refinements of intracardiac stimulation in combination with a subtile analysis of endocavi- tary electrocardiograms improv~d the understanding of human intracardiac conduction. These new procedures include the possibility to study the initia- tion and termination of tachycardias. - The pertinent interest in these devel- opments and the intention to learn more about the basic fundamentals of excitability and conduction under both normal and pathological circum- stances were reasons to organize an international symposium on that topic. - The papers contained in this book were presented at this meeting on diagnos- tic and therapeutical tools of cardiac pacing, held at Munich on November 7 and 8, 1975, sponsored by the first Medical Clinic of the University of Munich and generously supported by Medtronic. Especially focused are the investigations on sinus node function, disturbances of av-conduction and electrophysiology of supraventricular and ventricular tachycardias. The content of the book that is emerging from the symposium were created by the authors. I wish to thank them for teaching us about the recent advances in cardiac tissue stimulation by electricity. Much credit is due Priv. Doz. Dr. B. Uideritz, who organized the symposium and published these proceedings.

"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.

Herewe offer anew approach to understanding and managing common medical conditions. With the needs of our readers in mind we present clearer, more extensive and more expansive views on them. Traditional medical textbooks are wordy tomes with well worn patterns dealing in set order with 'causes, symptoms and signs, diagnosis and treatment'. They offer formal instant snapshots of diseases. We have devised an economic synoptic style, and we have endeavoured to give acomprehensive and an on-going long term movepicture ofeach condition and to relate this to the analysisofsymptoms and signs, to diagnostic assessment and to management and treatment. We have selected 22 important conditions and for eachhave followed the same sequence of questions and answers: * What is it? giving a brief summary of the current understanding of the nature of the condition. * Who gets it when? showing the age-sex distributions and influence ofother factors such as social class, international comparisons, andtheirlikelyfrequency ingeneralpractice and at the district general hospital. * What happens? analysing the significance of symptoms and signs, the likely course and outcome and how these influence care. * What to do? an appreciation of the nature and presentation of the condition, and their relevance to diagnosis and management.

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."

With contributions by D. Albrechtsen, O.H. Bentdal, H. Bondevik, I.B. Brekke, P. Fauchald, J.G. Fjeld, A. Flatmark, A. Foss, A. Hartmann, H. Holdaas, R. Innes, A. Jakobsen, N.E. Klow, B. Lien, O. Oyen, P.F. Pfeffer, K. Rootwelt, G. Sodal and K. Vatne

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.