Edwin J. Wylie

Extrarenal fibromuscular hyperplasia

Abstract Clinical, radiologic, and pathologic studies on nineteen patients with lesions in the extrarenal arteries that resembled fibromuscular hyperplasia are described. In eleven patients fibromuscular hyperplasia was present in the renal arteries. Patients with involvement of the celiac artery were the only ones who had symptoms of visceral ischemia. Fibromuscular hyperplasia of the internal carotid arteries was observed in six patients, two of whom had symptoms of cerebral ischemia. Nine patients with fibromuscular hyperplasia of the carotid or renal arteries had intracranial aneurysms, and in two others intracranial hemorrhage developed in the absence of demonstrable aneurysms. The histologic similarities between intracranial aneurysms and other types of aneurysms that appear in patients with fibromuscular hyperplasia, the frequency of intracranial aneurysms in patients with extracranial fibromuscular hyperplasia, and the similar sex and age incidence suggest a common etiologic origin.

Revascularization methods in chronic visceral ischemia caused by atherosclerosis.

A comparison of revascularization methods used in 35 patients who underwent 39 operations for chronic visceral ischemia caused by atherosclerosis is presented. All but two of these various methods have been abandoned either because of technical difficulties encountered during the procedure, or the high failure rate observed after operation. The two techniques which overcame these objections are: (1) antegrade aorto-celiac prosthetic grafts, and (2) transaortic endarterectomy using a thoracoretroperitoneal approach.

Measurement of collateral cerebral hemispheric blood pressure by ocular pneumoplethysmography

A new technic of ocular pneumoplethysmorgraphy for the simultaneous determination of blood pressures in the ophthalmic artery branches of the internal carotid arteries is described. It provides a noninvasive, atraumatic method for assessing hemispheric blood flow. When performed with simultaneous carotid compression, it provides a means for assessing the availability of collateral blood flow to the ipsilateral cerebral hemisphere. Clinical applications related to carotid artery disease and carotid artery surgery are discussed.

Vascular “steal” phenomenon: An experimental study ☆

Abstract Bilateral lower extremity blood flow determinations were made in experimental animals before and after cross-over grafting operations. The effect of the graft was to double the flow through the new afferent parent artery rather than to “steal” blood from the peripheral bed of the artery from which the graft originated. An arteriovenous fistula on the side to which the graft extended caused as much as a tenfold increase in graft flow without “stealing” from the contralateral extremity. Flow measurements before and after a common carotid-subclavian artery bypass operation in a patient with proximal subclavian occlusion demonstrated that this shunt does not decrease blood flow of the peripheral common carotid artery.

False aneurysms occurring after arterial grafting operations

Abstract Thirty-two false aneurysms occurred as a consequence of anastomotic disruption when synthetic grafts were used for vascular reconstruction. This complication was usually limited to end to side anastomoses between the graft and the common femoral or popliteal arteries. The frequency of disruption of anastomoses at these sites has been 23.7 per cent. Observation during operative repair of the false aneurysm indicated that the arterial wall adjacent to the suture line was usually the site of disruption. Of the various methods of surgical management used, excision of the distal portion of the graft along with the segment of artery to which it had been anastomosed and replacement by an arterial autograft has been the most successful. Disruption has not been a complication of primary operations designed to avoid implanting synthetic grafts adjacent to an active joint.

Complications of carotid endarterectomy.

Complications associated with carotid endarterectomy range from local nerve injuries and difficulties in controlling blood pressure to transient or permanent neurologic deficits and death. A thorough knowledge of such possible complications and of techniques to avoid and manage them is essential. This article reviews the anatomic and technical factors that relate to such complications and discusses their possible causes and management.

Surgery of the aortic arch branches and vertebral arteries.

Experience with 192 operations of vascular reconstruction for atherosclerosis in the proximal brachiocephalic and vertebral arteries is reported. These procedures constitute only 10 per cent of operations for extracranial arterial occlusive cerebrovascular disease at the University of California, San Francisco, in the past 20 years. All patients were asymptomatic. Except for six patients with cerebral embolization from ulcerating lesions, symptoms resulted from cerebral hypoperfusion. Prevention of ultimate stroke was the primary objective of operation in patients with embolization and in patients with stenosis or occlusion of the common carotid arteries. Purely obstructive lesions in the subclavian and vertebral arteries were symptomatic only when there was bilateral involvement and the objective of operation was the relief of disabling symptoms of hypoperfusion for these otherwise essentially benign lesions. Prior correction of associated stenosis of the carotid artery often removed the need for a proximal operation. The majority of the operations were endarterectomy or transposition, or combinations of the two. Cervical bypass grafts, because of their less certain durability, were used only when a more direct operation was neither feasible nor safe.

Management of occlusive lesions of the branches of the aortic arch

Abstract The clinical progress of 157 patients with atherosclerotic occlusive lesions of the major branches of the aortic arch is reviewed, with emphasis on the relation of the lesions to cerebral symptoms or stroke. Fifty per cent of these patients were free of significant symptoms from the onset or were made so by a prior carotid bifurcation endarterectomy. No operations were performed on the major arch branches in these patients. The subclavian artery was the prominent site of the proximal lesion. Follow-up examinations indicate that the lesions in these patients do not in themselves lead to stroke and that the indications for operation, therefore, are determined by the need for relief of symptoms. Revascularization operations were performed on eighty patients with genuine disabling symptoms. The innominate and common carotid lesions were more prone to cause disability than were the subclavian. Removal or bypass of the obstructing lesion was generally satisfactory in relieving symptoms.

Hypertension caused by fibromuscular hyperplasia of the renal arteries.

Abstract Case histories of three hypertensive women in whom hypertension was apparently caused by the stenosing effect of fibromuscular infiltration of the renal arteries are described. Each of these women was in the fourth decade of life and had had hypertension during previous pregnancies. Blood pressure was restored to normal in each patient by either renal artery reconstruction or nephrectomy. The clinical and pathologic characteristics of this recently recognized arterial disorder are described.

Unusual problems of abdominal aortic aneurysms

Complications other than rupture occurred in 12 per cent of 254 patients operated on for an infrarenal abdominal aortic aneurysm. The unusual problems encountered included aortocaval fistula, inflammatory aneurysm, aortoenteric fistula, aortic thrombosis, peripheral embolization, and retropsoas rupture. The clinical manifestations and management of these lesions are discussed.