T: IE YiYY.Y ATES ARM'/



MEDICAL DEPARTMENT; UNITED STATES ARMY

SURGERY IN WORLD WAR II

VASCULAR SURGERY

Edited by

DANIEL C. ELKIN, M. D.

MICHAEL E. DeBAKEY, M. D.

OFFICE OF THE SURGEON GENERAL

DEPARTMENT OF THE ARMY

WASHINGTON, D.C., 1955
The volumes comprising the history of the Medical Department of the

United States Army in World War II are divided into two series: (1) The

Administrative and Operational series which constitutes part of the general

series of the history of the United States Army in World War II, published

under the direction of the Office of the Chief of Military History, and (2) the

Professional, or clinical and technical, series published as The Medical Department of the United States Army under the direction of the Office of The

Surgeon General. Both series are being prepared by the Historical Unit,

Army Medical Service. This is one of number of volumes to be published in

the latter series.

Major General George E. Armstrong, The Surgeon General

Advisory Editorial Board

on the

History of Surgery

Michael E. DeBakey, M. D., Acting Chairman

Frank B. Berry, M. D,

Brian Blades, M. D.

J. Barrett Brown, M. D. Sterling Bunnell, M. D.

Norton Canfield, M. D.

B. Noland Carter, M. D.

Edward D. Churchill, M. D.

Mather Cleveland, M. D.

Daniel C. Elkin, M. D.

John B. Flick, M. D.

Frank Glenn, M. D.

M. Elliott Randolph, M. D. Isidor S. Ravdin, M. D.

Alfred R. Shands, Jr., M. D. Howard E. Snyder, M. D.

R. Glen Spurling, M. D. Barnes Woodhall, M. D. Robert M. Zollinger, M. D.

Colonel Joseph R. Shaeffer, MC (Ex Officio)

Colonel John Boyd Coates, Jr., MC (Ex Officio)

Colonel John Boyd Coates, Jr., MC, U. S. A., Editor in Chief

For sale by the Superintendent of Documents, U. S. Government Printing Office

Washington 25, D. C. Price $4.25 (Buckram)
THE MEDICAL DEPARTMENT OF THE UNITED STATES ARMY

VASCULAR SURGERY IN WORLD WAR II

Edited hy

DANIEL C. ELKIN, M. D.

MICHAEL E. DeBAKEY, M. D.

This volume was prepared by the Historical Unit, Army Medical Service, under the direction of Colonel Calvin H. Goddard, MC, AUS, formerly Editor in Chief; Associate Editor for Vascular Surgery, Helen Orr.

Foreword

The group of historical volumes now in preparation upon the activities of

the United States Army Medical Department in World War II constitutes the

third series of such works devoted to recording the formal history of that

department under war conditions. The first such series, published over the

years 1870-88, comprised six ponderous tomes, three of medicine and three of

surgery, which appeared under the title Medical and Surgical History of the

War oj the Rebellion. The second, following World War I, embraced fifteen

volumes published in seventeen parts (1921-29). This series was entitled

History of the Medical Department of the United States Army in the World War.

Two volumes of the seventeen dealt with surgical matters.

The present treatise, Vascular Surgery, is among the first of the third

series to receive publication. It will offer mute but convincing testimony to

the vast progress recently recorded in the field whereof it treats. Not that

vascular surgery, per se, is new phenomenon. In its simplest form, ligation,

it was practiced in the American Civil War on great many more occasions than

is generally known. Thus, in 672 recorded operations for wounds of the face

alone, no less than 69 involved ligation of an artery or vein—the common

carotid artery figuring in 55 of these. Based on cases whose dispositions

were known, mortality for the entire series was 65 percent, for cases involving

the common carotid about 72 percent, and but of the 65 patients operated

upon (3 of these, common carotid cases) were later able to return to duty.

Despite the amount of space accorded other surgical specialties in our

World War medical history (e. g., 535 pages on neurosurgery in one of the

surgical volumes), vascular surgery is there dismissed with single paragraph.

As result, the meteoric expansion of activity in that field to the point where

its adequate discussion in World War II records calls for an entire volume,

becomes especially significant. Truly, vascular surgery has come of age.

GEORGE E. ARMSTRONG

Major General, United States Army

The Surgeon General

VII

Preface

The history of injuries produced by war wounds is in effect the history of

surgery. surgical record of World War II is therefore no innovation except

that certain features are now for the first time receiving substantial recognition

and treatment. One of these features concerns vascular surgery.

This volume does not purport to be complete record of casualties with

vascular injuries in World War II. Data from many of the theaters of operations are unavailable—notably China-Burma-India, Southwest Pacific, and

Pacific Ocean Areas, and records from the North African, Mediterranean, and

European theaters are far from complete. Under battle conditions, the existence of vascular injuries was often masked by more extensive injuries to bone

and soft tissue. Furthermore, many deaths on the battlefield which might

rightfully have been attributable to wounds of the major arteries were not so

recorded.

This volume does purport to give reasonably complete accounting of

complications which followed combat-incurred vascular injuries in casualties

evacuated to the Zone of Interior. It also includes an accounting of peripheral vascular disorders observed in Army personnel during World War II, with

the exception of trenchfoot, immersion foot, and cold injuries, which will be

discussed in separate volume in the Medical History series.

The principles of vascular surgery have been established for many years,

and in the interim between World Wars and II many significant technical

advances were made. Vascular injuries, however, are relatively infrequent

in civilian life, and few surgeons, even those particularly interested in the subject, had had large experience with them.

The problem of supplying competent specialized care for the numbers of

casualties with these injuries was, therefore, difficult one. It was solved in

World War II by the establishment of three vascular centers to which surgeons

experienced in this specialty were attached.

It is to the credit of Surgeon General James C. McGee and his successor,

Surgeon General Norman T. Kirk, that these centers were inaugurated soon after

the first casualties began to arrive in this country. The chief consultant in

surgery, Brigadier General Fred W. Rankin, by his untiring efforts in securing

and holding trained personnel and in procuring proper equipment, was responsible in large measure for the success of this undertaking. In this he had the

understanding aid of his assistants, Colonel B. N. Carter, MC, and Colonel

Michael E. DeBakey, MC. For the first time in history there was concentration

of clinical material under the supervision of specialists who could carry out

concurrently definitive treatment and important phases of clinical investigation.
VIII

As result, knowledge regarding the circulatory system has been extended

and interest has been generated in field which, though long recognized,

has attracted few workers.

The lessons learned, as reflected in the low mortality rate and the remarkable functional results achieved in these centers, came not by chance but

through careful planning and execution. Those who had part in it prayerfully

hope that these lessons will not soon be forgotten.

DANIEL C. ELKIN, M. D.

Professor of Surgery

Emory University

Emory University, Ga.

28 May 1954.
IX

Contents

Page

FOREWORD

PREFACE vii

Chapter

SPECIALIZED CENTERS FOR THE MANAGEMENT OF VASCULAR INJURIES AND DISEASES

II EVALUATION OF THE VASCULAR STATUS IN TRAUMATIC

AND NONTRAUMATIC LESIONS OF THE BLOOD VESSELS.. 17

III ACUTE BATTLE-INCURRED ARTERIAL INJURIES 60

IV ARTERIAL ANEURYSMS AND ARTERIOVENOUS FISTULAS. GENERAL CONSIDERATIONS 149

ARTERIAL ANEURYSMS AND ARTERIOVENOUS FISTULAS,

CIRCULATORY EFFECTS OF ARTERIOVENOUS FISTULAS. 181

VI ARTERIAL ANEURYSMS AND ARTERIOVENOUS FISTULAS,

ALTERATIONS IN THE CARDIAC SIZE IN ARTERIOVENOUS FISTULAS 206

VII ARTERIAL ANEURYSMS AND ARTERIOVENOUS FISTULAS,

TECHNICAL CONSIDERATIONS IN THEIR SURGICAL MANAGEMENT WITH SPECIAL REFERENCE TO EXPOSURE OF BLOOD VESSELS 225

VIII ARTERIAL ANEURYSMS AND ARTERIOVENOUS FISTULAS,

MAINTENANCE OF ARTERIAL CONTINUITY 264

IX ARTERIAL ANEURYSMS AND ARTERIOVENOUS FISTULAS,

SUCCESSFUL SUTURE OF THE ABDOMINAL AORTA FOR

ARTERIOVENOUSFISTULA 302

ARTERIAL ANEURYSMS AND ARTERIOVENOUS FISTULAS,

ANTICOAGULANT THERAPY IN REPARATIVE SURGERY. 310 XI ARTERIAL ANEURYSMS AND ARTERIOVENOUS FISTULAS,

SYMPATHECTOMY AS AN ADJUNCT MEASURE IN OPERATIVE TREATMENT 318

Part I. Preoperative Sympathectomy and Sympathectomy Coincidental with Vascular Surgery 318

Part II. Postoperative Sympathectomy 346

XII ARTERIAL ANEURYSMS AND ARTERIOVENOUS FISTULAS,

SPONTANEOUS CURES 361

XIII PERIPHERAL VASCULAR DISTURBANCES THROMBOANGI- ITIS OBLITERANS, ARTERIOSCLEROSIS, AND ARTERIAL

THROMBOSIS AND EMBOLISM 375

XIV PERIPHERAL VASCULAR DISTURBANCES VASOSPASTIC DISORDERS. RAYNAUD’S SYNDROME AND RAYNAUD-LIKE

DISORDERS 383

XV PERIPHERAL VASCULAR DISTURBANCES POST-TRAUMATIC

VASOMOTOR DISORDERS 395

XVI SYMPATHECTOMY IN CIRCULATORY DISTURBANCES OF

THE EXTREMITIES 422

INDEX 439

CHAPTER

Specialized Centers For the Management of

Vascular Injuries and Diseases

Daniel Elkin M. D.*

The arrest of hemorrhage and the preservation of an adequate arterial

supply to injured extremities have been the primary concern of military surgeons in all the wars of history. In each successive war the relative number

of vascular injuries has steadily become larger because the development of

weapons of increasingly higher velocity has magnified the chances of vascular

trauma.

During World War II, as result of widespread use of weapons of such

type, multiple wounds were more frequent. Dozens of nonfatal wounds were

often observed in the same casualty and as high as two hundred wounds have

been recorded. Furthermore, while case fatality and amputation rates were

high in injuries of the major arteries, improved methods for the control of

hemorrhage, shock, and infection greatly decreased the incidence of death and

mutilation and increased the numbers of casualties who lived with possible

post-traumatic complications.

The medical records of World War supplied almost no information about

vascular injuries in American military personnel. Early in World War II it

became evident that this type of injury was likely to be frequent and would

create grave problems. While the principles of vascular surgery had been

established for many years, and prior to the outbreak of World War II many

significant advances had been made in this field, the fact remained that wounds

of this type occurred infrequently in civilian life and that surgeons with extensive experience in this specialty were few.

ESTABLISHMENT OF VASCULAR CENTERS IN THE ZONE OF

INTERIOR

The problem of supplying competent specialized care by experienced personnel for large numbers of casualties with vascular injuries was solved in

World War II by the establishment in the Zone of Interior of vascular centers

to which surgeons experienced in vascular surgery were attached and in which

•Whitehead Professor and Chairman of Department of Surgery, Emory University. Brigadier General, MC

USAR (Ret’d.).

Unless otherwise specified, all data contained in this chapter are derived from reports prepared for this purpose by

J. W. Kahn (formerly Captain, MC, Ashford General Hospital), H. B. Shumacker, Jr. (formerlyLt. Colonel, MC, Mayo

General Hospital), and A. H. Storck (formerlyLt. Colonel, MC, DeWitt General Hospital).

WD Memo W40-14-43, 28 May 43.
VASCULAR SURGERY IN WORLD WAR II

other surgeons could be trained. To these centers were sent patients with

vascular injuries and diseases.

The establishment of these centers made it possible to carry out the necessary treatment of such patients with an economy of equipment, personnel, and

effort which would havebeen impossible had the patients been scattered through

large number of hospitals. It also permitted the observation of patients

with vascular injury and disease in numbers far beyond those of any similar

previous experience. Careful and detailed records were kept and analysis of

data derived therefrom permitted deductions and conclusions which could not

be gained from the small series of cases previously observed by surgeons in

civilian practice.

The first vascular centers to be activated were located at Ashford General

Hospital, White Sulphur Springs, W. Va., and Letterman General Hospital,

San Francisco, Calif. These centers were established by War Department

memorandum dated 28 May 1943. The former center continued in operation

throughout the war and was not deactivated until 30 June 1946. The author

of this chapter served as chief of the vascular surgical section throughout the

period of operation.

The vascular center established at Letterman was active until 23 December

1943 and the patients on the vascular ward at the time were transferred to

Torney General Hospital, Palm Springs, Calif., which had been officially designated vascular center 17 December 1943.® Lt. Col. Russell H. Patterson

served as chief of the center during the months period of activity at Letterman.

Torney General Hospital continued to house the vascular center until 12 June

1944 when DeWitt General Hospital, Auburn, Calif., was officially designated

as hospital to which patients with vascular disorders should be sent. Capt.

(later Major) LeRoy J. Kleinsasser served as chief of the vascular surgical

section at both Torney and DeWitt General Hospitals. He held this position

until May 1945 when he was succeeded by Maj. (later Lt. Colonel) Norman E. Freeman who served until the center was deactivated.^

Early in 1944 the influx of patients with vascular disabilities from the European and Aleutian theaters reached point where it became necessary to

establish another center for patients with vascular disorders. third vascular

center was therefore designated at Percy Jones General Hospital, Battle Creek, Mich., 12 June 1944. 10 This center was active only short time for on 25

August 1944 Mayo General Hospital, Galesburg, 111., was designated vascular

center and all patients and personnel were transferred from Percy Jones to

See footnote 2, p. 1.

Final Rpt, 1946, Ashford General Hospital. HD. Annual Rpt, 1943, Letterman General Hospital. HD

Ltr, Gen Somervell to CQs all SvCs and MDW, 17 Dec 43, sub: Hospitals designated for specialized treatment. SO: 323.7-5.

WDCir 235, 12Jun44. Annual Rpt, 1945, DeWitt General Hospital. HD. Ibid.

10 See footnote above.
SPECIALIZED CENTERS IN ZONE OF INTERIOR

Mayo General Hospital. 11 The vascular center at Mayo continued in operation

until 17 October 1946 12 when it lost its designation. Lt. Col. Harris B. Shumacker, Jr., served as chief of section in this center during its entire period of

operation.

ORGANIZATION

Although the vascular centers were briefly conducted as specialized surgical

sections attached to the surgical service of the hospitals in which they were

located, they soon became, for all practical purposes, independent units.

The organization was not precisely the same at all centers though it was

always based on the principle that medical and surgical specialists should be

in constant consultation with each other and should collaborate in the management of individual patients.

Organization at Ashford General Hospital. At Ashford General Hospital,

at Torney, and at DeWitt during most of its period of operation, all patients

with vascular disorders were assigned to the vascular surgical section. At

these centers, when circumstances permitted, the following organizational

setup was considered ideal:

surgeon in charge of the center with wide experience in the field of

vascular surgery. He performed most of the operations, was responsible for

all administrative, medical, and surgical policies (in conformity with existing

directives), and supervised all medical and surgical treatment.

An assistant surgeon, an experienced general surgeon, with fairly wide

experience in vascular surgery. He supervised the center and carried out

surgical procedures in the absence of the director.

Two medical officers with thorough grounding, through training and

experience, in the physiologic concepts of vascular diseases and injuries. They

supervised or performed special tests, skin temperature and oscillometric studies,

and diagnostic spinal punctures and lumbar sympathetic blocks (in collaboration

with the chief anesthetist). At least officers were necessary as it proved impossible for single officer to appraise the vascular status of more than patients

per day.

physiotherapist to give both diagnostic and therapeutic advice.

An officer to supervise reconditioning once definitive treatment was

concluded.

cardiologist to serve as consultant in appropriate cases and to advise

on nonsurgical therapy. (While this officer was attached to the medical service, he was available for consultation at all times.)

neurologist and neurosurgeon to serve as consultants; the former to

attend weekly ward walks during which new patients were seen and the latter

WD Cir 347, 25 Aug 44. 1J Annual Rpt, 1946, Mayo General Hospital. HD.
VASCULAR SURGERY IN WORLD WAR II

to cooperate in the performance of sympathectomies. (These officers were

attached to the neurologic service, but were available for consultation.)

Organization at Mayo General Hospital. The plan of operation at Mayo

General Hospital differed from that at Ashford General Hospital in that the

unit was divided into medical and surgical sections. The general understanding at this installation was that patients with vascular conditions requiring surgical treatment should be admitted directly to the surgical section.

All other casualties were admitted to the medical section, from which, after

the proper workup, they were transferred to the surgical section whenever

surgery seemed indicated. Generally speaking, patients were admitted to the

medical section if the diagnosis was trenchfoot, frostbite, thrombophlebitis,

Raynaud’s disease, peripheral edema, or vasospastic and obliterative arterial

disease without ulceration. Patients were admitted directly to the surgical

section if the diagnosis included arterial aneurysm, arteriovenous fistula,

traumatic lesions of the blood vessels, gangrenous and other open lesions of

vascular origin, varicose veins, hemangioma, or venous thrombosis. These

policies, while carried out with reasonable consistency, were by no means

inflexible. Patients with post-traumatic vasospastic disorders, for instance,

might be admitted to the surgical section in some instances and to the medical

section in others. The decision depended upon the particular clinical manifestations which the patient presented at the time of his admittance.

This plan was adopted at DeWitt General Hospital in May 1945 and was

followed until the center was closed. 13

Collaboration Among Services

No matter what the details of organization were in any particular center, the management of patients with vascular lesions was always combined responsibility. The amount of work prevented collaboration in every case, but

whenever it was to their best interests, patients were treated jointlyby internists

and surgeons. They were never regarded as the sole responsibility of one

service or the other.

At all centers, collaboration with the department of roentgenology was

excellent. The physical therapy and reconditioning department participated

actively in the care of patients. Their personnel supervised corrective exercises

and gave the special treatments required by patients with cold injuries and

with trauma to the major arterial stems. When personnel of the physical therapy department was in short supply, as it frequently was, corrective gymnastic

exercises were developed by the reconditioning section and were used, as far as possible, as substitutes for physical therapy.

In all centers, full use was made of the occupational therapy departments,

partly for reconditioning purposes and partly to supply diversion during necessarily prolonged periods of hospitalization. Red Cross workers also

13 See footnote 8, p. 2.
SPECIALIZED CENTERS IN ZONE OF INTERIOR

participated in the programs at the vascular centers. At DeWitt General

Hospital special ward was set aside for patients who agreed to discontinue

smoking as phase of the therapy. Special privileges were granted to these

patients and Red Cross workers were particularly cooperative in providing

recreation.

Ward Rounds

Time was saved and efficiency increased by the coordinated ward rounds held weekly at each center. They were attended by all members of the medical

and surgical staffs and by others concerned with the treatment of patients with

vascular lesions. At these rounds new patients with problems of special

interest or special difficulty were presented, the management of unusual cases

discussed and agreed upon, and general policies were explained. Weekly

progress notes on each case were also dictated at this time by the section chief.

In addition to the ward walks, dry clinics were held at regular intervals.

PATIENT LOAD

Ashford General Hospital

The original allotment of beds for the vascular center at Ashford General

Hospital was 50 out of total bed capacity of 1,875; this was increased as the

patient load increased, and at the height of military activity 600 beds were so

allotted. Typical of the proportionate distribution of cases was the report

made by representative of the Office of The Surgeon General 14 who inspected

the center in September 1944. At that time, of the 241 patients in the vascular

section of the hospital, 164 had trenchfoot, 33 had aneurysms or arteriovenous

fistulas, 16 thrombophlebitis, thromboangiitis obliterans, Raynaud’s

disease, frostbite, and 13 miscellaneous vascular conditions.

The heavy patient load carried by the Ashford General Hospital Vascular

Center during 1944 and 1945 (Table 1), and the number of operations performed

there during those years (Table 2), clearly indicate the wisdom and expediency

of concentrating patients with vascular injuries in centers where they can

receive highly specialized treatment. The statistics also provided evidence

that concentration in these centers of the few available specialists is an economical use of personnel, for under any other setup their particular skills would be

dissipated.

Percy Jones—Mayo General Hospitals

Because of the physical limitations of Percy Jones General Hospital,

only 28 patients were admitted directly to its vascular section. Another 23

were transferred from other sections of the hospital; 78 were seen in consultation

but not transferred. Thirty-eight operations were performed, including 23

sympathectomies and excisions of arteriovenous fistulas.

14 Memo, Lt Col M. E. DeBakey, Chief Oen Surg Br, Surg ConsultantsDiv for SQ, 13 Sep 44, sub; Report of visit

to Ashford General Hospital. HD: 730 (Ashford Oen Hosp).
VASCULAR SURGERY IN WORLD WAR II

Table 1. Combined Diagnostic Analysis Report Ashford General Hospital

Vascular Center

[1 January 1944—31 August 1945]

Diagnosis

Number of patients

1944 1945 Total

Arteriovenous fistula:

Anterior tibial 11 11

Axillary

Brachial 11 17 Carotid artery and jugular vein 14 11 25 Cavernous sinus

Cirsoid

Common iliac

External iliac

External carotid

Internal carotid

Femoral 33 40 73

Parietal scalp

Peroneal

44

10

Popliteal 17 27

Posterior tibial 10

Radial

Subclavian 12 14 26

Temporal

Tibial _.. 14 13 27 Transverse scapular

Vertebral

Innominate

Vessels of foot

Multiple arteriovenous fistulas:

Femoral, tibial, carotid (3)

Radial, right and left ulnar vessels (3)._

Two tibial left, one tibial right (3)

Radial and Brachial (2)

Arterial Aneurysm:

Anterior tibial

Axillary

Brachial 10 16 26 Carotid

Common iliac

External carotid

Femoral 13

Gluteal

Intracranial

Postauricular

Posterior tibial 12

10

11

Popliteal

Radial

Subclavian
SPECIALIZED CENTERS IN ZONE OF INTERIOR

Table 1. Combined Diagnostic Analysis Report Ashford General Hospital

Vascular Center—Continued

[1 January 1944—31 August 1945]

Diagnosis

Number of patients

1044 1945 Total

Arterial Aneurysm—Continued

Ulnar ______

Thoracic aorta

Trenchfoot syndrome 348 634 982

High altitude frostbite 22 24

Thrombophlebitis, acute and chronic 156 186 342

Raynaud’s disease 37 60 97

Thromboangiitis obliterans 66 98 164

with Raynaud’s disease

Arteriosclerosis obliterans 13 19 32

Acrocvanotic syndrome 68 39 107

Secondary vasospasm 61 50 111

Varicose veins 15 15

Thrombosis, arterial 13

Thrombosis, venous 11 11 22

Postoperative ligation of major vessels 21 25 46

Postoperative arteriovenous fistula

Postoperative arterial aneurysm

Postoperative tonic vasomotor spasm

Venous incompetency

Constriction of arteries by scar__

Dilatation of brachial artery

Causalgia

Embolic syndrome

Hemangioma 10 10 20

Angioma

Sudek’s atrophy 11

Scalenus anticus syndrome

Periarteritis nodosa

Meralgia paraesthetica

Carotid body tumor

Rheumatoid disease with secondary vasospasm

Venous obstruction

elangiectasia

Recurrent hematoma, left thigh

Traumatic gangrene of hand

Muscular pseudohypertrophic dystrophy

Veno-vitallium graft femoral artery

Fibrosis of calf muscles secondary to vascular insufficiency

Foreign body in ventricle.

in myocardium

Lymphedema, chronic

Scleroderma, diffuse.

Vasomotor imbalance 12 14

330323 O—55
VASCULAR SURGERY IN WORLD WAR II

Table 1. Combined Diagnostic Analysis Report Ashford General Hospital

Vascular Center—Continued

[1 January 1944—31 August 1945]

Diagnosis

Number of patients

1944 1945 Total

Vascular reevaluation

No vascular disease._

152

11

71

24

223

35

Total 1, 180 1, 547 2, 727

Table 2. Combined Operative Analysis Report Ashford General Hospital

Vascular Center

[1 January 1944—31 August 1945]

Procedure

Numberof operations

1944 1945 Total

Excision of arteriovenous fistula:

Femoral 22 35 57

Popliteal .. 18 20 38

with resection of fibula.

Posterior tibial 15 22 37

with resection of fibula.

Anterior tibial

with resection of fibula.

Carotid artery and jugular vein 17

Subclavian, resection of clavicle 16

Brachial 10 14

Ulnar

Carotid

Peroneal

Axillarv 10

with resection of clavicle

Iliac

Profunda femoris

Vertebral

Transverse cervical

Transverse scapular, with resection of clavicle.

Superficial temporal

Cirsoid of arm

Vessels of scalp

Vessels of foot

Vessels of hand

Excision of arterial aneurysm:

Brachial 15

Subclavian
SPECIALIZED CENTERS IN ZONE OF INTERIOR

Table 2. Combined Operative Analysis Report Ashford General Hospital

Vascular Center Continued

[1 January 1944—31 August 1945]

Procedure

Number of operations

1944 1945 Total

Excision of arterial aneurysm—Continued

Femoral

Popliteal

Tibial

Axillary

Profunda femoris.

Carotid

Radial

Cirsoid (1) hand and finger. (2) wrist. ..

Ulnar

Endoaneurysmorrhaphy:

Femoral. 11 Brachial

Tibial

Radial

Axillary

Iliac

Popliteal

Profunda femoris

Posterior tibial Ligation of artery:

Common iliac

Femoral

Internal carotid

External carotid 11

Vertebral.

Innominate.

Superficial temporal

Transverse cervical

Occipital

Tibial.

Ligation of saphenous veins 12 28 40

Amputation and debridement of toes and fingers 48 86 134

Amputation of feet

Excision of hemangioma 10 15

Scalenotomy

Excision of subclavian muscle

Excision of carotid body tumor Exploration for lacerated vessels

Excision ingrown toenail.. Dorsal laminectomy

Exploration subclavian artery, resection of clavicle

Suture femoral arterv
10 VASCULAR SURGERY IN WORLD WAR II

Table 2. Combined Operative Analysis Report Ashford General Hospital

Vascular Center Continued

[1 January 1944—31 August 1945]

When this vascular center was transferred from Percy Jones General

Hospital to Mayo General Hospital in September 1944, it was allotted 305

beds on the medical service and 195 beds on the surgical service. The allotment

was increased or decreased according to the patient load but was in the neighborhood of 500 beds for the first months the center was in operation. Bed capacity was increased to 724 on January 1945, and to 800 on 26 January. Early

in May 1945 the patient load decreased chiefly because of the diminution in the

number of trenchfoot casualties, and on 20 May the bed capacity was again

set at 500.

Between 15 September 1944 and October 1945, 500 patients were admitted directly to the vascular surgical section at Mayo General Hospital, 365 operative procedures were carried out, and 540 patients from other parts of the

Procedure

Numberof operations

1944 1945 Total

Application tantalum clip to internal carotid artery and

Venogram

Venous pressure determination

Rinpsy of vein for thromboangiitis obliterans

Sympathetic block;

Lumbar 320 77 397

Dorsal 34 34

Thoracic 12 12

Sympathectomy;

Lumbar 196 168 364

Dorsal 35 41

Lumbodorsal

Lumbothoracic

Thoracodorsal

Lumbodorsal-thoracic

Total 765 695 1, 460

Treatments:

Mecholyl iontophoresis 1, 627

110

565 2, 192

Intravenous typhoid injections 155 265

Injection of varicose veins 32 63 95

Spinal anesthesia vasomotor tests 58 47 105

Alcohol vasomotor tests

Total 'l, 830 830 2, 660
SPECIALIZED CENTERS IN ZONE OF INTERIOR 11

hospital were seen in consultation. The patient load on the medical vascular

section was 68 in September 1944, 247 in December, and over 500 in January

1945. It remained at about this level until April. By the end of this month

the medical service patient load had fallen to about 400, by the end of May

it was about 250, and by the end of July only 125 were occupying beds. After

this, the patient load was never over 100 on the medical service. In October

orders were received that no more patients would be sent to the center and

those remaining were gradually dispositioned, the center closing early in 1946.

Letterman Torney—DeWitt General Hospitals

Thirty patients with vascular disorders requiring surgery were admitted

to the vascular section of Letterman General Hospital during its period of

operation. Of particular note were 221 patients with trenchfoot admitted to

this center from Attu. 15 While facilities were adequate at Letterman to handle

the expected increase in patients with vascular disorders, the hospital was designated debarkation hospital and directives were issued arresting the flow of

patients requiring specialized care in order to make beds available for expected

evacuees from overseas. 16 At the time of deactivation, 23 December 1944,

patients with vascular disorders were dispositioned to Torney General Hospital which had been designated vascular center 17 December 1943. 17

33-bed ward which constituted the facilities of the vascular center

established at Torney General Hospital was almost completely filled from

the day of its opening. The rapid increase in patient load made it imperative

to secure further facilities and plans were made for more ward space as well as

for an examining room, constant-temperature room, and an office in one of

the hospital cottages. Before they could be carried out, however, the center

was transferred to DeWitt General Hospital, newly constructed hospital

where bed space was available to handle the great numbers ofpatients expected

who would require this type of specialized care.

At DeWitt General Hospital the original allotment of the vascular center

was 350 beds. 18 Additional beds were assigned as the patient load increased

and during the height of the trenchfoot load the allotment reached 500. 19

PERSONNEL

When the vascular centers were first planned it was realized that their

success would depend to great extent on the capabilities of the medical

personnel selected to staff them. Two factors were considered of primary

importance; (1) assignment to the centers of the limited number of medical

and surgical specialists of wide experience in the field of vascular injuries and

15 Annual Rpt, 1943, Letterman General Hospital. HD. 18 Smith, Clarence McK.: Hospitalization and Evacuation in the Zone of Interior. (Manuscript for an administration volume in this series.)

17 See footnote 6, p. 2. 18 Annual Rpt, 1944, DeWitt General Hospital. HD. 19 See footnote 8, p. 2.
12 VASCULAR SURGERY IN WORLD WAR II

diseases, and (2) retention of such selected personnel despite rotation policies.

The latter consideration was adjudged of particular importance in field as

highly specialized as vascular surgery. It affected not only the medical officers

but also the nurses, reconditioning personnel, physical therapists, medical

detachment enlisted men, civilian ward attendants, technicians trained in the

management of the constant-temperature rooms, and the WAC personnel.

In spite of endeavors to prevent them, rotation and changes in personnel were

frequent, and training programs to overcome the difficulties caused by this

situation were steadily in operation.

When the vascular centers were first established, shortages in medical

personnel were especially pronounced and especially serious. In an effort

to overcome this shortage an attempt was made at DeWitt to utilize the services of ambulatory officer patients of the Medical Corps, but for variety of

reasons the policy was not satisfactory. Some of the patients were physically

and emotionally exhausted from their combat experiences and were really

unfit for anything but rest. Others felt that their stay in the hospital was

limited and therefore had little interest in undertaking serious work. Still

others were expecting separation from the service. Whatever the reason,

the quality of work done by officer patients was frankly inferior and frequently

had to be done over by the regular staff. The plan thus resulted in loss of

time and effort rather than saving. It was quickly abandoned at DeWitt

and was not put into effect at either of the other centers.

The large amount of paper work required in vascular cases, because of the

many and repeated tests performed, made secretarial assistance of unusual importance. It was provided without too much difficulty at Ashford and Mayo

General Hospitals but was problem at DeWitt because of its inaccessible

location. The situation was somewhat relieved shortly before the center was

deactivated by the assignment of WAC personnel who served as medical clerks.

TRAINING PROGRAM

Because of the shortages of experienced personnel previously mentioned,

the training of additional professional and nonprofessional personnel proved an important part of the function of the vascular centers.

The numbers of medical officers qualified for assignment to the vascular

centers were augmented in several ways. Staff officers who were attached to

these centers and who had had no previous experience in vascular injuries and

diseases were rotated through the medical and surgical wards and eventually

assigned to the operating room. This procedure enabled them to become

familiar with methods of examination, diagnosis, and treatment. Medical

officers with previous experience, but assigned to other stations, were sent to

the centers where they were given intensive refresher courses. In addition, young medical school graduates who had completed their preliminary training

at Carlisle Barracks, Pa., were sent to the centers for instruction. This training
SPECIALIZED CENTERS IN ZONE OF INTERIOR 13

program proved fruitful for not only were specialists augmented in number but

also some developed such skill, dexterity, and judgment that they became

capable of handling independently complicated vascular lesions and major

vascular operations.

The training of nonprofessional personnel was more informal, and practically continuous, process. Ward personnel were instructed in the specialized

requirements of patients with various types of vascular injury. X-ray technicians, who had already received their basic training, were instructed in the

techniques of arteriography and phlebography. Other technicians were trained

in the operation of recording apparatus used in the constant-temperature,

constant-humidity rooms, and in the performance of special tests.

PHYSICAL PLANT AND EQUIPMENT

Ashford General Hospital

Ashford General Hospital, White Sulphur Springs, W. Va., was housed in

the Greenbrier Hotel. This hotel, one of the most beautiful in the world, was

converted to its new purpose without the loss of any of its traditional beauty

and charm. Patients in the vascular center located in this installation were

therefore cared for in structure that was physically adequate, well maintained,

and extremely attractive. Furthermore, the natural surroundings and recreational facilities were of great value in the rehabilitation of patients after their

definitive treatment had been accomplished. All the necessary facilities for

modern hospital were available including an operating pavilion, roentgenologic department, clinical laboratories, physical therapy section, reconditioning section, and photographic laboratories.

Initial difficulties in obtaining precision instruments and other equipment

necessary for the management of patients with vascular injuries and diseases

were overcome at the center by the loan of the personal instruments of one of

the officers attached to the staff. Some of his equipment was used throughout

the operation of the center because the Army was unable to supply certain

special types of instruments needed. 20 Within few months after the establishment of the center at this installation constant-temperature, constanthumidity room was constructed and provided with elaborate electrical controls

which permitted range of temperature from 40° to 110° F., as well as varying

degrees of humidity. This room was equipped with delicate precision instruments including Boulitte oscillometers of both the recording and the manual

type, apparatus for skin surface temperature determinations, instruments for

measuring skin resistance, and plethysmograph. Special lights, simulating

daylight, were provided for all examining rooms. chemical laboratory was

set up for blood volume studies and ballistocardiograph installed for the study

of the circulation in the presence of vascular lesions.

20 In addition, great help was received from Dr. John M. Emmett and directors of the Chesapeake and Ohio Railroad

Hospital located at Clifton Forge, Va., in the loan of instruments and linens, and the use of their operating rooms for

sterilization.
14 VASCULAR SURGERY IN WORLD WAR II

Percy Jones—Mayo General Hospitals

When the vascular center at the Percy Jones General Hospital was first

activated no special equipment was provided for the study of patients with

vascular injuries and diseases. The difficulty was overcome by member of

the staff who loaned his own thermocouple and recording oscillometer. Oscillometers, thermocouples, cutaneous resistance apparatus, intermittent venous

occlusion apparatus, Sanders oscillating bed, and an ultraviolet light unit for

intravenous fluorescin studies were requisitioned. Not all of these items were

standard, however, and there was considerable delay in securing them. Since

controlled temperature room was not available, studies which are preferably

done in cool atmosphere were carried out in one of the air-conditioned operating rooms at times when it was not being utilized for surgical work.

Shortly after the transfer of the vascular center from Percy Jones to the

Mayo General Hospital, the May Institute for Medical Research, Cincinnati, loaned the center thermocouple, an oscillometer, and plethysmograph. An

additional thermocouple and four oscillometers were eventually obtained

through Army channels. controlled temperature room which permitted

the constant maintenance of temperatures at any desired level between 40°

and 90° F. was completed in September 1945 and until that time serviceable

room was achieved by the use of an air-conditioning unit of the room type.

Letterman Torney—DeWitt General Hospitals

According to reports from Letterman General Hospital in 1943, facilities

and equipment were adequate for investigating and treating patients with

vascular disorders.21 However, the hospital was becoming crowded by the

flow of evacuees from overseas and since more beds were needed to handle

an expected increase in numbers, 22 the situation was solved by shifting the

patients requiring specialized treatment to other hospitals. 23

When the vascular center at Torney General Hospital was first activated,

33-bed ward constituted the facilities of its vascular center. The initial

requisition for equipment included oscillometers, thermocouples, derimeter,

and an intermittent suction apparatus. Shortly before the center was transferred to DeWitt, two sets of equipment for intermittent suction and two

portable potentiometers were received, though the thermocouples ordered were

not. This equipment was transferred to DeWitt and there efforts were made

by the staff to secure the items missing from the original requisition, as well as

to secure additional equipment. These efforts were not entirely successful.

Collins oscillometer was received in July 1945, but the Boulitte and

the Tycos recording oscillometers which had been requisitioned never materialized. Van Slyke blood gas apparatus requisitioned in May 1944 arrived

in July 1945. Other apparatus received after considerable length of time

21 See footnote 5, p. 2. 22 Health-Monthly Progress Rpt, 28 Feb 43. HD: 720.-1. 22 See footnote 16, p. 11.
SPECIALIZED CENTERS IN ZONE OF INTERIOR 15

included photoelectric cell apparatus for determination of the circulation

time, an ultraviolet dark lamp, and Samuels pulsimeter. Supplies of

fluorescin and Blakemore-Lord anastomosis ferrules were also late in arriving.

Henderson-Haldane gas analysis apparatus and plethysmograph were

requisitioned but never received. The two oscillating beds finally delivered

were used to good advantage in surgical cases before and after operation.

Special operating room equipment included pneumatic tourniquets, Bethune

tourniquets threaded and padded with split rubber tubing for direct arterial

compression, and manometer for direct measurement of intravascular and

intra-aneurysmal pressures.

When the vascular center was transferred from Torney to DeWitt General

Hospital request was made for constant-temperature, constant-humidity

room. When it was finally constructed and put into operation, alternating

hot and cold currents of air, readily discernible to anyone in the room, were

created every minutes. Engineers corrected this condition in part by reducing

the rate of air exchange.

In spite of the difficulties and delays encountered in securing special

essential equipment for the vascular centers, and in spite of the fact that some

apparatus requisitioned was never received, it was the consensus of the staffs

that in no instance was the care of patient seriously hampered nor the outcome

of any procedure seriously influenced by these lacks. Shortages in operating

room equipment were met by improvisations; those in diagnostic equipment

by greater reliance upon clinical methods supplemented by judgment and

experience.

It shotild be mentioned that the photographic laboratories established

at each of the vascular centers proved valuable, since much of the progress of

patients with vascular lesions can best be recorded pictorially.

RECORDS

Aside from the fact that careful and detailed records are essential in the

management of patients with vascular lesions, it was considered particularly

desirable to keep precise records at vascular centers because of the unique

opportunity provided for the collection of mass data concerning vascular

injuries. The compilation of these records was tedious and time-consuming

and was sometimes accomplished with difficulty since medical personnel were

overloaded with work and secretarial assistance was frequently inadequate.

Army medical history blanks proved unsuitable for the purposes of the

vascular centers and special forms were developed. 24 They were found

efficient and timesaving.

Much valuable material was collected from the photographic laboratories.

This included black and white photographs of clinical conditions and pathologic

lesions, colored photographs, transparencies for exhibit purposes, and drawings

24 Vascular Surgery—Forms. HD: 730.
16 VASCULAR SURGERY IN WORLD WAR II

of operative procedures. These were used to great advantage in the training

program.

CLINICAL RESEARCH

Delay in securing certain essential equipment prevented the carrying out

of some of the clinical studies which had been planned. Blood-oxygen studies, for instance, outlined at DeWitt General Hospital were never initiated because

of delay in the receipt of the chemicals required for use with the blood-oxygen

apparatus. Despite plans, no plethysmographic studies were carried out at

this center because the apparatus arrived after the patient load was so heavy

that it was impossible to perform these time-consuming tests. It is regrettable

that these and other studies could not be carried out because the amount

of clinical material available in time of war can never be duplicated in peacetime civilian practice nor, in time of peace, can available clinical material

be concentrated and controlled as it can in time of war. In all the centers,

however, clinical studies of immediate and future value were made on such

subjects as trenchfoot and other cold injuries, thrombophlebitis, vasospastic

states, ischemic paralyses, collateral circulation, the circulatory and other

effects of aneurysms and arteriovenous fistulas, and the use of sympathectomy

on various indications.
CHAPTER II

Evaluation of the Vascular Status in Traumatic and

Nontraumatic Lesions of the Blood Vessels

Ambrose H. Storck, M.

The evaluation of the vascular status of patients with traumatic and

nontraumatic lesions of the blood vessels encountered in World War II went

considerably beyond mere diagnosis and differential diagnosis. It was useful,

or essential, or both: (1) to determine the exact location and extent of lesion

or injury and to follow the progress of the disorder; (2) to determine vascular

tone, patency of arteries and veins, functional capacity of blood supply, and

adequacy of collateral circulation; (3) to establish need for surgical intervention,

to select correct operative procedure and optimum time for operation and to

assess the results of surgical therapy; (4) to establish therapeutic procedures

other than surgical and to assess their results; (5) to determine the disposition

of the patient whether for return to duty or for discharge, and, in the event of

the latter, to establish degree of disability for pension purposes and to advise

the patient regarding the resumption of his civilian occupation.

In medical installations in zones of combat and of communication the

excessive workload of the medical personnel and the lack of special equipment

made it mandatory to depend upon clinical methods alone for the study of

casualties with injuries to the blood vessels. Clinical methods also constituted

the major part of the investigation of the vascular status of casualties admitted

to the three vascular centers in the Zone of Interior. The main reason for this

reliance on clinical methods was that they yielded far more useful information

than other types of investigation. There were, however, other reasons. In

the beginning when the centers were first established, procurement of special

facilities and diagnostic equipment was very slow, and the patient loads were

heavy. In addition there were serious shortages in various categories of

individuals, professional and technical, able to operate the special equipment

as it became available. In fact it became necessary to institute training

program to overcome the lack of experience in management of vascular lesions

and to develop teamwork among the ever-changing personnel.

The outstanding results achieved at all the vascular centers in spite of the

initial shortages in equipment, supplies, and personnel, as well as of certain

shortages which persisted to the end of the war, demonstrated two things

clearly: (1) it is possible to provide safe and satisfactory care for patients

with vascular lesions with limited facilities and equipment for special diagnosis;

(2) given nucleus of experienced personnel, it is possible to train personnel

‘Professor of Clinical Surgery, Tulane University School of Medicine. Colonel, MC, USAR.
18 VASCULAR SURGERY IN WORLD WAR II

and to develop teamwork to meet all the essential requirements of vascular

center.

It should be mentioned, however, that the value of and need for certain

special facilities—controlled temperature and humidity rooms and minimum

of certain other equipment—were never questioned. Each center was provided with soundproof, specially insulated room built with inches of cork

block and with accoustically treated celotex on the ceiling, floor, and walls

(Fig. 1). Apparatus with automatic thermostatic controls made it possible to

regulate the temperature within these rooms at levels ranging from 40° to

110° Fahrenheit. Changes between the possible extremes of temperature

could be effected within 45 minutes and changes of 10° or less, within 15

minutes. The air, which was filtered, was kept at low humidity, usually 40

to 45 percent. Details of the provision of essential special diagnostic equipment

have been given in Chapter I.

Figure 1. View of room with temperature and humidity controls used for examination and

testing of patients with vascular injuries and diseases at vascular center of DeWitt General

Hospital.

Consideration of the various objectives of the vascular evaluation and of

their implications will make it clear why in most cases serial studies were carried

out before and after operation and why in many cases testing was an essential

part of the operative procedure. There were other reasons for the use of such

studies including the possibility of error in the first test or tests; transient
EVALUATION OF VASCULAR STATUS 19

psychic, environmental, and other influences which might affect the results; and possible improvement in, or worsening of, the patient’s condition over

period of days, weeks, or months. As rule, the diagnosis had been established

before operation was undertaken, but in an occasional instance it proved

impractical or impossible to localize the lesion accurately or to arrive at

diagnosis by indirect methods. In such cases surgical exploration was necessary for diagnostic as well as therapeutic purposes.

In this chapter the various clinical and laboratory techniques employed

in the evaluation of the vascular status of patients admitted to the vascular

centers at Ashford, Mayo, and DeWitt General Hospitals during World War II

will be described. The techniques were for the most part the same at all three

centers; any variations will be specified. An occasional method will be

described in greater detail in other chapters in this volume; however the indications for the various tests, the techniques, and the interpretation of results

will be discussed completely, though in some instances briefly, in this chapter.

Clinical Material. The types of disorders encountered in the vascular

centers were, with the exception of cold injuries, the same as those commonly

encountered in the peacetime civilian population, but with different

distribution.

With comparatively few exceptions all patients were in the age group

between 18 and 45. The younger patients far exceeded the older. An overwhelming majority were males, but as the war progressed, members of the

Army Nurse Corps and of the Women’s Army Corps were seen in increasing

numbers with various noncombat-incurred vascular disorders.

The racial distribution of patients with vascular lesions was as varied as

the racial makeup of the Army; however there were certain disproportions.

Comparatively few Negroes were seen at any of the centers and at Ashford

General Hospital, where special study was made, disproportionately large

number of Caucasians with thromboangiitis obliterans were noted to be of the

Jewish faith. Percentagewise these latter patients accounted for 35.8 percent

of those with the disease.

Trenchfoot, immersion foot, and frostbite, especially high altitude frostbite, presented problems new to most medical officers. As result, rapid formulation of diagnostic methods was necessary. Numerically, immersion foot

and frostbite were not important, but trenchfoot by reason of the overwhelming

number of cases was extremely important. On the other hand arteriosclerotic

vascular disease, frequently observed in civilian practice, furnished few problems because of the youth of most of the military personnel.

Recording Methods. Standard data concerning vascular casualties (history,

physical findings, and laboratory reports) were entered on the sheets regularly

in use in Army hospitals. In most cases special and repeated tests proved

necessary and the data thus secured were entered on special forms which had

Standardized techniques which were employed without modification will not be described in detail.
20 VASCULAR SURGERY IN WORLD WAR II

been devised at the three vascular centers. These forms were by no means

ideal but the heavy workload and the number of relatively or completely inexperienced persons who were recording the observations made shortcuts of this

sort necessary. The use of these forms assured the uniform recording of pertinent data and also simplified the tasks of review and analysis of the records

when lessening of the workload permitted these investigations. The special

forms devised for patients with trenchfoot and other cold injuries proved invaluable when the centers were suddenly called upon to test and treat large

numbers of casualties with these conditions.

In cases exhibiting vascular lesions of particular interest, photographs,

including color photographs, were employed to supplement the initial records

as well as to show the intermediate status of the patient and the final results

of treatment. Infrared photography was used to demonstrate collateral venous

channels not visible by inspection. Photographs were taken at the operating

table and specimens photographed according to the indications in special cases.

These photographs were often supplemented or replaced by illustrations drawn

by artists.

Both photographs and drawings were regarded as essential parts of the

record. They were provided as often as circumstances permitted because

physical appearances could thus be correlated with the results of various tests.

CLINICAL HISTORY

General Information

The special vascular history secured data which covered the patient’s chief

complaint, given in his own words; family history including any occurrence

of vascular disease in his forebears; previous history including any occurrence of

venereal disease, previous operations or injuries, possible exposure to excessive

cold, incidents of phlebitis or migratory thrombophlebitis, and any isolated

symptoms or manifestations of preexisting vascular disease; also his military

history including assignments in the Zone of Interior and overseas with details

of duties and experiences.

In addition, every patient with vascular injury or nontraumatic vascular

disorder was carefully questioned in order to secure chronologic, factual,

circumstantial account of its occurrence or development and to elicit symptoms

and happenings which might have possible relation to the vascular system.

The taking of this history afforded an excellent opportunity to gain some in- sight into the patient’s general attitude and characteristics. His own estimation of the disease or injury was frequently revealing, especially in regard to

his evaluation of the related degrees of disability and functional limitation.

The patient was questioned concerning the use of tobacco in the form of

cigarettes, cigars, pipe, chewing tobacco, and snuff, the amount used, and the

Vascular Surgery—Forms. HD: 730.
EVALUATION OF VASCULAR STATUS 21

duration of the habit. He was similarly questioned concerning the use of alcohol

and drugs. His dietary habits were inquired into with special emphasis on

those which might result in vitamin deficiency or general nutritional deficiency.

Specific Information

As far as was practical, data concerning the patient’s present illness or

injury were obtained in his own words, supplemented by such questioning as

might be necessary in order to obtain the essential information concerning:

1. The time and place of injury or the place and date of the onset of

symptoms.

2. The conditions or circumstances under which the injury was sustained or the symptoms first experienced. If the lesion was traumatic, special note

was made about the amount of the blood loss and whether or not infection had

followed.

3. The methods and circumstances of evacuation were elicited including

times and places, the manifestations en route, the findings so far as the patient

knew them, previous treatment, and results obtained during previous hospitalizations for the present condition.

4. All symptoms experienced. Detailed questions were asked about

those symptoms which might reflect abnormal vascular tone, vascular occlusion, or impaired vascular functional capacity. Details were also secured

upon the location, onset, duration, and severity of special symptoms and signs,

as well as on environmental conditions, activities, or other circumstances which

relieved or aggravated them.

5. Specific data concerning the character, intensity, and chronicity of

pain, as well as the circumstances under which it occurred, was aggravated,

or relieved. The occurrence of rest pain or pain following exercise was noted.

distinction was made between pain in the small muscles of the foot and pain

in the calf muscles; the experience at the vascular center of Mayo General

Hospital showed that this distinction was important in thromboangiitis.

Other symptoms and signs about which the patient was questioned if he did

not himself supply the information included coldness or abnormal warmth of

the hands and feet and other areas of the skin, excessive dryness of the skin

or excessive sweating, abnormal fatigability, numbness, tingling, burning,

anesthesia, hypesthesia, hyperesthesia, alternating warmth and coldness, cold

or heat sensitivity as distinguished from coldness or abnormal warmth, pallor,

rubor, cyanosis, edema, stiffness, vesicle-formation, desquamation, ulceration,

gangrene, loss of nails, varicosities, and symptomatic evidence of associated

nerve injuries.

6. Injuries or lesions occurring in parts of the body other than the extremities. Here different line of questioning was adopted. If an intracranial vascular lesion was suspected, such as an intracranial aneurysm or

carotid-cavernous sinus arteriovenous fistula, inquiries were made concerning
22 VASCULAR SURGERY IN WORLD WAR II

such symptoms as headache, vertigo, tinnitus, syncope, periods of unconsciousness, convulsions, motor or sensory abnormalities, nausea, and vomiting. If

an intrathoracic vascular lesion was suspected, the questioning was directed

to such symptoms as cough, expectoration, chest pain, voice changes, dysphagia,

and dyspnea. Myocardial changes, cardiac decompensation, and other cardiac

alterations were regarded as possible associated states in special types of injuries and lesions and the questioning in these cases was directed to the occurrence of palpitation, dyspnea, orthopnea, cough, and other symptoms and signs

indicative of cardiac involvement.

Emotional Status. Emotional and psychologic factors played more

important role in the military casualty than in the civilian patient. They

had to be taken into consideration in obtaining the clinical history and interpreting certain subjective reactions to physical examination such as pain,

tenderness, and claudication. Phlegmatic individuals, just as in civilian life,

tended to minimize their symptoms, while excitable or poorly adjusted patients

tended to exaggerate theirs. Intentional or unintentional distortion or

inaccurate description of symptoms was not uncommon.

Emotional factors connected with life in the Army were especially likely

to assume importance in the vasospastic group of patients. The most important

of these factors were regimentation, separation from family, fear, including

fear of return to duty, which was especially prominent in enlisted men as compared with officers, and the desire to be compensated for injuries. Judicious

questioning was necessary to elicit and evaluate these various factors. It was

also necessary to observe the patient and to consider him from the standpoint

of general appearance, attitude, off-guard behavior, and habits. These indirect observations were often of great importance in the evaluation of the

emotional and psychologic components of the vascular status. In some

instances neuropsychiatric consultation was necessary for complete evaluation

and disposition.

Repetition of Questioning. The more or less sudden changes which often

occurred in patients with vascular lesions as result of physical and other environmental influences or of emotional reactions, or as the result of rapid

regression or progression of the vascular lesion, made it necessary to question

the patient frequently concerning the status of his symptoms, the possible

appearance of new symptoms, and his own evaluation of his condition. Repeated questioning was as necessary as repetition of objective studies. It was

observed, for example, that patients with trenchfoot who had complained of

great pain, had actually manifested excessive sweating and color changes in

the affected part, and had gladly accepted litter transportation, often, shortly

after their arrival in the Zone of Interior, experienced rapid reduction of pain

and showed great improvement in other subjective manifestations. Improvement was always notable when these patients learned that it was not Army

policy to return patients with trenchfoot to duty. Failure to appreciate the

likelihood of these rapid changes and to look for them in patients with trench-
EVALUATION OF VASCULAR STATUS 23

foot and other vascular lesions could conceivably have resulted in unnecessarily

radical, actually harmful, therapeutic measures.

PHYSICAL EXAMINATION

General Considerations

Ordinary methods of physical examination were combined with special

methods which required no complicated apparatus or equipment. In the

course of routine physical examination search was made for indications of

injury to, or occlusion of, blood vessels, abnormal arteriovenous communications, abnormal vascular tone, impaired functional capacity, and trophic or

other changes. Special tests were then carried out according to the indications

of the particular case. Inspection, palpation, percussion, auscultation, and

mensuration were found to be essential phases of all such examinations. The

vascular findings were described in as much detail as time permitted and were

also indicated on special diagrams.

The initial physical examination was usually performed in ordinary environmental circumstances, in the ward, the patient’s room, or the standard

examining room. Subsequent examinations were conducted in room in which the temperature and humidity could be controlled. The temperature

was usually kept at 68° to 78° F. and the humidity at 40 percent. All examinations were carried out with the patients entirely, or almost entirely,

disrobed.

The possible effects of environmental temperature and humidity at the

initial (routine) physical examination, and of psychic and emotional influences

at all examinations, had to be taken into consideration in the interpretation

and evaluation of all findings. Another reason for repetition of physical

examinations was the possibility of rapid regression or progression of physical

manifestations of vascular lesions. This was particularly true in such types

of lesions as pulsating hematomas and aneurysms which sometimes increased

rapidly in size and consequently produced nerve damage and circulatory impairment distal to the site of the lesion.

Height and weight were recorded at the original examination, and weight

was determined as often as seemed indicated thereafter provided the patient

was not weighed at regular (usually weekly) intervals.

Vital Signs

In the absence of infection the oral temperature supplied no special information in patients with vascular injuries and lesions, but its observation formed

part of every physical examination. Pulse rate was determined in an artery

presumed free of injury or disease. Respiratory rate was recorded routinely

but seldom furnished information of much significance.

Blood pressure was also taken in some artery not directly involved in the

vascular injury or lesion and regarded as least affected by it. Determination

330323 —55
24 VASCULAR SURGERY IN WORLD WAR II

of comparative pressures proved useful method of examination in vasospastic

and obliterative vascular lesions, as well as in arteriovenous fistulas, arterial

aneurysms, and arterial occlusions which had been produced surgically. When

the extremities were fat or edematous determination of blood pressure was

often unsatisfactory and unreliable. Better results were secured in such cases

when special wide cuff was substituted for the usual sphygmomanometer cuff.

Serial determinations of the blood pressure were important as findings might

alter from time to time, sometimes from day to day. It was noted that after

the closure of large arteriovenous fistulas the blood pressure was sometimes

considerably elevated, even to hypertensive levels. Blood pressure determinations after temporary obliteration of the blood flow through an arteriovenous

fistula will be discussed later in this chapter.

Inspection

General inspection of the entire body was followed by detailed inspection

of special parts, particularly the extremities. Comparative observations were

always made on both extremities.

Inspection was directed to the following points:

1. General development and nutritional status of the body.

2. The facies, particularly for the presence of exophthalmos.

3. The poise, attitude, manner of speech, and general behavior.

4. The gait, whether normal, limping, asymmetrical, or of the heel type,

and whether there was weight-bearing on the lateral edges of the feet.

5. The respirations, whether normal, dyspneic, or orthopneic.

6. The general coloring, with special reference to pallor, cyanosis, or

mottling.

7. The distribution of hair on the toes, feet, legs, fingers, hands, and

forearms.

8. The muscular status, with special reference to atrophy or hypertrophy.

9. The skin, with special reference to vesiculation; pigmentation of abnormal degree or distribution; trophic changes, including thickening (hypertrophy) or thinning (atrophy); callus-formation; fibrosis; scleroderma; desquamation, with special reference to the degree and distribution.

10. The presence of amputations or contractures of the digits or of portions of the extremities.

11. The presence of healed or unhealed wounds, and of scars.

12. The presence of ulceration of the digits or of other areas.

13. The presence of infection and its differentiation into pyogenic and

mycotic types.

14. The presence of gangrene (moist, infected, or dry) and of lines of

demarcation and separation.

15. The condition of the nails and finger tips, with special reference to

ridge-formation, rolling, cracking, cornification, and clubbing.
EVALUATION OF VASCULAR STATUS 25

16. The presence of masses and their differentiation into pulsating and

nonpulsating types.

17. The presence of other abnormal pulsations.

18. The status of the blood vessels with special reference to visibly tortuous

arteries, collateral venous channels, and varicosities.

19. Abnormal sweating or abnormal dryness of the skin, its degree, distribution, symmetry or asymmetry, and constancy or intermittency. Special

sweating tests were carried out as indicated.

20. Edema, with special reference to location, degree, extent, and character

(whether pitting or nonpitting).

21, Color changes in the affected extremity.

Careful observation of changes of color in the extremities was of great

importance in vasospastic and obliterative arterial diseases and was occasionally

of value in the estimation of circulatory impairment in patients in whom there

had been loss of continuity of blood flow in the main arterial stems as the result

of trauma or operation. The examination called for no refined methods of

judging color but merely for careful observation of the involved extremity and

comparison with the opposite extremity. Good daylight was essential and the

preferable environmental temperature 76° Fahrenheit. Observations were

made with the patient recumbent and with the limb to be investigated placed

successively in the horizontal, dependent, and elevated positions. Note was

made of the extent and degree of cyanosis, rubor, pallor, and livedo reticularis,

and of the changes of color occasioned by return of the extremity to the horizontal position after either elevation or dependency.

In addition to the observations already listed, two possible clinical entities

were looked for: (a) phlebitis, with special reference to the location, extent,

degree of clotting, and activity or inactivity of the involved veins, and (b) migratory phlebitis, with special reference to the distribution and character of the

lesion, the presence of local pigmentation and fibrosis, and the appearance of

areas of fresh venous inflammation.

Palpation

Palpation was an indispensable method of examination in patients with

penetrating wounds. It was done with great care in the vicinity of the wounds

of entry and exit and in the area between them in order to detect possible

thrills and pulsations. When penetrating wound had been produced by

bullet, shell fragment, or other foreign body which had not made its exit, the

area between the wound of entry and the site of roentgenologic visualization

of the retained foreign body was carefully palpated. When there were multiple and widely distributed penetrating wounds, it was the usual practice to

palpate the entire body. Areas contiguous to fractures were also palpated

with special care.

Certain data secured by palpation were in confirmation of, or in extension

of, data already obtained by inspection; these particularly concerned edema,
26 VASCULAR SURGERY IN WORLD WAR II

abnormal dryness or excessive sweating, trophic changes in the skin, and the

presence of masses and abnormal pulsations. Other data obtained by palpation included:

1. Surface temperature, with particular reference to grossly detectable

deviations from the normal, including coolness or coldness, localized hot spots,

and diffusely increased heat.

2. Variations in sensation, including anesthesia, hypesthesia, hyperesthesia,

and tenderness. Tenderness in the ball of the foot was always looked for in

patients with trenchfoot, and tenderness in the calf was always investigated in

patients with suspected venous thrombosis.

3. Fixation of the skin as the result of recent or old traumatic or inflammatory processes.

4. The status of the musculature, with special reference to spasm and

atrophy. When the scalenus anticus syndrome was known or suspected to be

present, tenderness or spasm of the shoulder girdle was investigated.

5. Thrills, which indicated the presence of arteriovenous fistulas and

arterial aneurysms.

6. Venous thrombosis, which might be present in phlebitis involving the

superficial veins.

7. Varicosities not demonstrable on inspection, particularly in obese

patients or in patients with edema and cutaneous and subcutaneous fibrosis.

8. Atheromatous changes in the peripheral arteries.

9. Anatomic vascular anomalies, including absence and/or displacement

of arteries from their normal location as the result of aberrant development.

In fairly large number of apparently normal persons dorsalis pedis pulse

could not be palpated at all, while in others itwas found in anomalous locations.

In addition to generalized palpation of the whole body or of certain regions,

main arteries of both the upper and lower extremities (dorsalis pedis, posterior

tibial, popliteal, femoral, radial, brachial, and axillary) were palpated to deter- mine the degree of elasticity, the presence of arteriosclerosis, tortuosity, thrills, and the volume or amplitude of pulsation. Special attention was directed, when indicated, to other arteries such as the temporal artery.

If the radial pulse was palpated with the arm in hyperabduction, it was

borne in mind that compression of the subclavian artery may occur in some

normal persons when the arm is in this position, with resulting diminution or

obliteration of the radial pulse. It was also borne in mind that palpation of

the radial pulse during forced respiration against resistance may likewise reduce or obliterate it and that radial pulse may be absent as the result of developmental anomaly.

The degree of pulsation was recorded either as good, moderate, faint, or

absent, or on scale of to 4, indicating absent and normal. Care was

taken to indicate whether the record concerned the pulse on the right or the

left side; both were always tested.
EVALUATION OF VASCULAR STATUS 27

Percussion

Percussion was employed routinely to define the borders of the heart,

particularly for the demonstration of cardiac enlargement in patients with

arteriovenous fistulas. It was probably the least useful of the various methods

of physical examination employed in patients with vascular injury or disease.

Auscultation

Auscultation was carried out, as under ordinary circumstances, to detect

cardiac murmurs and variations in the cardiac rate and rhythm. These data

were of special importance in patients with arteriovenous fistulas This method

was also useful in searching for bruits in areas in which thrills had been palpated.

It was done routinely:

1. In patients with multiple penetrating wounds. In such cases it was

carried out, like palpation, over the entire body, especially along the course of

major arteries in search for vascular lesions manifested by the presence of

bruit.

2. In the vicinity of wounds of entry and exit and in the area between them,

or in the area between wound of entry and the site of roentgenologic visualization of retained foreign body.

3. In regions contiguous to fractures, in search for bruits which would

indicate associated vascular lesions.

The ordinary stethoscope was used at all the vascular centers. At the

DeWitt General Hospital there was used, in addition, the double stethoscope

known as the symballophone. This instrument permitted auscultation at two

separated points simultaneously.

Mensuration

Mensuration which demonstrated possible differences in the circumference

of the extremities at various levels was particularly useful in patients with

thrombophlebitis, arteriovenous fistulas, or arterial aneurysms. Comparative

measurements were always made on the contralateral limb and the method was

always used serially.

The practice differed somewhat at the three centers. At Ashford General

Hospital five measurements in the lower extremity were taken, at the midpoint

of the foot, the ankle, 18 cm. below the midpatella, at the level of the knee, and

18 cm. above the midpatella. In the upper extremity five measurements were

also taken, at the midpalm, the wrist, 10 cm. below the olecranon process, at

the cubital level, and 10 cm. above the olecranon process. These points were

marked on the extremities before mensuration was begun.

At the Mayo General Hospital Vascular Center the procedure was as

follows: The thigh was measured at point to inches above the upper border

of the patella; the leg to inches from the lower border of the patella; and the

lower leg 1.5 inches from the upper border of the internal malleolus. All

measurements were made first with the knee flexed and thenwith the extremity

lifted from the bed. The lower edge of the tape measure was placed slightly
28 VASCULAR SURGERY IN WORLD WAR II

above the guide mark and the extremity encircled at exactly the same level

all the way around.

Tests for Nerve and Muscle Status

The frequent association of other injuries with vascular injuries required

examination of the affected parts for bone, nerve, and muscle injuries which

had practically always been detected before the patients reached the vascular

centers but the sequelae of which were not always clear. Demonstration of the

sequelae of nerve injuries required testing for normal and abnormal reflexes,

areas of hypesthesia, hyperesthesia, and anesthesia, tenderness in the balls of

the feet, and atrophy of the muscles of the feet and hands. Observations

based upon active and passive movements and upon manipulation of the extremities or, in some instances, of the neck, furnished information about the

limitation of motion caused by muscle weakness resulting from nerve injury,

circulatory impairment, disuse, stiffness or ankylosis of joints, and pain resulting from movement but attributable to other causes.

The functional limitations manifested by the presence of claudication will

be discussed later in this chapter.

Ophthalmoscopy

The use of the ophthalmoscope was routine part of the general examination in patients in the upper age groups and in patients of all age groups with

intracranial aneurysms or with arteriovenous communications between the

internal carotid artery and the cavernous sinus. Examination of the retinal

vessels by this means often yielded information of considerable value.

CLINICAL LABORATORY TESTS

The majority of clinical laboratory tests were found to be of little or no

help in evaluating the status of patients with either organic or vasospastic

obliterative vascular diseases. This statement holds for the blood coagulation

time, the bleeding time, the sedimentation rate, and hematocrit determinations.

Prothrombin time determinations, while they were of no help in evaluation of

the vascular status, were essential in patients receiving dicumarol (bishydroxycoumarin) therapy. Coagulation time determinations did not reflect the anticoagulant effects of dicumarol as they did in patients receiving heparin.

Blood chemistry determinations seldom furnished significant data in the

patients seen at the vascular centers. This might have been expected as most

of them were young and healthy adults in whom abnormalities of the blood

chemistry were unlikely to be present.

The heparin tolerance test suggested by De Takats was used in limited

number of cases at the vascular center of DeWitt General Hospital but did not

yield uniformly dependable results and was considered of little clinical value.

De Takats, Q.: Heparin tolerance; test of clotting mechanism. Surg., Oynec. Obst. 77: 31-39, Jul 1943.
EVALUATION OF VASCULAR STATUS 29

SPECIAL TESTS WITHOUT INSTRUMENTS

To supplement the data obtained by ordinary methods of physical examination, certain maneuvers and tests which did not require special diagnostic

equipment were employed. One such group of tests consisted of Allen’s

blanching test, Samuels’ plantar test, the exercise test for the upper extremities, the ischemic pain test, and Homans’ dorsiflexion test.

Blanching Test (Allen)

Allen’s test, which was used when one of the main pulses in the wrist was

not easily palpable, was performed by elevating the patient’s hand above the

level of the head until blanching appeared. The radial artery was then compressed and the hand brought down. Persistency of blanching in the dependent

position was taken to mean occlusion of the ulnar artery, while prompt return

of color was taken to mean that the ulnar artery was patent. The test was

sometimes repeated after 1-percent procaine solution had been injected into

the stellate ganglion in order to eliminate possible vasospastic element.

Plantar Test (Samuels)

Samuels’ plantar test, which is an exercise test for the lower extremities,

was performed with the patient recumbent and the lower extremities elevated

at an angle of 45 degrees or more. The color of the soles was noted before and

after the limbs had been raised. The patient flexed and extended the feet with

the ankle as pivot for to minutes. If the arterial supply to the feet was

adequate, the plantar surfaces kept their normal pinkish tinge. In the presence

of arterial occlusion of even minimal degree decided pallor became apparent

usually within to minutes, though it did not necessarily involve the whole

sole; in some instances pallor was confined to the toes or the forepart of the foot.

The Samuels exercise test yielded positive results in number of patients in

whom positional color changes could not otherwise be demonstrated. It was

the general experience that the pallor produced by elevation of the extremity

in thromboangiitis and in surgical arterial occlusion was almost always accentuatedwhen this test was employed. The experience at Mayo General Hospital,

where the test was widely used, was that results were invariably negative in

Raynaud’s disease and in thrombophlebitis.

Exercise Test for the Upper Extremity

The exercise test employed for the upper extremities was the counterpart

of the Samuels’ plantar test for the lower extremities. The patient elevated his

hands with palms directed toward the observer and flexed and extended his

fingers for minutes. Blanching occurred in areas affected by arterial obstruction of any origin, while areas to which the blood supply was normal kept their

normal pinkish tinge. When stellate ganglionectomy was contemplated, this

test, following injection of the stellate ganglion with 1-percentprocaine solution,

furnished some evidence of the results to be anticipated from the operation.
30 VASCULAR SURGERY IN WORLD WAR II

Ischemic Pain Test (Schecter and Ragan)

The ischemic pain test for diagnostic use in peripheral vascular disease was

devised by Capt. Adolph A. Schecter and Maj. Charles A. Ragan in the Mediterranean Theater of Operations, when trenchfoot had become serious problem

there. With the patient recumbent, the cuff of sphygmomanometer was

placed around the leg just above the knee and the pressure within it elevated

enough to obliterate the gross arterial flow (usually 220 mm. of mercury).

Occlusion of the blood flow was continued for maximal period of minutes

during which time the patient described any unusual sensation in the limb.

After 5-minute rest period the arterial supply was again occluded for maximal period of minutes and this time the patient flexed and extended the foot

once every seconds. In this period he again described any unusual sensation.

The results of the test were considered positive if the patient complained of

pain in or around the base of the toes in the region of the metatarsal or longitudinal arch of the foot as distinguished from pain on the dorsum of the foot at

the level of the malleoli and along the anterior surface of the lower leg which is

the pain caused by exercise.

The results of this test were too variable to permit much reliance to be

placed upon it in the study of patients with vascular lesions. The time of

onset and the intensity of the pain after occlusion of the blood supply could not

be correlated definitely with other diagnostic criteria or with the actual progress

of patients with trenchfoot. Moreover, control study of normal individuals

revealed that minor sensations which they described while the test was in

progress could be interpreted as similar to, or identical with, those experienced

by patients with trenchfoot.

Another consideration which made the ischemic pain test of questionable

value was that its results depended upon the patient’s subjective interpretation

of his experience. Prolonged observation of patients with trenchfoot made it

clear that fair evaluation of their subjective complaints was most difficult.

With continuous hospitalization even slight complaints tended to become

intensified in their minds, and only men of strong character and high morale

were likely to resist the subconscious temptation to enlarge on their troubles

when they were given the opportunity offered by this test.

Dorsiflexion Test Homans)

Homans’ dorsiflexion test, which is widely used in civilian practice in the

diagnosis of thrombosis of the deep veins of the leg and foot, was also widely

used in the vascular centers. The results were regarded as positive if pain

occurred in the calf muscles when the foot was placed in dorsiflexion. Compression of the plantar portion of the foot was also practiced to determine

whether pain would be produced in it by this maneuver. In military practice

this test was often found to yield positive results in the absence of thrombosis

Ragan, C., and Schecter, A. E.: Clinical observations on early trenchfoot. M. Bull. Mediterranean Theat. Op. 3:

264-266, Jun 1945.
EVALUATION OF VASCULAR STATUS 31

if there had been trauma to the leg, particularly to the calf muscles or to the

Achilles tendon.

Other Tests

Occlusion of the direct flow of blood between the artery and vein involved

in an arteriovenous fistula, by pressure at or proximal to the fistula, gave rise

to two phenomena which were elicited as part of the special vascular examination. Branham’s (Nicoladoni’s) sign is temporary reduction in the pulse rate

following occlusion. It was present in all arteriovenous fistulas observed at the

vascular centers except for few in which the opening between the artery and

vein was extremely small. Studies at the vascular center of Ashford General

Hospital showed that this sign did not occur when atropine in appropriate

dosages was administered intravenously before digital compression was applied.

Gunderman’s sign is transient rise in the diastolic blood pressure following digital compression of the artery. The systolic blood pressure is either

unaltered or only slightly elevated. This sign was present in all the arteriovenous fistulas observed at the vascular centers unless the opening between

the artery and the vein was unusually small.

TESTS OF THE COLLATERAL CIRCULATION

The extent and adequacy of the collateral circulation was matter of

great significance in the diagnosis, management, and prognosis of vascular

lesions. It was determined by variety of tests and observations including

Delbet’s test, observation of the effect of prolonged compression of the artery

involved in an aneurysm or arteriovenous fistula, reactive hyperemia tests,

the claudication time test, and the reflex vasodilatation test. number of

other clinical tests were introduced at the vascular centers but proved unreliable

and were not widely employed. Additional studies of the collateral circulation

were made by special methods such as arteriography and determinations of

intravascular pressure during operation. These methods will be described

later in this chapter under appropriate headings.

The safety of an operative procedure, predicated on preoperative studies

which indicated the existence of an adequate collateral circulation, was based

on the premise that no important collateral vessels would be sacrificed during

operation. If this condition was not met, disaster was likely to follow.

De/bef's Sign

Delbet’s sign is the clinical evidence of adequate circulation distal to an

aneurysm, even in the absence of distal arterial pulsations in the part. When

this sign was present the collateral circulation could be assumed to be good.

Its presence was of particular value in aneurysms. It was repeatedly observed,

even when the arterial pulses had disappeared distal to the lesion, that if good

circulation had been maintained in the limb, ligation of major artery was

unlikely to be followed by any ischemic difficulties.

Delbet, P.: Extirpation d’un anevrisme poplite; guSrison. Bull, et into. Soc. de chir. de Paris 35: 865-870, 1909.
32 VASCULAR SURGERY IN WORLD WAR II

In some cases observed at the vascular centers Delbet’s sign was not

present originally but appeared after sympathetic block or sympathectomy

had been performed. It was often present in high subcutaneous ruptured

aneurysms in which other tests for the collateral circulation could not be

satisfactorily performed because of the great size of the aneurysm or because

tenderness and pain on pressure precluded compression of the artery.

Occlusive Compression Test

Another useful test of the adequacy of the collateral circulation was

observation of the color and warmth of the hand or foot during prolonged

occlusive compression of an aneurysm. If the part remained warm and of

good color, good collateral circulation could be assumed. The position of the

extremity during the period of occlusion was important in the evaluation of

the circulatory status. It was considered necessary to assay the circulatory

status of the hand or foot in positions other than the horizontal one. Marked

pallor has been found to occur when the extremity was elevated, although both

color and warmth would remain normal in the horizontal position during periods of compression lasting as long as 30 minutes.

When ligation of the internal carotid artery had to be performed for

cavernous sinus-internal carotid fistulas or similar lesions, it was customary

to determine by means of mechanical compressor (Fig. 2) whether the patient

could tolerate compression of the carotid vessels, eventually for as long as

30 minutes, without symptoms. One of the chief drawbacks to the satisfactory

performance of this test was the difficulty of maintaining precise and complete

compression of an aneurysmal lesion over prolonged period of time. With

mechanical compressors it is often impossible to maintain exact occlusion of

Figure 2. Mechanical compressor for carotid artery.
EVALUATION OF VASCULAR STATUS 33

the desired portion of the artery for long period and with digital compression

the fingers soon become exhausted.

Claudication Time Test

The distance that patient with peripheral vascular disease was able to

walk before the onset of annoying or incapacitating claudication proved practical criterion of the competency of the circulation. This very simple test

could be employed not only as an index of the patient’s functional vascular

capacity but also as means of weighing the possible effectiveness of various

therapeutic regimens including general measures, drug therapy, sympathetic

block, and surgical procedures performed directly on the blood vessels. The

test also proved useful after treatment, partly to determine results in the

individual patient and partly for the group evaluation of various methods of

management. By this means, for instance, it was possible to weigh the relative

merits of quadruple ligation and excision in arteriovenous fistulas against those

of restorative procedures of one kind or another.

In patients who suffered from claudication, sympathetic block with procaine hydrochloride was useful and dependable means of determining before

operation the improvement to be expected in this symptom from sympathectomy. The effect of reflex dilatation on the claudication time was also studied

as an index to the element of vasospasm present and the expected results of

sympathectomy.

Reactive Hyperemia Test

The combination of observation of Delbet’s sign, prolonged occlusive

compression of the blood supply, and the reactive hyperemia test proved

generally safe and satisfactory method of determining the adequacy of the blood

supply of the part before operation. The reactive hyperemia test, which was

introduced by Moschcowitz in 1907 to determine the safe level for amputation

in gangrene of the extremities, was proposed as method of estimating the

efficiency of the collateral circulation by Matas in 1910 and has been widely

used for this purpose ever since. In the vascular centers it proved particularly

useful in instances of arterial aneurysms and arteriovenous fistulas in which

surgical correction was contemplated.

In the performance of the test two observers always participated to be

certain that the blood flow through the aneurysm or fistula had been successfully checked and to facilitate observations on color changes in the extremity.

The reactive hyperemia test was performed as follows: With the patient

recumbent, the limb to be tested was elevated after which as much blood as

possible was drained out of it. If the lesion was in the lower extremity, this

was accomplished by applying digital pressure on the dorsal and plantar surMoschcowitz, L.: Die Diagnose des Arterienverschlusses bei Qangraena pedis. Mitt. a. d. Orenzgeb. d. Med. u.

Chir. 17 216-228, 1907.

Matas, R.: Some of the problems related to the surgery of the vascularsystem; testing the efficiency of the collateral

circulation as preliminary to the occlusion of the great surgicalarteries. Tr. Am. S. A. 28: 4-54,1910; also in Ann. Surg.

53: 1-43, Jan 1911.
34 VASCULAR SURGERY IN WORLD WAR II

faces backward toward the heel and up toward the ankle. If the lesion was in

the upper extremity, the hand could be thoroughly blanched by asking the

patient to make tight fist, or by milking the blood from the fingers and hand

by the same procedure employed in the foot. The milking maneuver was continued until adequate blanching had been obtained.

blood pressure cuff, which had previously been applied about the limb

distal to the aneurysm or fistula, was then quickly inflated to pressure of 200

to 220 mm. of mercury and complete interruption of the arterial inflow below

this level achieved. The hand or foot, which by now was extremely pale, was

lowered to comfortable horizontal position. Before the test the most distal

point at which digital compression of the artery completely stilled the aneurysm

or fistula had been determined. This was indicated by absence of pulsation,

thrill, and bruit. Four minutes after inflation of the blood pressure cuff, digital

pressure was applied to this predetermined area and was maintained for

minutes during which the absence of pulsation and thrill was checked by palpation and the absence of bruit by auscultation. One minute after digital

pressure had been applied (that is, minutes after occlusive pressure had been

produced by means of blood pressure cuff), the cuff was suddenly deflated and

the rapidity, completeness, and intensity of the resulting flush were observed

and recorded in seconds. The time interval which elapsed before hyperemia

began in the most distal portion of the extremity, that is in the digits which it

reached last, was recorded and the number of seconds which elapsed before it

became complete in extent and in intensity was also recorded. After digital

pressure was released, it was noted whether any further improvement occurred

in the completeness or intensity of the hyperemia. If full and complete hyperemia occurred in less than minutes, the collateral circulation was regarded as

adequate.

The basal conditions under which the reactive hyperemia test was performed, as well as the precise technique, were matters of considerable importance. Reactive hyperemia was always more pronounced when the limb to be

tested was in state of vasodilatation rather than of vasoconstriction. In the

absence of sympathetic denervation, limbs which were the site of aneurysms

or arteriovenous fistulas were, like normal limbs, capable of wide variation

in vascular tonus. On the other hand, in deciding at the vascular centers

whether the test should be performed under conditions conducive to vasodilatation or vasoconstriction, it was concluded that the initial test should be performed in circumstances which would induce neither vasodilatation nor vasoconstriction, for the practical reasons that the patient was destined to live in an

ordinary environment after the test and that constant maintenance of vasodilatation could not be assured unless sympathectomy was performed.

Although Matas had determined that the reactive hyperemia test could

be carried out with blood pressure cuff, he believed that an Esmarch bandage

was preferable because it brought about more complete deprivation of blood

and therefore more intense reaction. In the vascular centers, however,
EVALUATION OF VASCULAR STATUS 35

compression by the Esmarch bandage was reserved for those unusual cases

in which adequate blanching of the limb could not otherwise be achieved, and

even in these instances it was used only to milk the blood out of the limb;

obstruction of the blood flow was maintained by means of the blood pressure cuff.

Digital rather than mechanical compression of the artery was preferred

because more accurate occlusion could be achieved with less hazard of compressing adjacent or collateral vessels at the same time. Much emphasis was

placed upon complete compression of the lesion. If this was not achieved and

some blood still flowed through the compressed vessels, faulty deductions concerning the efficacy of the collateral circulation were likely to be made with

disastrous consequences.

The site of compression of the artery was selected with great care since the

most distal point at which digital occlusion produced cessation of pulsation,

thrill, and bruit was taken to represent that portion of the artery which opened

into the aneurysmal sac or communicated with the vein or sac in instances of

arteriovenous fistulas. This was therefore the point at which, unless reparative procedure could be performed, it would be necessary to ligate the artery.

Compression of the artery at some point proximal to the optimum point,

though it might bring about cessation of pulsation, thrill, and bruit, could

give rise to misleading conclusions. On the one hand, it might occlude the

blood flow through collateral vessels which would be preserved if operative

ligation proved necessary; the test would therefore demonstrate less adequate

collateral circulation than actually existed. On the other hand, compression

proximal to the aneurysm might leave open collateral channels which it might

be necessary to sacrifice at operation; the test would therefore suggest that the

collateral circulation was better than was actually the case. In one instance the

misinterpretation apparently arose chiefly from transmission of pressure to the

laminated thrombus in saccular aneurysm. Incorrect interpretation might

also result when the collateral channels were so located that the

could not be stilled by pressure without direct compression of these vessels also.

Misleading or actually erroneous concepts could be derived from the

reactive hyperemia test if an uninvolved main arterial stem was compressed

together with minor artery which was the site of the lesion. Even under

these circumstances, however, it was sometimes possible to locate the lesion

definitely and to demonstrate that pulsation, thrill, and bruit could be eliminated while at the same time the blood flow in the main arterial stems remained

unaffected. When this could be demonstrated there was little need for anxiety

concerning the nutrition of the part after excision of the lesion.

It was sometimes possible, in patient who presumably had an axillary

aneurysm or arteriovenous fistula, to demonstrate that the lesion actually

involved the thoracoacromial trunk, the subscapular vessels, or other branches.

However, in single instance the lesion involved not only minor branch but

also the main artery. The patient, observed at the vascular center of Mayo

General Hospital, was 41-year-old soldier who had an arteriovenous fistula
36 VASCULAR SURGERY IN WORLD WAR II

of months duration which was thought to involve one of the circumflex humeral

vessels. Bruit and thrill could be eliminated by direct pressure without disturbing the brachial pulse. During operation it was found, as had been thought,

that the anterior circumflex humeral artery and vein communicated through

small sac, but it was also found, as had not been suspected, that the superior

portion of the axillary artery opened into this sac through large fistula.

The confusion arose because it had been possible to compress the sac in such

manner that the openings from the two arteries and the vein were occluded

while the axillary artery itself was left patent. Ligation was required because

the damage to the axillary artery was too extensive to permit repair. Consequently, the efficacy of the collateral circulation had to be confirmed during

the operation by observing the color and warmth of the hand during prolonged

temporary occlusion of the axillary artery with rubber-shod clamp.

The reactive hyperemia test was frequently performed serially before and

after induction of reflex vasodilatation, or before and after sympathetic block

or sympathectomy. It was by no means uncommon for test which had

indicated inadequate circulation before one or the other of these procedures, to

indicate an adequate circulation after removal of the vasoconstrictor influence.

Miscellaneous Tests of the Collateral Circulation

The tests already described were those chiefly used to test the adequacy

of the collateral circulation in the presence of vascular lesions. Two other

tests were tried out but were not found sufficiently useful to warrant their

continued use. The first was performed by milking the blood from the subpapillary venous plexus by compressing the arterial lesion while rolling snugly

fitting rubber band from the tip of digit to its base, then noting the time

required for return of color after release of the constricting band. Results

were not uniformly in accord with the time components of the reactive hyperemia test.

Another test in this category was performed by simultaneous digital

pressure upon the arterial lesion and on some area on finger or toe. The

time in seconds required for the return of color was compared with the time

required for the return of color in the same digital area in the contralateral

limb. The test was also carried out without compression of the arterial lesion.

The results of this test, like those of the preceding, were not uniformly in accord

with the time components of the reactive hyperemia test.

TESTS OF VENOUS FILLING TIME

The simple venous filling test proved of considerable value in demonstrating

the rate of circulation in an extremity. It was performed by first elevating

the extremity to collapse the veins, then replacing it in the dependent position

and noting in seconds the time required to fill the veins on the dorsum of the
EVALUATION OF VASCULAR STATUS 37

hand or foot. Periods up to 10 seconds were considered within the normal

range.

However, unreliable results were obtained from this test when vasospasm

was present since arterial inflow is slow under these circumstances. Moreover,

the results did not distinguish between reduction of blood flow caused by organic arterial involvement and that caused by vasospasm. In order to obtain

this differentiation it was necessary to perform the test after injecting 1-percent

procaine solution into the appropriate sympathetic ganglia, supplemental

procedure which also furnished useful data concerning the results to be expected

from sympathectomy.

The modification of the simple venous filling time test devised by Tuffier

and Hallion in 1912 was particularly intended for use in aneurysms and arteriovenous fistulas. As the test was performed at the vascular centers the limb

was elevated 30 degrees above horizontal and kept in that position until the

veins were well emptied. The aneurysm or arteriovenous fistula was then

occluded by digital pressure and blood pressure cuff, previously placed about

the limb distal to the lesion, was inflated to pressure of 60 mm. of mercury

after which the limb was lowered to the horizontal position. If the veins filled

within 30 to 60 seconds the collateral circulation was regarded as adequate.

Experience at the vascular centers revealed certain defects in this test.

When edema or venous stasis was part of the picture the results were likely to

be unreliable. If the veins did not fill well, as frequently happened when

vasospasm was marked, an accurate estimation of the venous filling time was

impossible. Finally, in some patients, particularly those with large arteriovenous fistulas, venous filling sometimes occurred as soon as the fistula was

compressed even though the limb was elevated.

test to determine the adequacy of the circulation in the fingers or toes

(subpapillary venous filling time) was carried out by making firm digital pressure

against the ball of the digit for about minutes to empty the blood from the

subpapillary venous plexuses. Pressure was then released and the time required for the area to flush was recorded as immediate or normal, slightly or

moderately delayed, and markedly delayed.

TESTS FOR SPECIAL CONDITIONS

Varicosities. All the tests employed in Army hospitals to determine the

competency of venous valves and the patency of superficial or deep veins are

well known and have been extensively used for many years. No new or significant data resulted from their use during World War II. The tests most

commonly employed were the Perthes test, the Trendelenburg or BrodieTrendelenburg test, and the Ochsner-Mahorner comparative tourniquet tests.

At the vascular center of Mayo General Hospital it was thought that simple

Tuffier and Hallion: Sur un precede permettant de prevoir que 1’irrigationsanguine persistera dans un membre

apres ligature de son artere principale. Compt.rend. Soc. de biol. 73: 608, Dec 1912.
38 VASCULAR SURGERY IN WORLD WAR II

observation of venous filling with the tourniquet at various levels of the extremity was more helpful than any other method in determining the site of vascular

incompetency in patients with varicose veins.

Scalenus Anticus Syndrome. The scalenus anticus test was used to study

the effect upon the subclavian artery of an abnormally small compartment

formed by the scalenus anticus muscle and the first rib. Results of this test

were regarded as positive if diminution of radial arterial pulsation could be

demonstrated while the patient turned his head toward the unaffected side

with the chin extended upward. Another test consisted of pulling upward

against weight held in the hand on the affected side in an attempt to extend

the arm tensely upward. Diminution of the pulsation of the radial pulse could

be demonstrated in this test also. Sole reliance was not placed upon palpation

of the pulse or the appearance of the extremity; cuff was placed over the

brachial artery before the test was begun, and additional comparative data

secured by means of an oscillometer while it was in progress. In patients with

the scalenus anticus syndrome significant tenderness or spasm could sometimes

be revealed by simple palpation of the muscle.

Procaine hydrochloride solution was injected into the scalenus anticus

muscle in order to confirm the tentative diagnosis of scalenus anticus syndrome

and to ascertain the possible effects of scalenotomy. If relief of subjective

and objective symptoms followed the injection, the diagnosis was regarded

as established and it was concluded that scalenotomy would be beneficial.

Before the solution was injected, the patient was placed in recumbent position with the head turned to the unaffected side. The scalenus anticus muscle was identified by palpation behind and lateral to the sternomastoid

muscle. While the index finger of the left hand palpated the lateral border of the muscle, needle was inserted into the lateral edge and the muscle was

infiltrated with 1-percent procaine solution throughout the lower half, care

being taken not to infiltrate the phrenic nerve or brachial plexus. Within

to 10 minutes it was usual to find the muscle completely relaxed and the

patient temporarily relieved of his symptoms.

Axillary Vein Thrombosis. The objective of tests for axillary vein

thrombosis was to demonstrate interference with the return flow of blood from

the arm. One very simple test was to observe whether or not the veins collapsed when the patient elevated the affected arm. If thrombosis was present

they did not collapse. In another test the patient opened and closed the hands in pumping motion while the arms were dependent. If thrombosis

was present the superficial veins of the forearm became overdistended on the

thrombosed side, while on the normal side distention did not occur.

SKIN TEMPERATURE DETERMINATIONS

Since sweating or moisture alters the results of skin temperature readings,

all such determinations at the vascular centers were made in rooms in which
EVALUATION OF VASCULAR STATUS 39

temperature and humidity were controllable. The room temperature was

kept between 68° and 78° F. and the humidity at 40 percent for basal tests.

Readings were made only after the patients had been exposed to this environment for 30 minutes.

Skin temperature determinations were chiefly of value in supplying an

objective recording of the actual temperature of part. They were seldom

required for mere diagnosis though they were both valuable and necessary in

such difficult diagnostic problems as the determination of possible differences in the mechanism of circulatory disturbances in one extremity as compared

to the contralateral one, or in one digit as compared to others. They were

also useful in cases in which it was necessary to determine whether the disorder

was purely obliterative, had vasospastic element, or was entirely vasospastic.

Several types of skin temperature meters were in use at the vascular

centers. Although all were probably equally efficient, preference as to type

varied from center to center.

The skin temperature of certain points on the body was taken routinely

in addition to the temperature of whatever special areas might be implicated in

the individual patient. The areas tested in the lower extremity were the

dorsum of the terminal phalangeal area of each toe, the middorsal area, the

midplantar surface, the heel, the intermalleolar region, the ankle, the midleg,

the knee, and the midthigh. In the upper extremity the test points were the

distal phalangeal portion of each finger, the midpalm, the middorsum, the

wrist anteriorly, the midforearm anteriorly, the medial aspect of the elbow,

and the midportion of the upper arm anteriorly. chart indicating each of

these points was posted in the controlled temperature rooms to assure uniformity

in the skin temperature determinations. Even minute variations in the points

at which control and subsequent determinations were made might affect

the results. For this reason it was customary to mark with ink or dye the

exact points at which initial readings were made so that subsequent readings

could be made at precisely the same points. When this precaution was not

observed, errors of as much as several degrees Fahrenheit sometimes occurred.

The opinion was that such variations might possibly be accounted for by the

presence of sizable intracutaneous capillaries at one point and not at another,

even though the points of reading might not be more than millimeter apart.

Psychogenic factors such as nervous tension, excitement, and noise, were

found to have decided influence on skin temperature readings. Every

effort was therefore made to reassure the patient and put him at ease. All

controlled temperature rooms in which tests were made were soundproof.

Repeated determinations were made in cases in which the initial readings

were thought to be inaccurate for any of the reasons listed. Successive

temperature determinations were also made in some cases to study the effect

of changes in the room temperature (Chart 1).

330323 0—55
40 VASCULAR SURGERY IN WORLD WAR II

Chart 1. Graphic recording of skin temperature determinations in relation to changes in room

temperature.

OSCILLOMETRY

Oscillometric studies were carried out with various instruments such as

the Collins nonrecording oscillometer, the Samuels pulsimeter, and the Boullitte,

Pechon, and Tycos instruments.

When the manual nonrecording method was used, the cuff of the oscillometer was inflated until the pulse in the extremity was completely obliterated.

At this point readings were taken at 10-mm.levels until pressure was reached.

In the lower extremity readings were made in the foot, above the ankle, in the

leg, at the popliteal level, and at the midthigh. In the upper extremity

readings were taken at the wrist, in the forearm, and in the arm. The maximum

oscillation and the level in millimeters at which it was observed were recorded

as the oscillometric index (for example, 7.5 oscillation at 100 mm. was

recorded as 7.5/100).

When the recording oscillometer was used, record was made of oscillations

from the level of the pressure at which obliteration of the artery occurred to

0. Readings were in millimeters of mercury. The curves recorded were

studied for amplitude and character.
EVALUATION OF VASCULAR STATUS 41

The opinion was expressed at all three vascular centers that while the

oscillometer was of some value in the diagnosis of vascular lesions it was neither

too reliable nor too useful. The following general observations were made;

1. Most of the patients who had been referred to the vascular centers

merely because no dorsalis pedis pulse could be felt on either side in the usual

location were found to have better than normal oscillometric readings across

the feet. It was the impression that in these patients the lack of detectable

dorsalis pedis pulses could be explained by developmental absence of an

anomalous position of the artery.

2. The oscillometer, while seldom necessary for the establishment of

diagnosis or for the evaluation of treatment, was useful in providing an objective

recording of the volume of the larger peripheral pulsations and in an occasional

difficult diagnostic problem. It was sometimes of value in demonstrating

whether obliteration had occurred in large arterial stem, especially when

there were palpable peripheral pulses in the involved limb. This was true in spite of the instrumental lag or error inherent in the test.

3. The oscillometer recorded only gross pulsations as compared with the

plethysmographic record which indicated quick pulse volume changes as small

as 0.1 cu. mm., or more gradual changes as great as 800 cubic millimeters.

4. The oscillometer was found to give misleading information in arteriosclerosis, and to lesser degree in thromboangiitis, in that oscillations were

sometimes found to be small or absent even when there was fair or good

arteriolar and capillary circulation. The explanation is obvious: The oscillometer does not depict the circulation in the smaller vessels. Oscillometric

readings alone, therefore, could not be accepted as an index of circulatory

adequacy but had to be interpreted in the light of other observations.

5. Oscillometric studies of patients with thromboangiitis obliterans frequently proved interesting because they revealed consistent asymmetry of the

oscillations of the contralateral limb even when the readings on the poorer side

were still within normal limits. This was observed consistently enough to be

accepted as sign in thromboangiitis obliterans. Patients with clinical evidence of migratory thrombophlebitis, but without symptoms of arterial incapacity, also usually presented early asymmetry of oscillations.

6. Oscillometric readings frequently were within the normal limits in

patients with trenchfoot and Raynaud’s disease.

7. In number of cases of thromboangiitis obliterans, oscillometric read

ings were normal even when there were clear-cut signs of impaired circulation

in the toes, such as trophic and color changes. It was believed that in these

cases the disease had affected only the smaller vessels. In other patients

oscillations ere reduced in the absence of color changes, while the results of

such tests as the reactive hyperemia test and the reflex vasodilatation test

showed that the circulation was still normal. In these cases it was thought that

occlusion of large vessel had occurred but that adequate circulation was being

maintained through collateral vessels.
42 VASCULAR SURGERY IN WORLD WAR II

SWEATING TESTS

Various tests were employed for the accurate demarcation of areas in

which sweating did not occur or was excessive. They were most frequently

used in hyperhidrosis, including the variety associated with trenchfoot, but

they were also useful in any other condition in which abnormalities of sweating

were apparent. They were employed for diagnostic purposes to determine the

possible effects of sympathectomy, and as an index of the patient’s progress.

The starch-iodine test was most useful.

VENOUS PRESSURE DETERMINATIONS

Venous pressure determinations were made in an extensive series of cases

at the vascular center of DeWitt General Hospital but furnished no important

information except in an occasional case of arteriovenous fistula or arterial

aneurysm which was causing pressure on an adjacent vein, or in an occasional

case of venous obstruction resulting from either thrombosis or surgical ligation.

These determinations were thought to be particularly significant in cases of

suspected superior vena cava thrombosis and axillary vein thrombosis.

The only equipment necessary was venous pressure manometer. Observations were made during rest and during or immediately following exercise.

Determinations on patients with thrombophlebitis were sometimes normal in

the resting stage while repetition of the test during or after exercise confirmed

the suspected obliteration of the veins. In such cases the venous pressure rose

above and did not return to the control level for to minutes.

At Ashford General Hospital venous pressure determinations were made in

some cases by direct mensuration at the site of an arteriovenous fistula by the

introduction of ureteral catheter through an appropriate vein in the region

of the fistula.

DETERMINATION OF THE CIRCULATION TIME

Measurements of the circulation time were made through the introduction of foreign substance into the blood stream at one point and subjective or

objective perception of the time of its arrival at another point. At the DeWitt

General Hospital equipment was supplied for the determination of the circulation time by the photoelectric-methylene blue method, but it was concluded

that the information supplied by this, as well as by other methods, was not of

much practical value.

BLOOD VOLUME DETERMINATIONS

Blood volume determinations were frequently made before and after

operation, particularly in patients with arteriovenous fistulas. These studies

confirmed earlier observations to the effect that there is an increase in the

blood volume in response to the presence of an arteriovenous fistula and
EVALUATION OF VASCULAR STATUS 43

return to the normal level following obliteration of the communication. Special studies with the dye dilution method and with the ballistocardiograph

were made at the Ashford General Hospital and are reported in full in ChapterV.

SKIN RESISTANCE DETERMINATIONS

Determinations of the skin resistance were made in limited number of

cases by means of portable cutaneous resistance recorder or dermometer.

Although this method proved of no practical value in the evaluation of the

vascular status of patients with vascular injuries or disease, it did provide

significant data concerning the influence of the sympathetic nerves on the

vascular system and the possible effectiveness of sympathetic nerve block

and sympathectomy. It was also useful in cases in which there was associated

loss of sensory nerve supply to an extremity.

PLETHYSMOGRAPHY

It was intended that each of the vascular centers would be supplied with

plethysmographs, but these instruments did not reach the point of production

and distribution before the end of the war. Although the vascular centers at

Ashford and Mayo were able to acquire this instrument, the center at DeWitt,

to which the author (A. H. S.) was assigned, was without one during the entire

period of its operation. This was unfortunate for while no patient suffered

because the instrument was lacking, investigation of the vascular status of

many patients would have been expedited had it been available.

This instrument is capable of recording with great quantitative accuracy

volume changes in the part under investigation caused by variations in the

blood within the small arteries and the arterioles, venules, and capillaries, as

well as changes in the intercellular and extracellular fluid and lymph. Plethysmographic recordings reveal with greater accuracy than any other method the

differentiation between vasospastic phenomena and phenomena caused by

organic occlusive disease, the degree of arterial patency or occlusion, the state

of the collateral circulation, and the benefits to be expected from sympathectomy (the latter evaluation being made from observation of the changes produced by sympathetic procaine block).

Plethysmographic studies are reliable only if the test is made under

standard conditions. The relative height of the part under investigation

greatly influences both the magnitude and the character of volume deflections.

All examinations are therefore made with the part in question at heart level.

In the recumbent position the toes are essentially at this level, and the fingers

are so supported during the test that they are also at this level. The extremity cups must not touch each other since if they do artefacts will occur.

The patient must be comfortable for any discomfort will result in tremors and

other movements which will be recorded as artefacts. The maximum amount

of mental relaxation is essential because psychic disturbances are always

reflected in the vascular response. For this reason noise, haste, excitement.
44 VASCULAR SURGERY IN WORLD WAR II

and even the sight of the instrument should be guarded against and the examination should be made under optimum conditions to produce relaxation.

These conditions include indirect lighting, comfortable room temperature,

ordinary room furnishings, and calm and confidence on the part of the examiner. If plethysmographic studies are done under any other circumstances,

they must be interpreted in the light of the environment.

WHEAL TESTS

The intradermal saline test was employed in number of cases in an

endeavor to determine the adequacy of the collateral circulation in patients

with vascular injuries and disease, but it did not prove practical. In this

test, if the circulation is good, the wheal should persist for nearly an hour but

accurate compression of an artery for this period of time is almost impossible.

The histamine wheal test, which was also devised to estimate the efficiency

of the collateral circulation, was not highly regarded at the vascular centers

for it revealed nothing which could not be determined equally well by other

means, and sloughs of tissue at the site of the injection, sometimes accompanied by ulceration, contraindicated its general use. After the aneurysm or

the vessels involved in an arteriovenous fistula had been occluded by digital

compression, drop of 1:1,000 solution of histamine phosphate was placed on

the skin of the affected extremity and the area was needled through the drop

until wheal developed. If the collateral circulation was good, the wheal

was apparent in to minutes. It was thought that the prompt occurrence

of flare prior to the development of the wheal was as important as the latter

phenomenon.

FluorescinWheal Test

method for determining the adequacy of the collateral circulation by

means of fluorescin wheal testing was employed with considerable satisfaction

at the DeWitt General Hospital by Capt. Theodore B. Massed. It was

based on the similar test developed by Neller and Schmidt 10 to determine the

safe level for amputation in limbs which were the site of impending or early

gangrene. These observers found that when fluorescin was injected into the

veins, sites of minute trauma in an area in which the peripheral circulation was

not severely impaired would display brilliant fluorescence, but that no fluorescence would appear if the circulation was inadequate to supply the normal

metabolic needs of the tissues. They further found that the area offluorescence

corresponded to the wheal component of triple response to injury as described

by Lewis. 11

Massell, T. B.: The fluorescin wheal test for collateral circulation in the preoperative evaluation of patients with

aneurysms and arteriovenous fistulas. Surgery 21: 636-645, May 1947. 10 Neller, J. L., and Schmidt, E. R.: Wheal-fluorescence; new method of evaluating peripheral vascular diseases;

preliminary report. Ann. Surg. 121: 328-337, Mar 1945. 11 Lewis, Thomas: Vascular Disorders of the Limbs Described for Practitioners and Students. New York, The

Macmillan Company, 1936.
EVALUATION OF VASCULAR STATUS 45

This method was used at the DeWitt General Hospital in small series of

cases to study the vascularity of granulating wounds, particularly in cases of

trenchfoot in which there had been spontaneous or surgical amputation of the

toes with subsequent granulation of wound surfaces. It was hoped that observations by this method might indicate the degree of vascularization of the granulating tissue more decisively than simple clinical observation, and would thus

serve as an index of the optimum time for skin grafting. In the 55 cases in which this method was used to determine the adequacy of the collateral circulation in aneurysms and arteriovenous fistulas, the results were found to be

reliable. They so closely paralleled clinical impressions gained by simple

inspection, however, that the time and trouble necessary to perform the

fluorescin test were not considered justified.

The following conclusions concerning this test were reached at the vascular

center of DeWitt General Hospital:

Wheal fluorescence provides delineation of the end-point of adequate

circulation. Comparison is usually possible with the opposite normal extremity

so that control criterion is constantly provided. Movement of the extremity

is not necessary during the test and as result there is little danger that the

compressor may slip and erroneous conclusions concerning the collateral circulation be drawn.

Three defects exist in the test which are, however, also present in the reactive hyperemia test: 1, It has limited use in cases in which the compressor cannot be tolerated

for anatomic reasons, or in cases in which sensory nerve is involved in scar

tissue at the site of the lesion and compression cannot be tolerated.

2. The compressor may occlude an important collateral branch in the

immediate vicinity of the aneurysm.

3. It does not indicate how much activity patient may enjoy following

arterial ligation. Although the collateral circulation may be sufficient to

prevent gangrene, ligation of major artery often results in marked limitation

of exercise tolerance because of weakness in an upper extremity or intermittent

claudication in lower extremity. The experience at the vascular center of

DeWitt General Hospital suggested, however, that claudication was likely to

be more severe in patients whose circulation, by the fluorescin wheal test, was

barely adequate rather than good.

TESTS OF VASOMOTOR TONE AND LABILITY OR REACTIVITY

The frequent need for differentiation of vasospastic from obliterative

vascular lesions, as well as the need for demonstration of vasospastic element

associated with organic obliterative lesions, required extensive employment at

the vasular centers of various methods of testing for the degree of vascular tone

and vasomotor lability. Tests most frequently used for this purpose were

the reflex vasodilatation test, the basal vascular tone test, immersion of the
46 VASCULAR SURGERY IN WORLD WAR II

hands or feet in ice water, Kerr’s trigger reflex test, the cold shower test, and

general body cooling test. The specialized technical procedures used for the

same purpose, including spinal analgesia, sympathetic block, and peripheral

nerve block, are discussed later in this chapter under the heading “Nerve

Conduction Interruption Tests.”

The reflex vasodilatation test employed extensively at all centers in both

vasospastic and obliterative vascular lesions was carried out as follows: The

patient was placed in controlled temperature room in which the temperature

was maintained from 68° to 72° Fahrenheit. The distal portion of the extremity to be studied was exposed to this temperature for at least 20 minutes,

following which skin temperature determinations were made. Seven or eight

hot water bags, filled with water as hot as could be tolerated, were then placed

in the axillae and about the abdomen and the patient was wrapped in blankets

except for the extremity being studied which was left exposed to the environmental temperature. When it was more convenient portable body baker was

used in place of the hot water bags and blankets. As soon as profuse sweating

became evident, skin temperature determinations were made, and repeated

at 20-minute intervals for at least an hour and half.

In the normal person there was rise of temperature in the digits to between

87.80° and 95° Fahrenheit. This type of response, associated with reduced

oscillometric readings, was interpreted to mean that the collateral circulation

was good. In the patient with occlusive vascular disease the temperature rise

in the digits after body heating was usually only slightly above control initial

levels.

The degree of reflex vasodilatation was also useful for studying relief of

rest pain and increase in functional capacity as evidenced by lessening of claudication. modification of this method was employed to test the reactivity

to heat and cold. The patient was conditioned for 30 minutes in controlled

temperature room at 75° F. with the humidity kept at minimum saturation.

Initial observations of the skin surface temperatures of the upper and lower

extremities, together with oscillometric observations, were made for control

purposes. The room temperature was then lowered to 65° F. and the patient

kept in this environment for 45 minutes. Additional observations of the skin

surface temperatures and additional oscillometric studies were made at this

time, and repeated after the temperature of the room had been elevated to

85° F. and the patient exposed to this environment for 45 to 60 minutes.

Curves were plotted to show graphically the response to environmental changes.

In still another method of testing, the patient was first placed in controlled temperature room in which temperature was maintained between 68°

and 71° F. with the distal portion of the extremity to be studied exposed to the

room environment. At the end of 30 minutes, control skin temperature readings

were obtained. The patient was then taken into cold room (usually large

icebox used for the storage of food) in which the temperature varied between
EVALUATION OF VASCULAR STATUS 47

32° and 14° Fahrenheit. He was accompanied by an observer who recorded

changes in the appearance of the digits and any symptoms which might develop.

At the end of 15 to 20 minutes he was returned to the controlled temperature

room where skin temperature readings were repeated.

The precipitation of digital syncope and other symptoms by immersion

of the hands or feet in ice water was attempted in patients with Raynaud’s

disease or other vasospastic conditions. Many patients, however, in whom

digital syncope occurred when they went out of doors on cool day failed to

exhibit demarcated pallor following immersion of the affected part in ice

water. This experience, which occurred at all the vascular centers, was contrary to what was expected and was never satisfactorily explained. It meant,

however, that other methods of inducing digital ischemia had to be resorted to.

Kerr’s trigger reflex test was used at the vascular center of DeWitt General

Hospital where it proved extremely useful in Raynaud’s disease. Both hands

were immersed simultaneously, one in water at 59° F. and the other in ice

water to which enough salt had been added to reduce the temperature to

about 34° Fahrenheit Invariably the hand immersed in ice water became and

remained crimson, while the hand immersed in cool water (59° F.) usually

became cyanotic as the result of spasm brought on by moderate cooling.

Chilling the entire body in cold shower bath for minutes almost invariably induced digital syncope in the hands of patients with Raynaud’s

disease although exposure to room temperature of 48° F. in controlled temperature room, like immersion of the affected part in ice water, frequently

failed to produce this result.

One method employed to determine the degree to which vasospasm contributed to the circulatory stasis was the application of heat to the contralateral

unaffected extremity and the measurement of the height to which the temperature (reflex) rose in the affected extremity.

The injection of typhoid vaccine was occasionally employed to release

vasoconstriction and to determine capillary dilatability. The ratio between

the elevation in the oral temperature and the elevation in the temperature of

the extremities following its use was termed the vasomotor index. The test is

obviously not selective and was not regarded as of great value in the few cases

in which it was employed.

NERVE CONDUCTION INTERRUPTION TESTS

Sympathetic Ganglion Block

Chemical interruption of sympathetic nerve conduction by means of

sympathetic ganglion blocks was considered an extremely reliable test at the

vascular centers of Mayo and DeWitt General Hospitals where this method

was extensively employed. It was regarded as of special value for indicating

the contribution of vasospasm to circulatory deficiency and in providing
48 VASCULAR SURGERY IN WORLD WAR II

indications of what might be expected from sympathectomy. At the vascular

center of Ashford General Hospital sympathetic block was not thought to be

either as practical or as reliable as the spinal analgesia vasomotor test.

Even at the centers in which nerve block was looked upon with favor,

however, its limitations were realized. Like all tests for vasospasm itwas useful

simply in ruling out vascular occlusions. None of these tests indicated the

degree of positive vasomotor activity with which the patient would respond

to environmental factors or to psychogenic influences.

At DeWitt General Hospital when the lesion was in the lower extremity

1-percent procaine solution was injected into the first, second, third, and fourth

lumbar ganglia first on one side and then on the other. At Mayo

procaine was injected singly at the level of the first or second sympathetic

ganglion. At DeWitt when the lesion was in the upper extremity procaine was

injected into the stellate ganglion, but at Mayo the block was carried out

posteriorly at the level of the first dorsal ganglion.

Peripheral Nerve Block

The experience at DeWitt General Hospital warranted the conclusion that

observation of the effects of peripheral nerve block on pain, color, temperature,

and functional capacity was essential in ruling out arterial occlusion whenever

the skin temperature of the affected part did not rise considerably following

the application of heat to the body or following sympathetic ganglion block.

The Use of Anesthetic Agents for Testing Purposes

Neither general nor intravenous anesthesia was used for vasomotor testing

at any of the vascular centers. Spinal analgesia was employed extensively at

Ashford General Hospital where it was thought to be more consistently reliable

than sympathetic ganglion blocks and to be attended with fewer complications

or unsuccessful results. It was the belief at the other centers that the lowering

of the blood pressure likely to occur after induction of spinal analgesia made this test less reliable than selective chemical interruption of sympathetic nerve

conduction by sympathetic ganglion blocks.

Spinal analgesia was induced in patient without preliminary medication and with his stomach empty, after he had been in the controlled temperature room for 30 minutes. At this time control readings of the skin temperature of the lower extremities and oscillometric determinations were made.

When they had been concluded, 100 to 120 mg. of procaine hydrochloride

were injected into the spinal canal at the interspace between the spinous processes of the fourth and fifth lumbar vertebrae. Analgesia was thus established from level midway between the umbilicus and the symphysis pubis to

the toes. When the complete effects of the injection had been felt, observations

were made concerning pain, color, and sweating of the extremities, and the

skin temperature and oscillometric readings were repeated.
EVALUATION OF VASCULAR STATUS 49

At the end of the test the patient was returned to his bed on litter and

was kept flat on his back, without pillows, until the following morning. There

were no untoward reactions in any of the large number of cases in which the

test was used at the vascular center of Ashford General Hospital.

DETERMINATION OF THE BASAL VASCULAR TONE

Studies along the lines of those carried out by Naide 12 to determine the

basal vascular tone of patients with vascular diseases and injuries were made

at the vascular center of DeWitt General Hospital in the hope that this method

of investigation might furnish more accurate index of vascular tone than

could be obtained by other means. Naide had found it necessary merely to

observe the skin temperature response in the finger tips during cooling period

in order to classify patients into two basic groups, those with high and those

with low vascular tone. patient was regarded as having high vascular

tone if the hands were cool (below 77° F.) after he had spent 15 minutes, clothed

only in light gown, in controlled temperature room at 68° Fahrenheit.

If, on the contrary, the hands remained warm (77° F. or above) after the

exposure, the vascular tone was considered low.

The tests made at the DeWitt General Hospital were carried out during

the summer in the early morning when the environmental temperature was

comfortably cool. The patients were in basal resting state, had had no

breakfast, and had not been permitted to smoke before the test was made.

Skin temperature measurements were made with galvanometer in controlled temperature room with the environmental temperature at 68° F. and

the humidity at 40 percent. The digital skin temperature was measured at

the start of the test and every 10 minutes thereafter over period of an hour.

Forty-five patients with lesions of the major arteries were studied by this

test, 25 before operation for aneurysms or arteriovenous fistulas, 17 after

ligation of the main artery to the extremity in the course of operations on

arterial lesions, and after ligation of major artery shortly after injur}” and

development of arterial thrombosis, also after injury.

The results of the test were in agreement with the clinical impression

in 32 of the 45 patients. In 10 of the 13 patients in which agreement did not

exist, analysis of the end results permitted comparison of the clinical impression and the results of the test. In of these 10, the test indicated normal

or low vascular tone while clinical signs clearly indicated an abnormal degree

of vasoconstriction; repetition of the test in several instances did not alter the

findings. In another patient the special study indicated high vascular tone

while the clinical study and end results indicated absence of vasoconstriction.

In the remaining patients the test for basal vascular tone proved superior

to the clinical appraisal. In of these patients persistent symptoms of inter11 Naide, M.: Test for vascular tone in humans and its application to the study of vascular diseases with special

reference to etiology and prevention of thrombophlebitis. Am. J. M. Sc. 207 606-620, May 1944.
50 VASCULAR SURGERY IN WORLD WAR II

mittent claudication suggested that sympathectomy should be performed

even though other clinical evidence of abnormal vasoconstriction was lacking.

The other patient, in spite of clinical evidence of increased vasomotor tone,

did not develop symptoms of vascular insufficiency. Possibly the fact that

the arterial lesion in the latter case was situated in the midfemoral region may

have facilitated the development of collateral circulation in spite of the presence

of vasoconstriction.

From the experience at DeWitt General Hospital it was concluded that

the test for basal vascular tone could not be relied upon alone in the selection

of cases for sympathectomy since in series of 45 cases it proved superior to

clinical judgment in only instances, while in others reliance upon it would

have dictated incorrect therapy. It was tentatively concluded that the variation in the results of the test at DeWitt General Hospital and those obtained

by Naide might be explained by the difference in the character of the case

material. All the patients in the Army hospitals were vigorous young individuals who had sustained local vascular trauma. This trauma might well

have set up some degree of segmental vascular spasm which was independent of

the general vasomotor tone.

ELECTRODIAGNOSTIC STUDIES

Electrocardiograms were made before and after operation in practically all

patients with aneurysms and arteriovenous fistulas, as well as those with

peripheral arteriosclerosis and thromboangiitis. The marked abnormalities

commonly found in patients in civilian practice with arteriovenous fistulas of

long duration were unusual among the patients with the same condition examined at the vascular centers. The explanation is undoubtedly twofold:

(1) in military practice diagnosis is made early; and (2) fistulas are eliminated

surgically before pronounced cardiac damage occurs.

Electro-encephalographic studies were carried out in few cases of cavernous sinus-carotid artery fistulas both before and after compression to control

the passage of blood through the affected artery, but they provided little or no

information which could not be obtained by simpler methods.

ROENTGENOLOGIC METHODS

Plain Roentgenograms

Plain roentgenograms of the extremities were employed to demonstrate or

exclude (1) calcification in the arteries and veins and in aneurysmal sacs, (2)

foreign bodies, (3) subcutaneous trabeculation, and (4) bone changes occurring

in conjunction with vascular disease or injury.

Roentgenograms of bones of the extremities often revealed changes in the

functional vasospastic group as well as in the organic group of diseases. Osteomyelitis and atrophy of the terminal phalanges associated with ulceration were

sometimes observed in thromboangiitis obliterans and Raynaud’s disease.
EVALUATION OF VASCULAR STATUS 51

Marked diffuse atrophic changes (osteoporosis) were sometimes observed in

the severe acrocyanotic syndrome which followed some cases of trenchfoot.

Whether the demineralization was the result of disuse or of chronic decrease

in blood flow remains to be explained. It was usually observed, however, that

some improvement in the roentgenologic picture followed use of the limb

Sudeck’s disease, with its pattern of pain, vasospasm, and dysfunction,

was associated with mottled form of decalcification of the bones of the affected

limb. The roentgenographic appearance in such cases differed from the smooth

type of decalcification observed in disuse atrophy or chronic ischemia. Some

observers took the position that smooth atrophy was transient stage likely

to be found in all extremities that had been immobilized for reasons of disease

or injury.

Arteriography and Phlebography

Arteriography. Arteriograms (Figs. 3A, B, and C) were used extensively

at the vascular center of DeWitt, occasionally at that of Mayo, and never at

Ashford. At DeWitt visualization of the arteries was thought to be valuable

method of making precise studies of aneurysms and arteriovenous fistulas both

before and after operation and of arteriovenous fistulas and saccular aneurysms

during and after spontaneous closure. The end results of arterial reconstruction were also evaluated by this method. Thorotrast (colloidal suspension of

thorium dioxide) or diodrast (iodopyracet) were the radiopaque substances used

for arterial visualization and there were no serious reactions to the use of either

agent, though the injection of diodrast was in few instances followed by hot

flushes, transient nausea and vomiting, or rash which lasted only short

time. There was also an occasional local reaction. Arteriography was not

used at the vascular center of Ashford General Hospital because the staff believed that arteriograms were often misleading and further that serious reactions

might result from the use of the agents.

At DeWitt General Hospital both diodrast and thorotrast were used, though

thorotrast was preferred if impending gangrene was feared since mild to moderate spasm occasionally followed the use of diodrast. All patients scheduled

for either arteriography or phlebography were given preliminary sublingual,

conjunctival, or intravenous test with the agent to be used, and adrenalin was

kept at hand for immediate use if reaction should develop. The technique

for both agents was the same. plain roentgenogram of the extremity was

usually taken before the opaque substance was injected in order to determine

the optimum x-ray factors to be used.

If the lesion was in the lower extremity the groin was shaved and prepared

as for surgery. All exposures were taken in the dorsal decubitus. When the

femoral artery had been identified by palpation of the skin crease, 19-gage

needle was inserted and directed obliquely downward at an angle of about 45

degrees to prevent its going through both walls of the artery. As soon as the

vessel wall could be felt pulsating against its tip, pressure was decreased and
52 VASCULAR SURGERY IN WORLD WAR II

Figure 3. Serial arteriographic study of restorative operation in femoral arteriovenous fistula. A. Preoperative visualization of fistula {22 May 1945). B. Postoperative visualization of right femoral artery after restorative operation on artery and vein {19 October 1945). For

this view the opaque substance was injected into the right femoral artery in the groin. C.

Postoperative visualization of right femoral vein after injection of opaque substance into

vein on medial side of ankle. Note shell fragment in right thigh in all views.

the needle was allowed to rest in that position until with very little additional

manual pressure the pulsations forced it into the vascular lumen. Then, as

soon as an assistant had compressed the artery proximal to the site of puncture

by digital pressure, 25 to 30 cc. of the radiopaque fluid was injected as rapidly

as possible and an exposure was made with the film held either in Bucky tray

or an ordinary cassette. Pressure was then released and an attempt was made

to obtain another exposure in order to visualize the more distal parts. If the

artery distal to the site of an arteriovenous fistula was of small size, the collateral

circulation was regarded as adequate.

Arteriograms in other regions were made by the technique described.

This was modified, as necessary, to fit the regional anatomy.

Phlebography. Phlebography by means of contrast medium was not

used at Ashford General Hospital for the same reasons that arteriography was

not used. It was employed, however, at the vascular centers of both Mayo

and DeWitt General Hospitals, 280 examinations being made at the latter. It

was the opinion of the staff at both these centers that phlebography, when used

with the proper precautions, was free from risk and that it was valuable

method of determining with accuracy the location and extent of venous thrombosis, venous patency or occlusion, and the results of reparative operations on

veins. It was thought to be of particular value after restorative operations on

veins implicated in arteriovenous fistulas.

The patient was placed on the table in the recumbent position and two

films, 14 by 17 inches, were slipped under the affected extremity. The first

extended from the groin to the popliteal space and the second, which slightly
EVALUATION OF VASCULAR STATUS 53

overlapped the first, from the popliteal space downward. The upper film was

held in speed cassette in Bucky tray. The lower was at first placed in

bakelite cassette with the upper metal border removed. Later wooden stage

was employed so that the film could be slipped in and out without moving the

leg, and cardboard holder was substituted for the bakelite cassette.

After the films were in position, heavy, rubber tourniquet was placed

about the upper portion of the thigh and tied just tightly enough to occlude

the long saphenous vein. Results were less satisfactory when the tourniquet

was applied too tightly. Another smaller, rubber tourniquet was applied just

above the ankle and tied tightly enough to make the veins on the foot stand

out. The radiopaque fluid was thus prevented from flowing directly into the

saphenous system. Veins on the dorsolateral aspect of the foot were preferred

as the site of injection since they do not enter the saphenous system directly.

Occasionally the tibial vein was exposed at the ankle and the fluid injected

directly into it.

Insertion of the needle into the vein was not always easy. Sometimes the

patient had to be asked to swing his foot over the side of the table into dependent position to dilate the veins. The best results were achieved with

20-gage needles and it was important that they be sharp.

After the films had been placed, the tourniquet applied, and the needle

inserted, 20 to 30 cc. of diodrast (35 percent) or thorotrast were injected slowly

into the vein over period of 30 to 45 seconds. The tourniquet about the

ankle was removed just before the last cc. of material were introduced.

While the diodrast was being injected the position of the extremity was readjusted, if necessary, and the leg steadied so that the film could be exposed immediately upon completion of the injection. The tube was centered over the

knee, or placed just above it, and the extremity was elevated to the maximum

height in order that all of it might be included in the roentgenogram. X-ray

factors varied with the size of the patient and the extent, location, and type

of vascular lesion, but were usually as follows: tube-target distance 40 inches,

milliamperes 100, kilovolts 70 to 80.

After the first picture had been taken, an assistant who had taken up his

position before the exposure was made, twisted the tourniquet about the thigh

tightly so that most of the dye was held in the extremity while the Bucky tray

was being reloaded. The tray was then centered beneath the pelvis underlying the course of the iliac vein, and the x-ray tube was centered to correspond

with the new position. The assistant removed the tourniquet from the thigh

with quick, steady movement, and the exposure was made fraction of

second later. The first films showed outlines of the veins of the thigh and

lower leg, and the second the proximal iliac veins and sometimes the lower

portion of the vena cava.

Following release of the tourniquet the patient usually experienced hot

flush over the head and neck and sometimes vomited. The reaction was

always fleeting.
54 VASCULAR SURGERY IN WORLD WAR II

The same technique was followed for phlebography of the upper extremity..

The exposure was usually made while the dye was being injected into the

antecubital vein.

Other Radiopaque Techniques

Angiocardiography was not employed at any of the vascular centers.

Cerebral angiography and aortography were employed in only few instances,

the radiopaque material being injected into the aorta for the purpose of visualization of the vena cava. Fairly satisfactory results were achieved in few

instances of arteriovenous communication between that vein and the aorta.

Soft-Tissue Techniques

Roentgenologic studies by soft-tissue technique were carried out chiefly

when arteriosclerosis of the peripheral blood vessels was suspected. The mere

demonstration of calcification of the blood vessels by plain roentgenograms

was not considered conclusive evidence of arteriosclerosis obliterans, and

confirmation by special techniques was required.

The incidence of calcification of the peripheral blood vessels in young

males between the ages of 30 and 40 years was remarkable. At Ashford General Hospital, for instance, between March 1944 and September 1945, 10 of

the patients x-rayed for reasons other than vascular disease (or complaints

referable to the vascular system) were found to have calcification of these

vessels. No patients in the group had any subjective signs of vascular incapacity nor, upon intensive study, could any objective signs of either organic

or vasomotor disease be discovered. Oscillometric readings, skin temperature

readings, and vasomotor tests were well within the limits of normal.

It was thought significant that none of the roentgenograms of these

patients showed spotty, mottled type of calcification. The shadows in every

case were smooth and uniform and gradually faded proximally into the normal portions of the vessels. These observations are in agreement with those of

others who have studied calcification in large series of unselected patients

for insurance purposes. It was invariably found that subjects with the smooth

type of calcification were relatively or absolutely symptom-free as compared

with those who showed the mottled type of calcification.

number of patients observed at the vascular centers with firm, noncompressible, easily palpable, cordlike peripheral arteries, who might have been

expected to show roentgenologic calcification of the vessels, failed to show it.

They had, however, other stigmata of generalized arteriosclerosis. They

were in higher age group than the younger men previously mentioned, and

their symptoms could reasonably be attributed to cardiovascular degenerative

disease. The possibility of generalized atheromatous disease, without visible

evidence of calcification, suggested form of medial sclerosis of the Monckeberg

type.
EVALUATION OF VASCULAR STATUS 55

Teleoroentgenography

Preoperative teleoroentgenograms were made of the heart and aorta in all

cases of arteriovenous fistula to serve as controls, and were usually made serially

during the postoperative period in order to study changes in the dimensions of

the heart after the closure of the fistula. Some degree of cardiac dilatation

was usually demonstrable before operation even if the fistula had been present

for as brief period as months, while the shadow was usually greatly reduced

in size within few weeks after the fistula had been closed.

Miscellaneous Roenfgenographic Studies

Roentgenologic examination of parts of the body other than the extremities was sometimes carried out, usually by means of radiopaque substances, if it was thought that vascular lesions might be causing filling defects or displacements or distortions of portions of the gastrointestinal tract, the biliary tract, or the urinary tract.

OBSERVATIONS DURING OPERATION

For several reasons, observations concerning the adequacy of the collateral

circulation and the effects of temporary occlusion of the affected vessels were

made during operation. In few instances these furnished the only means

of determining accurately the status of circulation in the part, the reactive

hyperemia test and other preoperative studies having provided equivocal or

obviously incorrect information. In the majority of cases, however, investigation during operation was supplemental to the preoperative investigation

and was employed (1) to confirm the preoperative conclusion that major

blood vessel could or could not safely be occluded by ligation, suture, or endoaneurysmorrhaphy; (2) to establish the need for immediate sympathectomy

or sympathetic ganglion block; and (3) to determine whether all vessels communicating with the arterial lesion had successfully been occluded by the

procedure employed.

Observations were made with the artery patent and then with the artery

occluded. It was desirable to occlude the vessel at point just beyond the

nearest proximal collateral branch in order to reduce the chance of occlusion

of the collateral by progression of thrombus from the blind arterial sac.

Occlusion at this point provided the clearest evidence of the full potential

collateral circulation and the best indication of what could be expected following permanent occlusion of the artery. Trial occlusion elsewhere left blind

segment of artery between the site of occlusion and the nearest collateral,

and this segment, if of considerable length, might be responsible for sufficient

absorption of pulsation to reduce the amount of blood flow through the collaterals.

Trial occlusion was carried out by digital compression or with rubbershod clamp or catheter. The Bethune tourniquet was also useful.

330323 0—55
56 VASCULAR SURGERY IN WORLD WAR II

Inspection

When the vascular lesions or the component blood vessels were exposed

significant information was obtained. Simple inspection revealed:

1. The effects produced by prolonged direct occlusion of the involved

artery (a) at the site of the vascular lesion, (b) distal to the operative field,

and (c) at the proposed site of surgical obliteration.

2. The size and anatomic relationship of aneurysms and arteriovenous

fistulas, with and without occlusion of the component vessels.

3. The size and relationship of the component vessels. In general, arteries proximal to an arteriovenous fistula were enlarged, but if the artery distal

to the lesion was small then adequate circulation could be assumed to exist.

4. Pulseless aneurysms which occasionally were incompletely filled with

blood. Aneurysms with little or no evident pulsation, suggesting obliteration

of the sac with organized blood clot, were often found to be far from “dead.”

5. The effect of prolonged occlusion of the involved artery on the color

of hand or foot. Color changes proved to be extremely reliable. The

period of observation was often 20 to 30 minutes to allow time for full dilatation of the collateral vessels which occupies several minutes, and to allow

for the appearance of whatever ischemic manifestations might occur. It had

to be borne in mind, if ligation of the artery was done under spinal or general

anesthesia, that the vasomotor impulses were in state of inhibition and

regardless of the observations during operation it might be necessary later to

eliminate sympathetic impulses if the circulation should be compromised by

vasoconstriction.

6. The adequacy of the collateral circulation as manifested by pulsation

in or free flow of blood from the distal end of the involved artery during occlusion of the proximal artery. This is known as the Coenen-Henle phenomenon 13

and was the most widely used method of determining, during operation, the

adequacy of the collateral circulation. The observation of free flow of

blood from the distal end of the involved artery was possible only after the

aneurysm was opened, which was not done unless there was reasonable evidence of the existence of satisfactory collateral circulation. This phenomenon

indicated only that the local circulation was adequate. It did not necessarily

follow that the collateral circulation was adequate throughout the entire

extent of the vascular tree distal to the site of arterial involvement. It was

also true that adequate collateral circulation could exist throughout the entire

extent of the vascular tree distal to this site in the absence of retrograde pulsation or blood flow, the explanation being the presence of thrombus or the

existence of cicatricial constriction of the artery distal to the point at which

it was opened at operation.

13 Coenen, H.: Zur Indikationsstellung bei der Operation der Aneurysmen und bei den Oefassverletzungen.

Zentralbl. f. Chlr. 40: 1913-1916, Dec 1913. Henle, A.: Zur Indikationsstellung bei der Operation der Aneurysmen und

bei den Oefassverletzungen. Ibid. 41; 91, Jan 1914.
EVALUATION OF VASCULAR STATUS 57

7. The state of the intima, the possible presence of an inflammatory reaction

involving all layers of the vessel wall, and the presence of arteriosclerosis or

atheromatosis. This information had much to do with shaping the decision

for or against restorative surgery. final decision often could not be made

until the vein and artery had been separated at the site of the fistula. The

ragged appearance of the vessel sometimes made it seem impractical or actually

impossible to restore the continuity of the vessel, while closer examination

reversed the decision by revealing that the vessel wall was pliable and that

there was little or no intimal damage. In some instances considerable loss

of substance made it seem unlikely that repair could be done without obliteration of the lumen. If, however, the arterial or venous defect was examined

from the standpoint of possible transverse or oblique closure instead of longitudinal closure, different decision might be reached.

Palpation

Palpation during operation was employed to furnish the following information:

1. Pulsation of the distal arteries following proximal occlusion. The

significance of this observation has already been discussed in item under the

subheading immediately preceding.

2, Pulsation of an aneurysm or arteriovenous fistula before and after

temporary or permanent occlusion of contributory vessels. This observation

established which vessels were contributory and also established the effectiveness or completeness with which obliteration of contributory vessels had been

accomplished.

3, Thrill, with and without occlusion of contributory vessels.

4. Tension of aneurysmal sacs and the involved vessels or intervening sacs

of arteriovenous fistula. High tension in an arteriovenous fistula indicated

that the opening into the vein was small.

5. Grossly detectable temperature changes (coolness or coldness) of

hand or foot during 20- to 30-minute or longer period on occlusion of the

exposed involved segment of an artery. In observing the effect of arterial

occlusion on the temperature of part distal to the site of occlusion, it had to

be kept in mind that there is lag of variable duration in the occurrence of

full dilatation of collateral vessels following occlusion of the main afferent artery

to an aneurysm or arteriovenous fistula, as well as to part which is not the

site of such lesions. Instrumental determination of the temperature was

used in some cases.

Auscultation

At the vascular center of DeWitt General Hospital direct auscultation

with sterile stethoscope applied over the lesion was extensively employed

during operation, with and without occlusive compression of the component

veins and arteries, in an investigation of bruits. The results were frequently
58 VASCULAR SURGERY IN WORLD WAR II

informative but were not invariably dependable for the same reason that the

Coenen-Henle phenomenon could not always be relied upon. Direct stethoscopic examinations of aneurysmal sacs were also employed before the conclusion of the operation to be certain that all communications had been

surgically occluded, if such result had been intended.

Intrasaccular Inspection

In the occasional case in which the information definitely could not otherwise be obtained, it was necessary to inspect the inside of the aneurysmal sac

to be sure that all vessels communicating with the sac had been identified and

occluded. When occlusion of all visible communicating vessels had been

achieved, either temporarily or permanently, the sac was quickly incised and

bleeding points sought. Speed in opening the sac and locating possible bleeding points after occlusion of the afferent artery was essential if full advantage

was to be taken of the delay in complete dilatation of the collateral vessels

which follows occlusion of the afferent artery.

Temperature Determinations

At Ashford General Hospital series of tests for circulation in the lower

extremities was made in the course of operations in which the external or

common iliac arteries were ligated and divided as part of the surgery for

aneurysms and arteriovenous fistulas. For control purposes skin surface

temperatures of the toes on both feet were recorded with the patient under

spinal analgesia. Similar determinations were made at 5-minute intervals

during the operative procedure, the temperature reading being correlated with

the precise stage of the operation. It was thus possible to relate the temperature change to the effect of ligation and division of the iliac artery and vein.

It was interesting to observe that in spite of complete anesthesia with corresponding inhibition of the sympathetic nerves, the major blood vessels reacted

by spasm to manipulation, ligation, and division.

The toes of both feet were again tested after the effect of anesthesia had

disappeared and followup temperature readings were made daily for days.

At the end of this time the temperature readings of all the toes of both feet

were always equal. The patients were then subjected to vasomotor testing in

cold room. Despite the fact that the major arterial stem had been interrupted

only days before, the responses to temperature changes were found to be the

same in all cases.

Direct Intravascular and Intrasaccular Blood Pressure Determinations

The need had long been evident for some quantitative test for adequacy

of the collateral circulation which the surgeon could employ during operation

when he felt some doubt about the safety of ligation of the main arterial blood

supply to the extremity. Direct measurement of the blood pressure within the

aneurysmal sac or distal artery was carried out in 23 cases at the vascular center
EVALUATION OF VASCULAR STATUS 59

of DeWitt General Hospital as means of supplying such information. The

method proved of particular value when the proximity oflarge collateral arteries

to the lesion made preoperative tests of the collateral circulation of doubtful

value, or when unsuspected collateral vessels of considerable size were found

communicating with the sac and had to be temporarily or permanently occluded

before the sac was opened to avoid excessive bleeding.

Since Hamilton manometer, which would have been ideally suited for

intraluminal pressure determinations, was not available, an apparatus for this

purpose was devised by Maj. Norman Freeman of the vascular center of

DeWitt General Hospital. It consisted of small 3-way stopcock fitted with

short lengths of rubber tubing which connected 20-gage needle with 10-cc.

syringe. An anaeroid manometer similar to that used with blood pressure

cuff was attached to the third outlet. The instrument, which was not itself

sterile, was used in transparent oiled silk cover which could be sterilized.

After surgical exposure of the lesion the component vessels were encircled

with heavy silk thread or rubber tubing. The needle was inserted directly into

the artery or into the aneurysmal sac and small amount (a few cubic centimeters) of physiologic saline solution injected to clear the system of blood.

The pressure could then be read directly on the dial. Oscillations of the manometer needle, although small, indicated that the needle was within the blood

stream. After the initial pressure had been measured each of the component

vessels was temporarily occluded and variations in pressure recorded. In no

instance wasremoval of the needle from the artery or sac attended with bleeding

of any consequence.

When this test was used one precaution was always taken: At least to

minutes were allowed to elapse after occlusion of the main afferent artery, to

permit full dilatation of the collaterals. If this was not done, grossly incorrect

conclusions resulted concerning the adequacy of the circulation following major

arterial ligation.

The mean initial intrasaccular pressure in the 12 arterial aneurysms studied

in this series varied between 110 mm. and 34 mm. of mercury and averaged

84 mm. of mercury. In the 11 arteriovenous fistulas the mean initial pressure

varied between 70 and 30 mm. of mercury and averaged 40 mm. of mercury.

In aneurysms, constriction of the afferent artery caused fall in the intrasaccular pressure to an average of 58 mm. of mercury, while in fistulas similar

procedure caused an average fall of 10 mm. of mercury. It was found that with

pressure of 32 mm. of mercury tissue survival could be expected. This is in

accord with Korotkow’s observation that pressure of 30 mm. of mercury is

adequate.
CHAPTER III

Acute Battle-Incurred Arterial Injuries

Michael E. DeBakey, M.

and

Fiorindo A. Simeone, M. D.**

Acute injuries of the major arteries have always constituted one of the

most serious problems of military surgery. They are associated with high

immediate death rate and not infrequently result in permanent disability. It

is curious, therefore, that so little information is available concerning them.

When the United States became actively involved in World War II, the

majority of medical officers knew practically nothing about vascular injuries.

Few factual data were available because this type of injury occurs infrequently

in civilian practice and because the recorded experience of previous wars was

meager. In the official American history of World War are contained data

on the gross incidence of arterial wounds and brief general statements regarding the management of the injured artery and vein, but no information is

provided regarding the results of arterial wounds in relation to the characteristics of the injury and the type of treatment. Very few medical officers were

familiar with the British experience concerning arterial injuries in World War

as recorded by Makins. In the years which elapsed between World War and World War II

numerous advances were made in vascular surgery, but they were confined to the

small groups of surgeons who were interested in this field and who developed

new methods or applied to it developments which had been made in other

fields. The principles of debridement were clarified and standardized. Chemotherapeutic agents of great effectiveness were introduced, as were vasodilating

and anticoagulant agents. Sympathectomy had become recognized therapeutic procedure in selected cases of vascular insufficiency. Yet in spite of

these advances the results secured in arterial injuries in World War II, at

least in the first months of American participation, were no better than those

‘Professor and Chairman, Department of Surgery, Baylor University College of Medicine. Formerly Colonel, MC,

AUS.

“Professor ofSurgery, Western Reserve University School of Medicine. Formerly Colonel, MC, AUS.

Love, Albert Q.: Statistics. TheMedical Departmentof the United States Armyin the World War. Washington,

Government Printing Office, 1927, vol 11, pt 1, p. 57-85.

Pool, Eugene H.: Wounds of soft parts. In The Medical Departmentof the United States Army in the World War.

Washington, Government Printing Office, 1927, vol 11, pt 1, p. 302-303.

Makins, Q. H.: Injuries to the blood vessels. In Official History of the Great War Medical Services. Surgery of

the War. London, His Majesty’s Stationery Office, 1922, vol 2, p. 170-296.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 61

reported by Makins in World War and in some respects were actually worse.

This anomalous situation is explained, at least in part, by the general ignorance

of medical officers concerning the principles of management of vascular

injuries.

It is only fair to point out that the unhappy experiences of American

surgeons with arterial injuries were not unique. In conference of British

surgeons held in Cairo in August 1943, Ogilvie reported that in the course of

the war he had observed no instance of ligation of the popliteal artery not

followed by gangrene. Blackburn in 1944 made substantially the same statement. British experiences in World War II thus did not support the observations of Makins in World War I. He had reported that amputation was

necessary in only 43.1 percent of 144 casualties with wounds of this artery.

When medical units were activated in the United States after the attack

on Pearl Harbor much of their basic training was devoted to such matters as

the use of the Lyster bag, the construction and disposition of slit trenches, map reading, military protocol, and other nonmedical subjects. Medical

instruction was limited chiefly to hospital administration. It included very

little concerning the management of combat-incurred wounds. Medical

officers learned practically nothing of the American medical experiences of

World War as they were recorded in the official history of that war or of the

valuable experiences of Allied medical personnel in the early years of World

War II. As result, American medical officers were sent to the various fronts

with certain amount of information concerning court-martial proceedings,

sanitation, and similar matters, but with almost no factual information upon

the pathology and therapy of war wounds.

The general ignorance concerning the management of combat-incurred

vascular injuries and the complacency felt concerning them by those who were

familiar with Makins’ observations and conclusions were in no wise altered by

the appearance, in 1943, of Military Surgical Manual containing section

on vascular injuries. Valuable as was some of the information it contained,

other material in this manual was quite misleading. In one table, for instance,

the source of which was not stated, the expected percentage of gangrene or

other disturbance was set forth for sudden ligation of various arteries. Ligation

of the aorta was stated in this table to be associated with 100-percent incidence of gangrene, and that of the common iliac artery and of the posterior

tibial artery (when both bones of the leg were fractured additionally) with an

incidence of 50 percent. But ligation of the popliteal artery with its concomitant vein, according to this table, was never followed by gangrene. The

figures presented in the table, the text stated, “. are rather out-of-date.

Today, by simultaneous division of the companion vein and by performing

Ogilvie, W. H.: War surgery In Africa. Brit. J. Surg. 31: 313-324, Apr 1944.

Blackburn, Q.; Surgery in the field. Lancet 1: 361-365, 18 Mar 44.

National Research Council, Division of Medical Sciences. Burns, Shock, Wound Healing and Vascular Injuries.

Prepared under the auspices of the Committee on Surgery of the Division of Medical Sciences of the National Research

Council. Military Surgical Manuals, vol 5. Philadelphia, W. B. Saunders Co., 1943.
62 VASCULAR SURGERY IN WORLD WAR II

sympathetic procaine block, several times if necessary, to avoid vasoconstriction and to encourage the collateral circulation, the chances of gangrene are

much smaller,”

Later in the text, in detailed discussion of ligation of the popliteal artery,

the following statements were made: “The artery can be doubly ligated and

divided with impunity in the upper part of its course but with less safety in its

lower portion, close to its division. Apparently the most danger is encountered

in those cases in which hematomas have been present for many hours or days

before treatment is instituted. Among such, gangrene of the foot is rather

common.”

Medical officers who relied upon these data were naturally disappointed

when their results did not approximate those given. Furthermore, in some

series of arterial wounds observed during the Tunisian campaign, gangrene

followed injury to the popliteal artery in almost all cases; finding in direct

contrast to the results cited in the manual which was in press at the time.

Constant attention to details of wound management, constant dissemination of information, repeated practical demonstrations of techniques by the surgical consultants and their assistants in the Mediterranean and European

Theaters of Operations were eventually supplemented by information from the

Office of The Surgeon General. As the concept of arterial injuries became more

nearly correct there was some corresponding improvement in therapeutic results. That the improvement was not more pronounced is an index of the

essential seriousness of this type of injury. Toward the close of the war the

amputation rate in interruptions of the popliteal artery, for instance, was

closer to 75 percent than to the 100 percent it had been in the beginning, but

it cannot truthfully be said that the results in this or in most other acute arterial

injuries were ever really satisfactory.

INCIDENCE

The incidence of acute arterial injuries is admittedly low in all recorded

wars, but such statistics as are available generally seem to underestimate their

frequency. Even in World War II, when real effort was made to report the

figures accurately, the data were still deficient in certain respects. This lack

of information is not difficult to explain: For obvious reasons, vascular injury

is seldom recorded as primary diagnosis and in many instances, including

both the most serious and the least serious cases, it is probably not recorded at

all. In many reports, cases which came to amputation as the result of such

complications of arterial wounds as life-endangering infection, such as gas gangrene, are not recorded as arterial injuries. In addition, analysis of the

available statistics requires considerable caution. Most series are actually or

relatively small, and many from previous wars include both acute and chronic

conditions. In drawing conclusions from them, therefore, many qualifying

circumstances must be taken into account.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 63

PreviousWars

Available statistics (Chart 2) suggest that the incidence of arterial injuries

among battle casualties of previous wars was extremely low. It was approximately 0.29 percent in the Civil War, and 0.8 percent, according to LaGarde,

in the 1,400 injuries sustained at Santiago during the Spanish-American War.

In the Russo-Japanese War, few years later, it was reported as 2.4 percent.

Chart 2. Incidence of arterial wounds among battle casualties in various wars. Nature and

source of these data are indicated in text, pp. 63-65.

Otis, George A., and Huntington, D. L.; The Medical and Surgical History of the War of the Rebellion. Surgical

History. Washington, GovernmentPrinting Office, 1883, vol 2, pt 3, pp. 763, 765. In the officialhistory arerecorded 485

cases ofprimary lesions ofblood vessels out of 2,235 cases “in which the bleeding vessels were definitely ascertained.” It

should beunderstood that some of these may have been cases of“secondary hemorrhage” in which the artery maynot have

been directly wounded. The incidence reported by DeBakey and Simeone in Annals of Surgery 123: 534-579, Apr 1946,

omitted such possible cases. On the assumption that the same proportion held for the remaining 1,010 cases inwhich the

blood vesselsinvolved were not named, the 485 would have been expanded to 704.

LaGarde, Louis A.; Gunshot Injuries: How They Are Inflicted, Their Complications and Treatment. New York,

WilliamWood Co., 1916.

Macpherson, W. Q.: Report 14. Port Arthur: The Russian Red Cross Society’s Hospital: Statistical Analysis of

2,080 Wounds Treated During the Siege. The Russo-Japanese War. London, His Majesty’s Stationery Office, 1908, p.

281-291.
64 VASCULAR SURGERY IN WORLD WAR II

Despite the lack of clinical discussion of vascular wounds in the official

American history ofWorld War I, the available information indicates that the

incidence of this type of wound among American troops was about 0.4 percent

of battle casualties. 10 The British official history, 11 in spite of the extensive

discussion of the subject which it contains, supplies no data concerning incidence

and Makin’s classic monograph 12 is no more helpful. His material, in fact, is

quite misleading unless it is remembered, as will be emphasized later, that it

includes nonacute as well as acute injuries. Itis limited to 1,191 cases and consists of series. One comprises 668 cases handled by numerous individual

surgeons in the British Isles and overseas and obviously includes nonacute as

well as acute injuries. The other consists of 523 cases observed in France by

single surgeon. Makins himself warned that only modified reliance could be

placed on any deductions drawn from this material. Almost the only data

available on the subject of arterial injuries per se among British troops in World

War are in Bowlby and Wallace’s report 13 of 277 ligations of major arteries (1.3

nercent) in 20,589 casualties treated at single casualty clearing station.

According to Maurer, 14 443 wounds of the blood vessels, 17 percent of

which involved only the veins, were observed among 8,000 wounded treated in

French ambulance service in World War I. When the wounds which are

exclusively venous are excluded, the incidence of arterial injuries in this series

was 4.6 percent. Mignon’s figures 15 for French ambulances (so stated that

tabulation is possible) show 399 vascular injuries, 2.0 percent, among 19,734

wounded. The French official history of World War 16 lists 6,397 vascular

injuries (0.3 percent) among 2,052,984 casualties. The German incidence,

according to Franz, 17 was three times as great, 0.99 percent.

Matas, 18 in his treatise on vascular injuries, stated that 24.7 percent of all

battle casualties treated in forward hospitals had injuries of the blood vessels

and that percent ofall wounded admitted to base hospitals presented traumatic

aneurysms. He does not indicate the source material for this incidence, which

is the highest recorded, nor does he identify the casualties involved.

World War II

Statistics for World War II are considerably more complete. Figures for some of the armies during certain portions of the fighting in Italy, in Western

10 See footnote 1, p. 60. 11 See footnote 3, p. 60.

Maklns, G. H.: On Gunshot Injuries to the Blood Vessels. Bristol, John Wright Sons, Ltd., 1919. '3 Bowlby,A.,and Wallace, C.: Thedevelopment of British surgery at the front. Brit. M. J. 1; 705-721,2 Jun 17. 14 Maurer, A.; Wounds of the vessels of the face, neck and limbs; their surgical treatment, based upon four hundred

and forty-three cases. Internat. Clin. 1: 164-195, 1921. >3 Mignon, A.: Le Service de Santfi pendant la Guerre, 1914-1918. Paris, Masson <fe Cie., 1926, Tome 2. ,e Ministere de la Guerre. Direction du Service de SantS. Etude de Statistique Chirurgicale Guerre de 1914-1918.

Paris, Imprimfrie ationale, 1924. 17 Franz, Carl: Lehrbuch der Krlegsehirurgie. Dritte Auflage. Berlin, Springer-Verlag, 1942. 18 Matas, R.: Endo-aneurismorrhaphy. I. Statistics of operation of endo-aneurismorrhaphy. II. Personal experiences and observations on the treatment of arteriovenous aneurisms by the intrasaccular method of suture; with special

reference to the transvenous route. Surg., Gynec. Obst. 30: 456-459, May 1920.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 65

Europe, and in the Pacific and China-Burma-India theaters, reveal 1,570

vascular injuries among 163,980 battle casualties (Chart 3). 19 At the time these

data were analyzed, figures from First and Ninth Armies were not available.

Experience cited for Third, Fifth, and Seventh Armies is that for which breakdown of arterial injuries was available. The annual reports of the surgeons of

those armies indicate that the total numbers of battle casualty admissions to

hospital and quarters during the entire war were 91,000, 73,000, and 84,000,

respectively. The total incidence of 0.96 percent in the samples is remarkably

close to the incidences reported from the separate theaters and armies. Similar correspondences noted in the distribution of vascular wounds (1,564) among

wounds of the extremities (108,405) observed in the separate theaters and

armies suggest that the overall incidence of 1.4 percent is fairly representative

(Chart 4).

Chart 3. Incidence of arterial wounds among American battle casualties in World War II.

Figures are based on samples as available and are not to be considered as complete. See text,

pp. 64~65 for details of selectivity.

19 Preliminary data based on sample tabulations of individual medical records indicate that during 1944 and 1945

(the only years for which such data are presently available), in the total Army, there were 12,600 battlewound and injury

admissions with artery involvement,or about 1.7 percentof the approximately 760,000battlewound and injury admissions

to hospital and quarters. Expansion of the data to include arterial injuries among battle and nonbattle wounds and

injuries produces percent of 0.8 for the 2-year period.
66 VASCULAR SURGERY IN WORLD WAR II

Chart 4- Incidence of arterial wounds among wounds of the extremities in American battle

casualties in World War II. Figures are based on samples as available and are not to be

considered as complete. See text, pp. 64~65 for details of selectivity.

As these statistics show, the total incidence of vascular wounds among all

casualties has been relatively and absolutely small in all wars. Even the large

numbers of wounded in World War II do not make the absolute number of

vascular wounds very large. The significance of the figures lies not in the

actual incidence but in the threat which these wounds carry to life and limb.

Only by examining the frequency with which these injuries appear as the

indication for amputation will their importance be realized. (Chart 5.)

Incidence in Relation to Amputation. No significant statistics compiled

from this point of view seem to have been recorded, but accurate data for

World War II are available from the Mediterranean and European Theaters of

Operations (Chart 5). Among 3,177 major amputations performed in these

theaters, 2,179 (68.6 percent) were the result of extensive trauma, 380 (11.9

percent) resulted from clostridial myositis or other serious infections, and 618

(19.5 percent) followed major arterial injuries. Records which became available

with the capture of German amputation center showed that among 1,359

major amputations, 64.3 percent were the result of trauma, which is close to the

American incidence of 68.6 percent. Thereafter the German figures are not in
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 67

Chart 6. Causes of amputation among American battle casualties in World War II. Figures

are based on samples as available and are not to be considered as complete. See text, pp.

for details of selectivity.

agreement with the American; 29.7 percent of the German amputations were

the result of clostridial myositis and only percent followed vascular injuries.

Corresponding figures on the Russian experience reported by Kramarov 20

showed trauma to be the cause of amputation in 16 percent of the cases, gas

gangrene and other infections in 79 percent, and vascular injury in percent.

The striking difference between the incidence of infection as cause for amputation in the American series and in the other series may be interpreted as

reflecting the excellence of the surgery done by American surgeons in forward

areas. The percentages of amputations because of vascular trauma provide

true concept of the magnitude of the problem and also indicate the inevitability

of the great majority of amputations for these injuries.

Regional Distribution. An analysis of the relative frequency with which

various arteries are involved in battle casualties (Chart 6, Table 3) shows that

the brachial, tibial, femoral, and popliteal arteries are involved far more often

20 Kramarov; Quoted by Aird, I.: review ofrecent Russian studies of gunshot wounds of the thigh. Bull. War

Med. 4: 619-620, Jul 1944.
68 VASCULAR SURGERY IN WORLD WAR II

than any others. They accounted for 70 percent of the total vascular injuries

reported by Makins 21 in World War and for 85 percent of those sustained by

American troops in overseas theaters of operations in World War II. The

explanation of this preponderance is simple: Casualties suffering from injuries

of larger arteries frequently did not live long enough to reach medical installations and therefore do not appear under precise diagnoses in medical statistics.

Furthermore, injuries of less critical arteries were frequently not discovered or,

if discovered, were not recorded.

comparison of the frequency of wounds of the brachial, tibial, femoral,

and popliteal arteries in the combined British and American statistics for World

War and in the American statistics for World War II shows that the incidence

of wounds of all four arteries as group was about the same in World War

Chart 6. Distribution of arterial wounds according to anatomic location in wounds of the extremities in various wars. Figures are based on samples as available and are not to be considered

as complete. See text, pp. 63-65, for details of selectivity. Incidences in this chart, it should

be emphasized, are based only on arterial wounds of the extremities, whereas those shown

in Table are based upon all arterial wounds. Arteries of the head and neck and renal

arteries have been excluded.

21 See footnote 3, p. 60.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 69

Table 3. Comparative Distribution of Arterial Injuries among World War

(British) and World War II (American) Casualties

II as in the previous war. However, in World War II the incidence of wounds

of the popliteal artery was higher than the incidence recorded previously. The

reason for these differences can only be surmised. Methods of recording were

probably more exact inWorld War II. Certainly in this war therewas greater

British World War (Makins •) American World War II

Artery Total injuries Loss of limb Total injuries Loss of limb

Number Percent Number Percent Number Percent Number Percent

Aorta 0. 100. 0. 12 66. Carotid 128 10. 38 29. 10 0. 30. External carotid ______

12

Renal 10 100 Vertebral ._ 0.

Subclavian. ._ 45 3. 8. 21 0. 85 28.

Axillary 108 9. 4. 74 3. 32 43. Brachial __ 200 16. 12 6. 601 24. 159 26.

above profunda 97 54 55 below profunda 209 54 25 Radial-ulnar 59 4. 5.

radial 99

ulnar 69

Radial and ulnar 28 11 39

Common iliac 0. 100. 13 0. 53.

External iliac. 0. 30 14 46

Internal iliac 0. 05

Femoral 366 30. 74 20. 517 20. 275 53.

above profunda 106 86 81

below profunda 177 97 54

profunda 27 1.

Popliteal 144 12. 62 43. 502 20. 364 72.

Anterior tibial 26 2. 3. 129 5. 11 8.

Posterior tibial. 97 8. 9. 265 10. 36 13.

Anterior and posterior tibial. 0. 28. 91 3. 63 69.

Peroneal 0. 50. 0. 28 14.

Anterior tibial and peroneal 0.

Posterior tibial and peroneal._ 0. 0. 20 40.

Both tibials and peroneals 0. 05 100.

Total.. ...

1, 202 218 18. 2, 471 995 40.

The figures compiled from Makins’ tables represent combinations of his totals for the categories of gangrene and

amputation, this plan being adopted to obtain the maximum number of cases without possible duplications. The

numbers represent the minimum number ofpatients who must have had amputations.

Thefigures for the aorta, the carotid, andrenal arteries indicate the numberof patients who died or developed cerebral

complications.

This total differs from the total of 1,191 cases in Makins’ master table because of the addition of 11 injuries of vessels

of the leg secured from detailed table presented in the text.
70 VASCULAR SURGERY IN WORLD WAR II

and more selective interest in vascular injuries than had been exhibited in

previous wars. Finally, in World War II there was greater emphasis on conservation of limbs than in other wars of history.

POLICIES OF MANAGEMENT

North African and Mediterranean

Theaters of Operations

In the North African and Mediterranean Theaters of Operations specific

directives were not issued for the treatment of vascular injuries, but no opportunity was lost to disseminate information concerning such injuries. 22 Case

teaching and technical demonstrations were also carried out by the surgical

consultant for the theater and by his assistants on their visits to both forward

and base hospitals. The following principles were emphasized:

1. Careful debridement in all cases with excision of all devitalized tissue

and preservation of all undamaged vessels however small.

2. Adequate incision to permit clear visualization of all structures implicated in the wound and to avoid out-of-sight manipulations.

3. Exploration of all major vessels whenever there was evidence of circulatory insufficiency in an extremity whether the artery lay directly in the

track of the missile or at some distance from it.

4. Procaine block of the sympathetic nerve supply to the extremity to

relieve spasm of the major vessels whenever it was suspected, or to improve

the collateral circulation to the limb when the main arterial supply had to be

ligated or manipulated.

5. Lumbar ganglionectomy for serious lesions of the major arteries of the

lower extremities whenever conditions permitted this procedure. For injuries

of vessels of the upper extremity sympathetic denervation other than by

means of procaine block was not recommended. This operation is too specialized to warrant its performance in the field, and the incidence of gangrene

following interruption of major arteries of the upper extremity was so much

less than the incidence in the lower extremity that it was not regarded as

necessary.

6. Suturing the arterial lesion whenever conditions were favorable.

7. Arteriectomy, thrombectomy, and other operations according to the

indications of the individual case.

Part of the teaching, in circular letters and in person, was concerned with

methods for controlling hemorrhage. Warnings were issued against the use

of tourniquets without special precautions, and the dangers of gauze packs

were also emphasized. If pack was necessary, the desideratum was that it

be removed at the earliest opportunity and that notation of its use be made

22 (1) Cir Ltr 13, Office of the Surgeon, NATOUSA, 15 May 43, sub: Memo on forward surgery. HD.

(2) Cir Ltr 46, Office of the Surgeon, NATOUSA, 29 Aug 44, sub; Surgical managementof the wounded (111). HD.

(3) Cir Ltr 8, Office of the Surgeon, MTOUSA, 10 Mar45, sub: Notes on care ofbattle casualties. HD.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 71

on the soldier’s record. The preferable method of controlling hemorrhage from

major vessels was stitch ligature.

In the hope that an adequate collateral circulation would develop, early

operation for aneurysm or arteriovenous fistula was not recommended. The

only justification for early operation in this overseas theater was the arrest

of hemorrhage or some similar emergency. deep hematoma, however,

which was impeding the circulation, was to be dealt with immediately.

European Theater of Operations

In the Manual of Therapy 23 prepared before D-day, for the European

Theater of Operations, the following instructions were given for the management of wounds of the large blood vessels:

Diagnosis:

1. Diagnosis is made by bright blood escaping from wound or an increasingly tense

hematoma.

2. Remember that the skin need not be broken in order for an injury to an artery from

contusion, fracture or dislocation to be present.

Treatment:

1. Control hemorrhage in cases in which blood is escaping from the wound by any of

the following methods: a. Elevation of the part. This should be done with due care of associated fractures, regardless of the local methods used.

b. Direct pressure on the wound with bulky dressing.

c. Secure the bleeding vessel with clamp and ligature, and ligate the companion

vein. This is only to be done when the open vessel can be easily seen in the wound,

lest blind clamping in the depths of the wound cause nerve injury.

d. Direct control of the artery by digital pressure at the root of the limb.

e. Ligation of the artery and companion vein at distance from the wound.

f. The use of tourniquetis to be discouraged except as temporary emergency measure

to facilitate control by other means, i. e., ligature, packing, and pressure dressing. Evacuation with tourniquet in place means the almost certain loss of the extremity distal to

the tourniquet. However, during evacuation, an unapplied tourniquet should accompany

patients with injuries to major blood vessels.

2. In cases in which the bleeding is chiefly subcutaneous, local pressure over the hematoma is the only emergency local measure indicated.

3. Cases with severe bleeding into fascial planes of the extremity have greater chance

of gangrene than those in whom the blood can escape. Priority evacuation is indicated

in these cases.

4. Replace lost blood, whether external or into tissues, with plasma and blood transfusion.

5. For transport, keep the body warm but apply no artificial heat to the limb.

6. Surgical technique for the ligation of important arteries. The following technical steps

should be employed in approaching individual blood vessels. The incisions depicted are

those suitable for reaching the vessels at point where they are undamaged. Where the

approach is through wound directly onto the lesion in the vessel, incisions should be much

larger than those here shown, in order to give enough exposure for adequate control of

hemorrhage. The decision as to the site for ligation is best made by constriction of the

artery in the wound with observation of the color, pulse, and temperature in the hand or

foot during constriction. This is safer than relying on constant pattern of collateral

circulation in system so subject to anomalies as the arterial tree.

23 Manual of Therapy, European Theater of Operations, May 44.

330323 —55
72 VASCULAR SURGERY IN WORLD WAR II

The Manual of Therapy 24 for the European Theater of Operations also set

forth the following general principles for the definitive surgical treatment of

vascular injuries;

1. Cases of large increasing hematoma not controlled by pressure should be explored.

Evacuate the hematoma and ligate the involved vessel.

2. Divide the artery between two ligatures and, for additional security, transfix both

stumps with ligature. Division of the artery permits more accurate and secure ligation

as well as providing the beneficial effects of periarterial sympathectomy to the extremity.

When ligation of major artery is required, the companion vein should be ligated as well,

since this decreases the likelihood of gangrene.

3. If the artery has not been opened, but is contused, and thrombosis has taken place,

it should be ligated and divided, and the exposed, thrombosed portion excised, and the

same procedure performed on the companion vein.

4. When approach to the artery through the wound appears too difficult, expose the

artery believed to have been injured so far proximal to the point of injury as to secure

clean, dry field. For temporary arrest of the hemorrhage, pass small rubber tubing or

tape around the vessel.

5. pulsating hematoma increasing in size and progressively interfering with the circulation of the extremity distal to the hematoma, requires surgical intervention.

6. Cases of arteriovenous fistulas are rarely detected in the first day or two after wounding. They are not per se an indication for operation and are better left until later date

unless there is complication, such as leakage or deterioration of the arterial supply to the

limb.

7. Supportive treatment for the patient in whom there is anxiety about the circulation

to limb should be as follows:

a. Heat the individual’s body and the root of the injured limb, protect the limb from heat loss by woolen coverings, if possible, but never heat the injured limb itself.

b. Perform paravertebral novocain block, if feasible, to overcome spasm of the collateral blood supply. This procedure to be repeated every 12 to 24 hours if beneficial

response is obtained.

c. If gangrene threatens, keep limb wrapped in sterile towel and observe closely for

the possible development of gas gangrene.

MEDICOMILITARY PROBLEMS IN TREATMENT OF ACUTE

ARTERIAL INJURIES

Any discussion of the therapy of vascular injuries must begin with the

premise that the restoration of the flow of blood through the original channel

is the desideratum. Unfortunately, even in civilian practice this can be accomplished in only limited number of cases, while in military surgery, for

variety of reasons, this number is still more limited. These reasons, which

have been present in all the wars of history, may be divided into two categories:

Those in which the factors are of such vital significance that they seal the fate

of the limb regardless of the form of therapy; and those which jeopardize the

effects of ideal therapy or preclude its institution.

24 See footnote 23, p. 71.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 73

Time Lag

The first factor which influenced the outcome in vascular injuries in World

War II, as in previous wars, was the time lag between wounding and surgery.

Therapy, designed to reestablish the circulation of the limb, must be carried

out within limited period after wounding. This limit was generally (if arbitrarily) set at to hours. While this criterion can usually be observed in

civilian practice, in military surgery it is frequently impossible because the circumstances of combat often do not permit prompt rescue and treatment. In sample group of 104 first-priority patients studied in the Mediterranean

theater, the time lapse from wounding to arrival at field hospital ranged from

to 34K hours and averaged about 12% hours. The time lag between wounding and tagging (first aid) ranged from few minutes to 25 hours and averaged

about hours. The time lag from arrival in the hospital to operation ranged

from to 10% hours and averaged about 3% hours. This delay was caused

chiefly by the necessity for resuscitation before surgery. In sample of 58

casualties with vascular injuries from the same theater, the time lag between

wounding and surgical treatment averaged about 15 hours, which is almost

twice the maximum period for safe arterial repair. After such length of

time, regardless of the nature of the original wound, thrombosis had usually

occurred in the vascular tree distal to the injury and the tissues of the wounded

extremity had been deprived of oxygen and nutrition too long for the changes

to be reversible.

From the military standpoint, it is doubtful that the time lag between

wounding and treatment can be reduced much lower than it was in World War

II. As the figures just cited show, nearly half of it was taken up by the period

between wounding and first aid and was therefore strictly military consideration. Furthermore, while in World War II every effort was made to bring

expert surgical care as near the frontlines as possible, it was impractical to

institute it at the level of the battalion aid station.

The establishment of vascular wounds as special category, to be handled

by special routine, was also not feasible. 25 For one thing, vascular injuries,

in spite of their seriousness, constituted such small proportion of the total

wounded that the imposition of another special category on the already overburdened military organization could not have been justified. For another,

the effective operation of such classification would have required of medical

corpsmen degree of differential diagnostic skill which they could not be expected to possess.

To preserve the circulation in the affected limb until patients with vascular

injuries could reach installations at which specialized treatment was available

numerous methods were suggested. Most of the suggestions were made by

physicians and surgeons without experience in the hard facts of military surgery and were not practical. Certain advocates of refrigeration, for instance,

25 Odom, C. B.: Causes of amputations in battle casualtieswith emphasison vascular injuries. Surgery 19; 562-569,

Apr 1946.
74 VASCULAR SURGERY IN WORLD WAR II

proposed its use under combat conditions. Aside from other considerations,

discussed later in the chapter, this method was completely impractical for

the battlefield.

The use of anticoagulant therapy (heparin) before the patient reached

hospital installation with laboratory facilities was also impractical. This form

of therapy can never be employed with safety unless the patient is under constant observation and in an installation where repeated determinations of the

clotting time of the blood can be made.

The same charges of impracticability, though perhaps to somewhat

lesser degree, can be made against sympathectomy and even sympathetic block.

Installations on the level of field hospital are not designed for such purposes

and the performance of these operations in them can not be justified in any

but occasional cases.

In view of these various factors, there was little to do but make the best

of the situation and to keep the time lag between wounding and treatment as

low as the military circumstances permitted. Admittedly if this lag could have

been reduced much better results could have been obtained. The importance

of the time factor can best be revealed by an analysis of 473 cases from the

American material, in 207 of which amputation had to be performed (Chart 7).

Only negligible number of the casualties in the 1- to 10-hour group were seen

much earlier than 10 hours, which explains why the results in that category are

not much better than the results in the whole group. When debridement had

to be delayed overlong the limb was often lost because of anaerobic infection,

though it is doubtful that this cause explained many of the cases in the 1- to

10-hour group. It played an increasingly important role, however, as time

progressed, and it probably accounted, at least in part, for the unhappy results

in the group observed 20 hours or more after wounding. On the other hand,

from the standpoint of possible reestablishment of the circulation, it is questionable whether time lag of more than 10 hours was of special significance, since,

as already pointed out, corrective measures must be instituted well within the

upper limits of this period if good results are to be secured.

Practical Difficulties

Reparative vascular surgery is always difficult surgery. It is time consuming, it requires special and delicate equipment, and it must be performed

by surgeon of highly specialized experience and great technical dexterity. 26

When casualties reached battalion aid stations they were usually observed by

nonspecialized medical personnel or, occasionally, by military administrative

officers. Men assigned to these stations were neither trained nor equipped to

institute specialized treatment. Even at field hospitals casualties were not

usually seen by experienced vascular surgeons. The infrequency of vascular

injuries would not have warranted the assignment of the limited number of

28 De Takats, O.: Vascularsurgery in the war. War Med. 291-296, Mar 1943.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 75

Chart 7. Effect of time lag between wounding and operation on incidence of amputation in

arterial wounds of the extremities among American battle casualties in World War II.

The data depicted are based on selected group for which the necessary information was

available. They do not include all arterial wounds during World War II.

medical officers in this group to installations on this level. Finally, when

casualties with vascular injuries did reach installations at which definitive

surgery could be done, the ablest surgeons, as already intimated, were working

against factors which were beyond their control and under conditions which

had usually ceased to be favorable. Outstanding results could not, therefore,

be expected.

Status of the Casualty

In addition to such external factors as the time lag and the lack of experienced vascular surgeons in forward areas, certain other factors inherent in

this type of injury precluded generally good results. One was the predominant

necessity of saving the casualty’s life before any endeavor was made to save

his limb. Even when the vascular injury was the only injury, the patient

was often in such poor condition from exposure, loss of blood, and other causes

when he reached the hospital that operation had to be postponed until he had

been sufficiently resuscitated to withstand it.
76 VASCULAR SURGERY IN WORLD WAR II

An important consideration in this connection was the amount of blood

lost. In the majority of vascular wounds considerable loss occurred before

first aid could be instituted. sample group of 27 patients studied during

the first week after wounding was found to have an average erythrocyte count

of only 2,700,000 per cubic millimeter. The hemoglobin concentration in 24

of the 27 patients was still only 60 percent of normal, though all of the patients

had been given whole blood in amounts which were thought to be adequate.

One patient in the group, with wound of the femoral artery, had lost 40 percent

of his normal blood volume when first seen.

Naturally, if the volume of circulating blood was reduced, the amount

which passed through the peripheral arteries was also reduced and the circulation in the distal portion of the extremity in which vascular injury had

occurred was still further curtailed and nutrition of the limb suffered accordingly. From both the systemic and local standpoints prompt restoration of

the circulating blood volume and hemoglobin concentration was essential. In

fact, the patient with wound of the extremity often required as much blood,

and sometimes even more blood, than one with wound of the chest or abdomen.

Associated Wounds

Another consideration which contributed to the seriousness of vascular

injuries was the presence of associated wounds which were often extremely

serious. In not more than third of all cases was the vascular wound the

only wound. Associated wounds of the abdomen, chest, or head sometimes

required attention far more urgently, as lifesaving matter, than did the

vascular wound, and vascular surgery had to be deferred in their favor. Other

local wounds might further impair, or altogether destroy, the regional circulation and make salvage of the limb entirely impractical. Compound fractures, for instance, frequently tore collateral vessels and favored the development of

inflammation and thrombosis. Patients were seen in whom plaster casts were

not adequately padded under the distal fragment of fracture of the lower

third of the femur. Damage to the femoral and popliteal arteries resulted,

and these cases almost invariably terminated in gangrene.

The series of vascular injuries which form the basis of this chapter show

how seriously the presence of associated fractures affected the outcome of such

injuries (Chart 8). The incidence of amputation was significantly higher when

the vascular injury was complicated by fracture. The observation is significant in itself and also suggests the importance, when studied in connection

with the British figures, of analyzing all the circumstances in any given series

of cases before drawing conclusions from comparative studies.

Nerve injuries were frequently associated with vascular injuries, as they

naturally would be, since with few exceptions all large blood vessels are accompanied by peripheral nerve trunks. This is especially true of the neck, and

of the brachial, femoral, and popliteal regions. The sciatic nerve was likely

to be involved in traversing wounds of the thigh, and the peroneal and tibia!
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 77

Chart 8. Effect of presence or absence of associated fractures on incidence of amputation in

arterial wounds of the extremities among American battle casualties in World War II. The data depicted are based on selected group for which the necessary information was

available. They do not include all arterial wounds during World War II.

components in large open wounds of the popliteal space. Nerve injuries often

had large share of the responsibility for the permanent disability which

followed some vascular wounds, but occasionally, and paradoxically, they

exerted transient beneficial effect in that they produced vasodilatation

peripherally in the area supplied by the affected nerve.

Site and Type ofInjury

On the basis of actual experience of surgeons in the field, and under the

conditions and limitations imposed by military practice, the categoric statement can be made that the site and type of vascular wound determine the

therapeutic procedure and therefore predetermine, so to speak, the end results.

The British experience in World War I, whenever detailed statistics are available for analysis (Chart 9), bear out this generalization. It is also borne out

by the American experience in World War II (Chart 9). Almost invariably it

could be anticipated that wounds of certain vessels, such as the popliteal artery,

were much more likely to be followed by ischemic gangrene than were those of

certain other vessels, such as the brachial artery. Indeed, for practical pur-
78 VASCULAR SURGERY IN WORLD WAR II

Chart 9. Effect of site of arterial wounds of the extremities on incidence of amputation in

American battle casualties in World War II and in British battle casualties in World

War I. The data depicted are based on selected group for which the necessary informa- tion was available and are not to be considered as complete. See text, pp. 63-65, for details of selectivity.

poses it was quite possible to make up categories of critical and noncritical

arteries. This observation held, however, only for single wounds. In the

material studied, wound of either the anterior or the posterior tibial artery

was relatively noncritical, but when both arteries were damaged the injuries

resulted in the second highest proportion of gangrene in both the British and

the American material.

Generally speaking, wounds of the lower extremity were more serious than

those of the upper extremity (Chart 10).27 The incidence of amputation was

considerably greater in wounds of the lower extremity, from the iliac through

the popliteal arteries, than in those of the upper extremity, from the subclavian

through the brachial arteries. Other considerations also entered into the

amputation rate. In injuries of the brachial and femoral arteries, for instance,

itmade difference whether the injury was above or below the profunda branch

(Chart 11).

27 The figure 2,453 is used instead of 2,471 as shown in Table 3, because included in the latter are 18 cases: aorta, 3;

carotid, 10; external carotid, 3; and renal, 2.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 79

Chart 10. Effect of site of arterial wounds of the extremities on incidence of amputation in

American battle casualties in World War II. The data depicted are based on selected

group for which the necessary information was available. They do not include all arterial

wounds during World War II.

The role of special vessels in producing the end results of traumatic vascular

surgery can be arrived at in another way. If the injuries of single vessels in

the forearm and leg (the radial, ulnar, anterior and posterior tibial, and peroneal

arteries) are excluded from the 2,453 arterial wounds of the extremities (see

footnote 27, p. 78) collected from American armies in various theaters of

operations (Table 3), the incidence of amputation after vascular injury rises

to 49.6 percent. If only multiple arterial wounds of the leg and wounds of

the iliac, femoral, and popliteal arteries are considered, the incidence of amputation rises to 62.6 percent (Table 3), similar selective analysis of the

British material reveals comparable conditions.

What these figures show is this: In any unselected group of vascular injuries the proportion of poor results will be high or low according to the number

of important or unimportant vessels involved. All recorded military experience is to this effect. The most common reason for the poor results of vascular

surgery in World War II was that the surgeon, no matter how great his skill,

had no factor of choice, and therefore no responsibility in regard to the site of

the wound. He had to institute therapy in accordance with its location, and
80 VASCULAR SURGERY IN WORLD WAR II

Chart 11... Effect of site of wounds of the brachial and femoral arteries on incidences of amputation in American battle casualties in World War II. The data depicted are based on

selected group for which the necessary information was available. They do not include all

arterial wounds during World War II. The 27 cases involving the profunda femoris shown

in Table have been excluded as not pertinent to this consideration.

its location was the determining factor in whether or not the limb could be

saved.

The extent of the arterial wound also played part in the end results.

Generally speaking, the larger the injury, (1) the greater was the chance that

the collateral circulation was also damaged, (2) the more extensive was the

necessary debridement, and (3) the greater was the chance of infection if

debridement was not adequate.

The actual type of injury was another factor of dominant importance in

determining the end results of arterial injury. Although in the American material from World War II it was possible from the records to separate only 620

of the 2,453 cases into distinct categories on this basis (Chart 12), the incidence of amputation seemed definitely related to the type of lesion. The

figures merely corroborate the clinical opinions of the surgeons who handled

these patients.

In those injuries in which thrombosis occurred, since this type of lesion

was always likely to cause widespread interference with the flow of blood

through collateral vessels, the worst results ensued, as might have been

expected. Circular Letter No. 178, dated 23 October 1943, from the Office
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 81

of The Surgeon General, 28 recommended that thrombotic segments of damaged

vessels be excised, not ligated, and later directives 29 from the Surgeon General’s

Office and other theaters of operations gave the same instructions.

Arterial lacerations usually represented serious type of injury. Minor

lateral lacerations, in which conservative surgery was possible, were seldom

encountered. In the present series (Chart 12) the category of lacerations and

transections includes 200 lacerations, 253 transactions, and number of cases

in which it could not be determined which of these lesions was present. In

the latter group the incidence of amputation, as might be expected in view of

its composition, was midway between the incidence of lacerations in which

interference with the circulation might be limited and the incidence in transactions in which there was abrupt interruption of the blood supply. Clean-cut

Chart 12. Effect of type of arterial wounds of the extremities on incidence of amputation in

American battle casualties in World War II. The data depicted are based on selected

group for which the necessary information was available. They do not include all arterial

wounds during World War II. The total number of lacerations and transections is greater

than the sum of the individual lesions in this category because it could not be determined

from 85 of the records which of these particular lesions was present.

28 Cir Ltr 178, SGO, 23 Oct 43, sub: Careof the wounded in theaters of operation.

29 TB Med 147, Notes on care of battle casualties, Mar 1945.
82 VASCULAR SURGERY IN WORLD WAR II

transections were seldom observed. In most cases tearing of the tissues

resulted in extensive loss of substance, usually associated with extensive damage

to the collateral circulation.

The category of arterial compression (Chart 12) includes only small

number of cases (10), but its importance is indicated by the fact that in of

the 10 cases amputation was necessary. Experience showed that this was

very important group because compression injuries commonly occurred in

association with fractures of the lower end of the femur with posterior displacement. No difficulties arose when the situation was corrected promptly. When

it was not, the consequences were usually disastrous.

category of injuries which does not appear in this classification because

it could not be identified from the records, but which is known to have been

observed in World War II, is the so-called concussion of the artery (stupeur

arterielle) 30 This was localized segmental type of spasm of the artery which

followed various forms of trauma. traumatizing agent which did not injure

the artery itself but passed near the vessel, or even at some distance from it,

was usually the cause. In such cases the limb was pale, cold, and pulseless,

but there was nothing to suggest hemorrhage, hematoma formation, or other

results of laceration. In differential diagnosis it had to be distinguished from

thrombosis. The spasm which followed arterial concussion usually lasted only

for some hours, but might last for many days (see Case 16). It was sometimes

sufficiently intense and prolonged to result in death of the limb, though as

rule itresponded well to debridement of adjacent lacerated tissues, conservation

of body heat, or sympathetic block. The latter procedure, to be successful, had to be accomplished as soon as practicable after the diagnosis was made.

If it did not achieve the desired results, then sympathectomy was performed.

In one case of arterial concussion observed in the Mediterranean theater, shell fragment produced wounds of entrance and exit on the lateral aspect

of the right calf at the midpoint. Although exploration revealed the track of

the missile to be between and cm. from the posterior tibial artery, this

vessel was in complete spasm.

Infection

In World War II infection was perhaps the least important of the limita- tions on therapy imposed by the circumstances of warfare. Battle wounds

were always potentially infected, it is true, but when adequate debridement

was carried out surgical procedures directed toward the treatment of the

vascular injury could be done at the same time with high degree of safety. It was not infection but other circumstances (time lag and type and location

of wound) which prevented reparative procedures in most battle injuries of

the blood vessels. The majority of the wounds in World War II were produced

by shell fragments; many of them were of considerable size, were associated

30 See footnotes 22 (3), p. 70; 28 and 29, p. 81.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 83

with extensive destruction of tissue, and were not favorably located (Charts

9, 10, 11). As result, the vitality of the limb was usually gravely impaired

before the surgeon ever saw the patient.

RESULTS OF ACUTE OCCLUSION

The results of acute occlusion of the major arteries in combat-incurred

wounds, whether caused by the injury itself or by ligation of the injured vessel,

have not been clearly established.

Part of the confusion, as has already been intimated, lies in the statistics

which for so many years were accepted as representing the incidence of gangrene

after acute traumatic vascular occlusion. Actually they represented no such

thing, since most of them included instances of aneurysm as well. The two

lesions are, of course, totally dissimilar. In acute occlusion, whether produced

by injury or ligation, the blood flow is cut off abruptly. In aneurysm the

occlusion occurs gradually, if at all, and by the time it has developed or the

aneurysm has been excised more or less adequate collateral circulation exists.

Furthermore, in many series gangrene is the only unfavorable result

reported. The percentage of cases in which primary amputation had to be

done because of arterial injury is completely disregarded and such series therefore do not represent the incidence of poor results in acute traumatic arterial

occlusion. As for the various series in which amputation is included—in

popliteal arterial occlusion, for instance, it varies from to 100 percent 31—it

is difficult to determine on what possible basis the calculations have been made.

Makins’ statistics, 32 which represent the largest collective experience in

World War I, furnish an excellent example of the confusion which results from

the inclusion of both acute and nonacute (aneurysmal) lesions in single series.

Actually, 49 percent of the cases in the series are aneurysms, and in such

vessels as the axillary and subclavian arteries the proportion is more than 70

percent. When, so far as possible, the favorable influence of aneurysm is

excluded, the proportion of poor results in Makins’ series rises from 18.1 to

26.5 percent.

When Makins’ figures are thus corrected, the American results in World

W'ar II, which at first glance seem much worse than those of the British in

World War I, are probably better. The American series does not include

aneurysms, the influence of which on statistics is always favorable, because,

as the experience at the vascular centers in the Zone of Interior clearly showed,

gangrene almost never occurs after operation for this type of lesion.

The confusion apparent in Makins’ series is almost always evident in other

reported series, e. g., Salomon, 33 and Soubbotitich. 34 On the other hand, from

31 See footnotes and 6, p. 61. 33 See footnotes 3, p. 60; and 12, p. 64. 33 Salomon, R.: Beltrag zur Lehre der arterlovenosen Schussaneurysmen. Beitr. z. klin. Chir. 113: 369-410, 1918. 34 Soubbotitich, V.: Quelques considerations sur les angvrismes traumatlques. Bull, et mem. Soc. de chlr. de Paris

42: 698-708, 1916.
84 VASCULAR SURGERY IN WORLD WAR II

every series in which aneurysms are excluded, the proportion of amputation

in vascular injuries is high. In 74 cases collected by Franz 35 from German

World War statistics the percentage of gangrene was 70.4 percent, and

Mocquot and Fey 36 reported an amputation incidence of 44 percent in 61

vascular injuries observed in French surgical ambulance.

The reported series which concern arterial ligation are no less confused

than those which deal with acute vascular injuries in which ligation has not

been done. From the period prior to World War I, no series large enough to

be representative is available, but Sencert, 37 who collected small number of

cases, reported that the incidence of gangrene ranged from percent when

ligation of the subclavian and brachial arteries was done, to 50 percent when

the common iliac artery was ligated. The author himself explained this remarkably wide range by the inclusion of aneurysms in the series.

On the basis of his personal military experience, Sencert 38 reported in

1918 that ischemic gangrene had occurred only twice in 70 cases of vascular

injury in which ligature was done few hours after injury and in which no

hematoma of any significance was present. The figures, again, cannot be

accepted at their face value because cases are included in which the injury

was venous, not arterial. When diffuse hematoma had formed, the results

were much less satisfactory, of 20 cases in which the axillary, femoral, and

popliteal arteries were involved, gangrene developed in 6. The figures are

perhaps somewhat selective because of Sencert’s own pronounced views concerning the important role of hematoma formation in arterial injuries.

Amputation after arterial wounds in World War II was usually done for

one of two reasons, gangrene or infection. The so-called toxic absorption,

which is assumed to be the result of autolysis of muscle in the ischemic limb

and which gives rise to systemic manifestations, should probably be classified

as infectious in origin.

Among American troops in World War II, ischemic gangrene, not infection, was the chief reason for amputation after vascular injuries (Table 4). Even

when clostridial myositis is combined with other infections it is seen that not

more than fifth of the amputations were performed because of infection.

This is in decided contrast to what happened in some other armies. Turovets, 39

for instance, in an analysis of the 12 amputations required in 49 vascular injuries sustained in the Russo-Finnish War of 1939-1940, found that 10 of the

12 were for gas gangrene or other infection while only were for ischemic

gangrene.

35 See footnote 17, p. 64. 39 Mocquot, P., and Fey, B.; Gravity des lesions arterlelles du membre interieur dans les plaies de guerre. Rev.

de chir. 63: 241-267, Mar-Apr 1917. 37 Sencert, L.: Le traitement des plaies vasculaires 1’avant. Lyon chir. 14: 638-686, Jul-Aug 1917. 33 Sencert, L.: Wounds of the Vessels. London, University of London Press, Ltd., 1918.

39 Turovets, I. Q.: Gunshot wounds of the blood vessels. Khirurgia No. 5-6,1942, p. 35-46. Abstr. Am. Rev. Soviet

Med. 1: 41, 1943, and Bull. War Med. 4: 628-629, Jul 1944.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 85

Table 4. Indications for Amputation in 189 Cases of Vascular Injury

There are otherreasons, in addition to the inclusion of aneurysms in Makins’

series, why the American results of arterial injuries in World War II seem worse

than the British results in World War I. In 86 percent of the American cases

the wounds involved important or critical arteries. This was true of only 70

percent of the British cases (Chart 6). The American figures, furthermore, include among the poor results all cases in which amputation was necessary

after vascular injuries regardless of the cause. It is possible, though exact

statements cannot be made on this point, that there are excluded from the

British figures some cases of gangrene and amputation which were classified as

infections rather than as vascular injuries, as well as those in which amputation

was necessary for extensive trauma and other complications of vascular injuries.

Finally, because of the more destructive weapons used in World War II, it may

be assumed that tissue destruction was greater among American wounded in

the Second World War than in the British cases of the First World War. As

result, in addition to the injury to the main arterial circulation, the collateral

circulation was frequently and seriously impaired. Further, debridement, which was probably more commonly practiced in the Second World War than

in the First, was more extensive. Debridement was, of course, an essential

procedure. Its omission in cases of arterial injuries would undoubtedly have

resulted in higher mortality rate, as well as in the loss of more limbs from

infection. When debridement is properly performed, however, it involves loss

of tissue and in extensive wounds its thorough performance inevitably entails

additional damage to the collateral circulation.

CONTROL OF HEMORRHAGE Packs

In the control of hemorrhage, packs were avoided as far as possible. Generally speaking, seepage was less harmful than the damage resulting from thenuse, for gauze packs inserted to check bleeding inevitably became tight and

when allowed to remain in place during prolonged evacuation eventually

Indication

1943 1944-45 Total 1943-45

Cases Percent Cases Percent Cases Percent

Primary

84.

14.

2.

43

64

13

13

32.

48.

9.

9.

43

111

21

14

22.

58.

11.

7.

Gangrene

Clostridial myositis

Other infections

Total

47

56 100. 133 100. 189 100.

Simeone, F. A.: Data from study of NATOUSA and MTOUSA proceedings of Disposition Boards for Amputees.

These amputations were done at Initial wound surgery, when vascular injury made survival of the limb unlikely.
86 VASCULAR SURGERY IN WORLD WAR II

caused good deal of damage. Quite properly, packs were used as temporary

expedient for controlling hemorrhage when they could predictably be removed

within few hours at hospital installation. The use of tourniquet was

thereby avoided.

Tourniquets

Tourniquets surely saved the lives of many soldiers in World War II who

otherwise would have died of hemorrhage. On the other hand, they were undoubtedly applied in some cases in which they were not really needed and were

responsible for the loss of some limbs which could have been saved. In all

theaters of operations surgical consultants and their assistants gave instruction

in the correct use of the tourniquet, emphasizing when its use was and was not

indicated, proper methods of application when its use was justified, and correct

management of casualty with tourniquet in place. Only by careful evaluation of the patient’s blood loss, state of shock, facilities available for blood

volume replacement therapy, time interval likely to elapse before primary

surgery could be done, and the extent of damage to an extremity, could proper

decision be made as to the application or removal of tourniquet.

Intelligent handling of this life- and limb-saving device demanded that each

casualty be treated as an individual problem. The application of tourniquet

for every wound of the extremity, with its release every half hour by rule of

thumb, was always potentially dangerous method.

Observations on the correct use of the tourniquet were best made in forward installations, chiefly in field hospital units, which accepted extremity

wounds in which hemorrhage was factor. It was in these units that most

patients who had had tourniquets applied were seen and it was therefore in these units that most of their life-saving and life-endangering results could be

observed. The following observations on tourniquets are based on the conclusions reached concerning them by Maj. Luther H. Wolff and Capt. Trogler

F. Adkins, 40 who were attached to the 2d Auxiliary Surgical Group. This team

operated for more than year in one of the “first priority” surgical hospitals on

the Italian front. It will be noted that certain of their data and conclusions

are at variance with practices accepted as correct before World War II, though

they are inagreement with the data and conclusions of most other surgeons who

had similar frontline experiences.

Choice of Tourniquets. Because complete control of bleeding is the primary

objective of tourniquet application, any result less than this must be considered

inadequate. For that reason the strap-and-buckle type of tourniquet issued

by the Army and generally used early in the war was not satisfactory piece

of equipment for first aid on the battlefield: It was so narrow that it cut into

the tissues, and it seldom controlled bleeding completely no matter how tightly

it was applied. The failure of this piece of equipment to produce desired results

10 Wolff, L. H., and Adkins, T. F.; Tourniquet problems in war injuries. Bull. U. S. Army M. Dept. 87: 77-84,

Apr 1945.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 87

could be explained in part by the usual practice of placing gauze roll or some

similar firm object over the affected vessel before it was applied. The vessel, being cordlike and elusive, frequently slipped out from under the roll and

bleeding continued. If the principal vessel was successfully occluded the collateral blood supply parallel to it was not, since the pad so elevated the tourniquet on either side that no pressure was applied to the vessels on either side of

the principal vessel. When the strap-and-buckle tourniquet was the only type

supplied, better results were obtained by substituting mechanic’s waste or

Carlisle dressing for the gauze pad, or by using no pad whatsoever.

The most satisfactory tourniquet was the pneumatic type in which the

pressure could be accurately adjusted and maintained. This type, however,

had two disadvantages: Pressure leakage was always possibility, and it was

too cumbersome and complicated for quick application on the field of battle.

However, when circumstances permitted, the pneumatic tourniquet which

records pressure in pounds per square inch or in millimeters of mercury was

safer. One pound of pressure in the model supplied was equivalent to 51.7 mm.

of mercury. When the tourniquet was applied to the arm, pounds of pressure

(250 mm. of mercury) was usually sufficient; in the leg the pressure seldom had

to exceed pounds (300 mm. of mercury).

The simplest and most effective type of tourniquet for frontline use was

not manufactured article but )2-inch softrubber tubing (U. S. Army Medical

Supply Catalog Item No. 3879000) in 6-foot lengths. When this size was not

available %-inch rubber tubing (Item No. 3878000) was an acceptable substitute.

Care had to be taken that only moderate tension was applied because complications which followed the use of rubber tubing were nearly always the result of

too much tension.

Technique of Applying Rubber Tubing Tourniquet. The bleeding extremity

was padded at the level at which the tubing was to be applied with towel,

shirt sleeve, trouser leg, or any similar available material. The tubing was then

wound around the limb in parallel turns under moderate tension only. The

end first applied was overlapped and anchored by the second turn, and the last

turn was anchored by the next-to-last turn. If the smaller-size tubing was used

more turns were necessary—from to 10 on the thigh, from to on the arm.

It was most important that tension be moderate. If several turns were applied

moderate tension was sufficient to occlude bleeding vessels completely and the

dangers inherent in tightly-applied tourniquet (a general fault) were thus

avoided.

The tourniquet was placed about the thigh or upper arm as close to the site

of injury as was feasible. If large defects were present care had to be taken to

apply it sufficiently far above the injury to prevent its slipping down into the

defect. Tourniquets placed about the forearm or leg were frequently not

effective since bleeding from incompressible interosseous vessels was likely to

continue and to lead to considerable loss of blood.

330323 0—55
88 VASCULAR SURGERY IN WORLD WAR II

Selection of Cases. Both judgment and experience were required to determine when tourniquet should be applied and when it could be omitted safely.

Many severe wounds of extremities, especially badly contused or avulsed

wounds not involving major blood vessels, required no tourniquets. An inadequate tourniquet could actually increase bleeding from this type of wound.

On the other hand, tourniquets were not used early enough and were insufficient

in many serious extremity wounds involving large blood vessels or in patients

with traumatic amputations. There may be some bias attached to this observation, since the only casualties admitted to hospitals on this level were

those in shock or with tourniquets.

Statistical data are not available to show what proportion of casualties

bled to death on the battlefield from wounds of the extremity, nor is it known

how many died from hemorrhage after they had received first aid. No comments on this point would therefore be justified. It was common experience,

however, to encounter in forward hospitals patients with wounds of the extremities to which tourniquets had not been applied and who survived the

transportation. Although their wounds on gross inspection did not appear

extensive, they had lost large volumes of blood. Studies of circulating blood

volume and other data obtained from many such individuals often showed that

they had lost from 33 to 50 percent, and sometimes more, of their circulating

blood volume. This blood loss might have been avoided by proper use of the

tourniquet.

It is true that when wounded soldier reached the field hospital, usually

within to hours after wounding, bleeding was likely to have stopped, but this

did not always prevent his condition from being critical from loss of blood.

Spontaneous arrest of hemorrhage took place as physiologic process in many

wounds of the extremity, but frequently it did not occur until the systolic

pressure had fallen and sufficient spasm had developed in the vessel for natural

processes to effect cessation of the blood flow.

It was an essential precaution to apply tourniquet to an extremity in

which there had developed, or was developing, large, pressure-producing

hematoma as the result of injury to major artery. Experience showed that

more damage could be done to the limb as the result of the pressure and hemorrhagic infiltration caused by this type of lesion than by the application of

tourniquet for reasonable time. It was highly unlikely that in such cases

the collateral circulation present about the hematoma immediately after injury

was sufficient to affect materially the viability of the distal tissues. It was also

thought that the early application of tourniquet increased the chances of

firm, occlusive clotting. It was shown repeatedly that operation for the release

of tension and for repair orligation of the damaged artery was simpler, and clots

and infiltrated blood could be handled more readily, if bleeding had not been

permitted to progress unchecked.

That reliance on natural methods is dangerous way to secure control of

hemorrhage is shown by the following case:
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 89

Case 1. sergeant was seen immediately after admission to field hospital, hours

after shell fragment had perforated the middle third of his left arm. No tourniquet had

been applied. Although the initial blood pressure was 115 mm. of mercury systolic and 60

diastolic he was extremely pale, restless, and apprehensive and had obviously lost large

quantity of blood. The pulse rate (in the carotid artery) was 128 beats per minute. Generalized vasoconstriction was intense. Examination of the wound showed no bleeding at

this time.

Within 10 minutes of admittance the patient’s condition began to deteriorate rapidly,

his blood pressure fell to 72 mm. of mercury systolic and 40 diastolic, and transfusion of

low-titer group blood was started immediately. The blood was forced in under pressure,

approximately 300 cc. being given in 15 minutes. In spite of the transfusion and other

standard methods for the treatment of shock, the man died 25 minutes after he had been

brought into the hospital.

complete necropsy revealed his only wound to be perforating one of the middle

third of the left arm, which had caused transection of the brachial artery and compound

comminuted fracture of the left humerus. The arterial wound showed no evidence of

intraluminal clotting. The patient had had no signs of symptoms of fat embolism before

death and no signs of this process were observed at necropsy. The cause of death was

recorded as hemorrhagic shock.

Comment. The details of the circumstances preceding the admittance of

this patient to the field hospital could not be obtained, and there are variety

of possible reasons why no tourniquet had been applied. Whatever they may

be, the statement is believed warranted that had tourniquet been applied

in this case, death from blood loss would probably not have occurred. As

this case, and numerous others, showed, an adequate tourniquet should be

applied proximal to any wound of the extremity which is bleeding freely. It

should be applied, moreover, at the earliest possible moment. Many of the

fears of damage from tourniquets are probably unfounded to large extent,

and certainly the saving of every possible ounce of blood is the more important

consideration from the standpoint of the patient’s general condition.

Release and Removal oj the Tourniquet. It is unfortunately true that in

World War II some limbs were lost because tourniquets were left in place too

long and gangrene developed. There was some disagreement, however, over

how long “too long” was. Wolff and Adkins’ experience in Italy 41 showed

that tourniquet could be left in place from to hours without clinically

detectable damage depending on the temperature of the atmosphere and of

the extremity. During the winter of 1943-44 they observed tourniquets

which had been left on as long as hours without apparent deleterious effects.

Surgeons of an auxiliary surgical group performed amputations on approximately

thousand patients in forward field hospital. These surgeons all observed

extremities on which tourniquets had been left applied up to hours, yet no

cases of gangrene solely from tourniquet were noted. In no case was there

an unusual degree of edema, slough of the skin edges, or any ischemia of the

muscles which could be attributed solely to the use of the tourniquet. Moreover, during the period of observation which lasted from to 10 days in most

41 See footnote 40, p. 86.
90 VASCULAR SURGERY IN WORLD WAR II

cases, no instance was observed in which the application of tourniquet had

caused either nerve injury or thrombosis.

About the development of gas bacillus infection it is necessary to be less

positive. This type of infection was observed in patients who had worn

tourniquets for various periods of time, but it was also observed in others

who had not worn them. Gas bacillus infection seemed somewhat more

prone to occur in the bloodless extremity to which tourniquet had been

applied, but no definite opinion was formed on this point. It was the consensus,

however, that even if these complications did occur more frequently, the role

of the tourniquet as lifesaving measure would still make its use imperative.

There are cases in which the removal or loosening of tourniquet is unwise

and unnecessary; in fact, the results may be disastrous. Experience has led

to the conclusion that under no circumstances should tourniquet be loosened

on patient in shock or in incipient shock unless means are present and

immediately available to control any hemorrhage that may occur and to replace

rapidly the volume of circulating blood. The presence of medical officer

was considered necessary. The following case histories illustrate the widsom

of these precautions.

Case 2. An officer was admitted to field hospital hours after he had been wounded

by shell fragment which traversed the right arm and produced compound comminuted

fracture of the humerus. This was his only wound. When he was admitted to the field

hospital he was in mild to moderate shock. The blood pressure was 110 mm. of mercury

systolic and 66 diastolic and the pulse rate was 112 beats per minute. The blood vessels were in state of vasoconstriction. Although he had obviously lost considerable blood his

condition was recorded as fair.

Examination of the wounded arm showed an improvised splint, tourniquet of the

strap-and-buckle type applied tightly at the level of the insertion of the deltoid muscle, and

fairly extensive perforating wound of the inner aspect of the lower arm. slight but

persistent oozing from the wound was thought to be of venous origin, the result of back

stasis from nonocclusive tourniquet. The tourniquet was therefore loosened and slipped

off after blood pressure cuff had been placed about the arm above it. Before the cuff

could be tightened, the severed brachial artery broke away and in the few seconds required

to pump up the blood pressure cuff enough blood was lost (not more than 100 cc.) to cause

drop in the blood pressure from 110 mm. of mercury systolic and 66 diastolic to 80 systolic

and 40 diastolic and to deepen materially the state of shock. It is not hard to imagine what

might have happened, since the circulatory volume was at critical level, if measures for the

prompt control of hemorrhage had not been available. The patient was immediately given

2,000 cc. of whole blood and after resuscitation had been accomplished successful operation

was performed. Recovery was uneventful.

Case 3. private was admitted to field hospital hours after he had sustained

traumatic amputation of the left leg, just below the knee, from German “Schu” mine.

He was in severe shock with blood pressure of 86 mm. of mercury systolic and 56 diastolic, and pulse rate of 116 beats per minute. Examination disclosed persistent trickle of

blood from the badly contused stump although there were two tightly placed strap-andbuckle tourniquets about the thigh. tourniquet of soft rubber tubing as substituted for these tourniquets and bleeding was promptly controlled. Vigorous resuscitative meas- ures were undertaken, including infusion of 2,000 cc. of whole blood. At the end of hours,

however, the patient was still in such poor condition that operation could not be considered.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 91

Ordinarily patient with wound of this sort could be prepared for operation within

an hour and one-half at the most; if he could not be, gas bacillus infection or continued

bleeding was the usual explanation. Examination of this man’s wound showed that the

dressings which had been applied over the stump after the original examination were saturated with blood and that pool of blood had collected under his buttocks. Questioning

disclosed that the tourniquet had been loosened by ward attendant at 30-minute intervals

ever since it had been applied, and as result the patient had been losing as much blood by

its periodic release as he was gaining by transfusion. The introduction of another 1,000 cc. of whole blood with the tourniquet tightly in place produced the desired results and rendered

the patient safe risk for surgery within short time.

It was repeatedly observed in the course of World War II that patients

who had lost small to moderate amounts of blood could tolerate further rapid

loss of small additional amounts without placing their chances of recovery in

jeopardy. It was also repeatedly observed that many patients who had lost

blood up to the critical level could maintain semblance of circulatory equilibrium only by intense vasoconstriction, rapid heart action, and other physiologic compensatory mechanisms. It was in these patients that urgent care

had to be used to prevent any additional decrease in blood volume. The rapid

loss of even 100 cc. of blood could completely break down the delicately

balanced compensatory mechanism and result in profound and often fatal

shock through failure of the vasoconstrictor apparatus. It was never safe

to loosen tourniquet in such cases, no matter how long it had been applied,

until the blood volume had been restored to safe level by plasma transfusions

or, better, by whole blood transfusions.

It also had to be borne in mind that patients may lose more blood than

is first apparent on loosening tourniquet, particularly tourniquet about the

thigh. The arterial system fills up more or less uniformly on release of

tourniquet, and if the vascular injury is some distance below the tourniquet

the injured area continues to drain off the blood in the intervening vessels,

even though the tourniquet is promptly reapplied upon the first sign of

hemorrhage.

Principles of Tourniquet-Application. On the basis of observations made

in the early months of the war, the following ideal plan was substituted for

the former plan of releasing tourniquet every 20 to 30 minutes:

1. An adequate tourniquet should be placed on an actively bleeding

extremity at the earliest possible moment after injury.

2. patient with tourniquet in situ should be given the highest priority

for transportation to the nearest available hospital and the presence of the

tourniquet should be plainly indicated on his record.

3. At the end of hours, providing the patient is not in shock and depending on the circumstances of the temperature and tactical situation, the tourniquet should be cautiously loosened under the supervision of medical officer.

The precaution of professional supervision should be omitted only in very

exceptional circumstances. If bleeding recurs, the tourniquet should be

reapplied at once. If hemorrhage apparently has been controlled, the tourni-
92 VASCULAR SURGERY IN WORLD WAR II

quet should be removed, but it should be kept available for instant reapplication and the patient should be kept under constant observation.

4. If patient is in shock from hemorrhage, the tourniquet should on no

account be removed within the first to hours of its application unless the

blood volume has been at least partially replaced by plasma or whole blood.

This plan involves calculated risk, but the possible loss of few inches of

badly damaged extremity cannot be permitted to compromise patient’s life.

5. At the end of the 4- to 6-hour period, removal or loosening of the

tourniquet should be matter of individual judgment on the part of the

medical officer. After to 10 hours have passed, it should be removed for it

can be assumed that sufficient spasm and clotting have developed to prevent

further bleeding. Even when the extremity is chilled, it is unwise to leave the

tourniquet in place longer.

6. The temperature of an extremity about which tourniquet has been

applied should be lowered as far as possible, short of actual freezing.

Numerous experimental observations have shown that the temperature of

bloodless extremity has much to do with the speed with which tissue necrosis

occurs, and that the metabolic demands of the tissues vary directly with the

temperature. This observation was of importance in tourniquet application,

tourniquet applied in the heat of the tropics, or in the desert, had to be loosened at shorter intervals than tourniquet applied in cool or cold climate.

While care was taken to prevent frostbite and other cold injuries in cold and

freezing weather, it was the rule to leave uncovered an extremity about which

tourniquet had been applied, and never to employ artificial means to warm it.

EXPECTANT TREATMENT

The salvage oflimbs which were the site of vascular injuries depended quite

as much upon multitude of details as upon the major surgical method used.

Careful wound debridement minimized the chances of infection, as did chemotherapy and antibiotic therapy. Every possible collateral vessel was spared.

Such circulation as was present was maintained by proper posturing and by

the correction of oligemia and anemia. Circulation through the collateral

channels was encouraged by the release of the vessels from vasoconstricting

influences by means of sympathetic block or sympathectomy. Heparin was

employed when circumstances permitted the proper precautions, to prevent

thrombosis. No single one of these measures, all designed to improve the circulation, could guarantee survival of any limb, but the careful use of all of them,

or of as many of them as possible, frequently made the difference between good

and poor result.

Some surgeons felt that in small and carefully selected group of vascular

injuries either uncomplicated healing might take place without any surgery

at all, or, if it did not, that aneurysm formation would take place. It is true that

there is an almost negligible incidence ofloss of limb after excision of aneurysms,
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 93

but it is also true that traumatic arterial lesion is not necessarily followed by

aneurysm formation. On the other hand, when it is possible to delay surgical

ligation for period of time, the status of the limb was frequently better than

whenit was necessary to perform it immediately.

Case 4- soldier wounded by enemy shell fragments in Italy on June 1944, at 1100

hours, incurred multiple penetrating wounds of the right hand, wrist, arm and chest wall,

and of the right knee in the popliteal space where he sustained through-and-through

wound of the popliteal artery. He suffered no fractures in the lower extremity. All wounds

were debrided in forward hospital on June between 2100 and 2135 hours, with the patient

under thiopentalsodium anesthesia.

On June, en route in hospital ship to general hospital in the base, the patient complained of pain in the right knee and during ambulance transportation he bled from the

wound in the popliteal space. Bleeding ceased spontaneously after loss of about pint of

blood.

He was taken promptly to the operating room where exploration revealed that the popliteal artery was enclosed in sac which was pulsating strongly. The sac was not

disturbed in the hope that an aneurysm would form. Since the wound looked clean, partial

closure of the muscle was done. firm dressing was applied down to the muscles and the

leg was partially immobilized in posterior plaster shell.

Roentgenograms the day after operation revealed metallic foreign body by mm.

in the right popliteal space. The total plasma protein concentration was 4.75 gm. per

100 cc. and the hematocrit value was 26.9 percent. By June transfusions had amounted to 1,850 cc. of whole blood.

On 11 June the patient complained of pain in the right popliteal space and said he

could “feel bleeding.” Upon examination, no blood was apparent on the dressing. On

12 June he complained of more pain during the night. When the splint was removed both

the dorsalis pedis and the posterior tibial arteries could be palpated on the right side, but

pulsations were decidedly weaker than on the left side. The right foot was warm and well colored and sensation was intact. When the dressing was removed fine-mesh gauze

pack was found in place, and as it was loosened brisk bleeding developed. firm pressure

dressing was applied and the patient was taken to the operating room at once. There

the pack was removed, the skin was closed with three interrupted sutures, and bleeding

was controlled by firm elastic bandage. transfusion of 500 cc. of whole blood was

given.

The following day the foot was warm. The patient could move his toes but he complained of pain in the right popliteal area radiating into the toes which were hypesthetic

but not anesthetic. Recovery proceeded smoothly until 19 June, when there was sudden

hemorrhage from the right popliteal space. pressure dressing was reapplied. The foot

was warm and motion in the toes was normal. On 20 June, the total plasma protein concentration was 6.5 gm. per 100 cc. and the hematocrit value was 33 percent.

Bleeding recurred 23 June and was again controlled by pressure dressing. Two

days later the toes were still warm and there was less complaint of pain. On this day,

however, there was another episode of bleeding which required the application of tourniquet as well as of pressure dressing. The total plasma protein concentration was 5.8 gm.

per 100 cc. and the hematocrit value was 35.5 percent. On 26 June right lumbar ganglionectomy, with excision of the second, third, and fourth lumbar ganglia, was done with the

aid of spinal analgesia.

On 27 June, the right popliteal artery was explored with the patient under ether anesthesia. After removal of large organized clot with pseudosac from the popliteal space,

through-and-through wound of the artery was found (Fig. 4). After the artery was
94 VASCULAR SURGERY IN WORLD WAR II

Figure 4• (Case 4-) Through-and-through wound of popliteal artery. Partially excised wall of hematoma is being retracted.

freed it was evident that suture of the injured vessel was not possible. The artery was

therefore ligated above and below the injuries with No. chromic catgut, the damaged

segment (about 1.5 inches) was excised, and the foreign body removed. The segment

which was excised lay between the outlet of the adductor canal and the middle geniculate

artery. The vein was not thrombosed and was not ligated. Five hundred cubic centimeters of blood were given in the course of the operation and 500 more after operation.

Before the operation the right foot was definitely warmer than the left, but on palpation neither the dorsalis pedis nor the posterior tibial artery was palpable. Motion and

sensation were normal except for mild hypesthesia to pin prick in the toes. The day after

operation the right foot was colder and dryer than the left foot. Motion continued to be normal in the foot and toes. No pulsations were palpable in the right posterior tibial and

dorsalis pedis arteries. Thereafter recovery was smooth, and by 30 June there was every

indication that the injured extremity would survive. By July when the patient was

evacuated, the temperature of both feet was the same. The popliteal wound was well

healed. The right calf was very slightly larger than the left, but no induration was palpable.

Comment. There are number of lessons to be derived from this case.

One is that it is possible for pulsation to be present in the dorsalis pedis and

posterior tibial arteries even when there is through-and-through wound of
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 95

the popliteal artery. Another is the advantage of delayed ligation of an

injured artery. This patient would almost certainly have lost his leg if the

popliteal artery had been ligated immediately after injury. On the other hand,

this case clearly shows that evacuation of patient with wound of this character

is hazardous. Early evacuation was permitted in this case because the wound

was not recognized. Had it been recognized, and had expectant treatment

been deliberately instituted in order to delay ligation of the artery, the patient

would have been kept under continuous observation until the vessel had been

ligated or the wound had healed, and the repeated hemorrhages could probably

have been avoided.

Conservative therapy of vascular wounds was advocated as deliberate

policy by some British surgeons at the Congress of Central Mediterranean

Forces Army Surgeons held in Rome in February 1945,42 but only few

American casualties were deliberately treated in this manner. Sandzen and

Evans 43 treated cases conservatively with excellent results in series of 89

vascular wounds, 64 of which involved major arteries, and Rose, Hess, and

Welch 44 treated of 100 cases conservatively, also with good results. In of

the cases the wounded vessels were exposed during debridement, but in the

other cases, in all of which the popliteal artery had been injured, they were

not visualized.

The selection of cases for conservative management required expert surgical

judgment, as well as good deal of courage. The chief objection to the method

was that it usually implied the omission of debridement which was so essential

part of the management of all war wounds that exceptions to its routine

performance had to be made with the greatest caution. An additional reason

for carrying out complete debridement in any case was that it afforded an

opportunity to repair laceration by suture or to perform nonsuture anastomosis. If the artery was intact its continuity could be determined without dislodging it entirely from its bed. Generally speaking, it was best to explore

even trivial wounds with the idea of performing remedial or reparative surgery

if there was evidence of complete interruption of the circulation. The following

case histories point out the advantages of exploration:

Case 5. soldier wounded by enemy shell fragments 20 May 1944 suffered 2-cm.

penetrating wound of the lateral aspect of the right knee with laceration of the popliteal

artery just below the geniculate branches. Only quarter of the anterior arterial wall

remained intact. Examination in forward hospital revealed the popliteal area and calf to

be tense and swollen. The right leg and foot were cold and motionless. No pulsations could

be felt in the popliteal, dorsalis pedis, or posterior tibial vessels.

42 (1) Brown, J. J. M.: plea for conservatism in the primary surgery of wounds of the main arteries of the limbs.

Proc. Cong. C. M. F. Army Surgeons, Rome, 12-19 Feb 45, p. 103-106. Also discussions by Major Robb and Major

Cleland.

(2) Erasmus, J. F. P.: The problem of wound excision in the treatment of vascular injuries. Proc. Cong. C. M.

F. Army Surgeons, Rome, 12-19 Feb 45, p. 112-113. 43 Personal communication to F. A. Simeone from S. C. Sandzen and B. H. Evans. 44 Rose, C. A.; Hess, O. W., and Welch, C. S.: Vascular injuries of the extremities in battle casualties. Ann. Surg.

123: 161-179. Feb 1946.
96 VASCULAR SURGERY IN WORLD WAR II

The patient was operated upon hours after wounding. The arterial laceration was sutured after removal of large hematoma and the deep fascia over the upper half of the

swollen calf muscles was incised. The right lumbar sympathetic trunk was blocked with

procaine hydrochloride. The right thigh and leg were enclosed in plaster with the knee

flexed to 30 degrees. No pulsations were felt in the posterior tibial and dorsalis pedis arteries

at the end of the operation.

The following day the ankle and dorsum of the right foot were warmer though the toes

remained cold and blanched. No pulse was palpable in the foot. Right lumbar sympathectomy was done with no obvious immediate improvement. Two days after operation

the right foot and toes were warmer and there was partial return of sensation and motion.

No pulse was palpable in the foot. Thereafter improvement was continuous until the

patient was evacuated to the base 11 days after injury At this time, although pulsations

had not returned in the dorsalis pedis or posterior tibial arteries, the circulation in the

injured extremity appeared satisfactory

Comment. The result achieved in this case would be good for any type

of acute injury of the popliteal artery. Before operation the circulation in

the extremity was apparently seriously impaired. The collateral vessels were

intact, and it is impossible to be certain whether the improvement which began

day or two after operation could be attributed to the function of the sutured

popliteal vessel or to the function of the collateral vessels which had been released from compression by removal of constricting hematoma.

Case 6. soldier was wounded by mine fragments 20 October 1944. He incurred wound with its point of entrance just above the head of the left fibula; the wound of exit

was on the posteromedial aspect of the left thigh at level cm. above the wound of entrance.

The popliteal artery was severed below the geniculate branches. At the evacuation hospital

the popliteal space and upper calf were found to be swollen and firm. The left foot was

cold and pulseless and only slight motion was possible.

With the patient under endotracheal ether anesthesia, operation was performed hours after wounding. large hematoma was evacuated from the popliteal space. The retracted

ends of the popliteal artery were identified and were approximated by slight traction and

30-degree flexion of the knee. Thrombi were removed from both ends of the severed vessel

and an end-to-end anastomosis was done with interrupted sutures of fine silk. All wounds

were debrided. long leg plaster was applied with the knee in 30-degree flexion. The left

lumbar sympathetic chain was blocked with procaine hydrochloride. At the conclusion of

the operation the condition of the foot was unchanged.

The day following operation the foot was still cold and pulseless but motion in the toes

had improved. Sympathetic block was repeated. On 22 October the foot and toes were

warm and free, and motion was possible although the dorsalis pedis pulse was still not

palpable. By November, when the patient was evacuated to general hospital, all the

toes were warm and sensation and motion in the whole extremity were practically normal.

Comment. The result in this case, in which the location of the lesion was

approximately the same as in the preceding case, is also good for laceration

of the popliteal artery. In both cases the location was the best possible for

maintenance of function of the collateral vessels. Since, however, improvement in the foot was delayed for days after operation, it is impossible to be

certain whether the popliteal artery functioned after suture or whether the

good result is to be attributed to an adequate collateral circulation.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 97

Supplemental Therapeutic Measures

Posture. The position of an extremity in which the blood supply is embarrassed as the result of disease or injury has long been controversial matter.

Directives and circular letters issued for the care of arterial injuries reflected

the conflicting opinions. Circular Letter No. 13, dated 15 May 1943,45 included elevation of the part among the emergency measures for the control of

hemorrhage, but advised that following ligation of vessel the extremity

should not be elevated but should be slightly depressed. In December 1943,46

the Surgeon of the Fifth Army issued directive in which it was stated that

inall cases in which the blood supply to an extremity is impaired the extremity

should be depressed. The Manual of Therapy issued in the European Theater

of Operations, May 1944, listed as measure for the control of hemorrhage

the following: “Elevation of the part. This should be done with due care of

associated fractures, regardless of the local methods used.” Circular No. 8,

dated 10 March 1945, issued from the office of the Surgeon, Mediterranean

Theater of Operations, stated: “The position of an extremity is important, as

elevation may accentuate ischemia. dependent position is preferable even

if moderate degree of edema appears to be the result.” This warning was

also repeated elsewhere. 47

These altered instructions reflected the conflict of opinion on this subject

which existed in civilian practice and can be attributed to failure to distinguish

between peripheral edema per se and peripheral edema associated with acute

arterial injuries. In these injuries, particularly in acute occlusions of the main

blood supply to limb, the blood flow to the part was impeded and had to be

maintained through the collateral circulation. Elevation of the extremity

above the level of the heart accentuated the ischemia by forcing the blood flow

to overcome the amount of gravity pull created by this position. Against this

argument was the fact that edema in the tissues, which under ordinary circumstances would be treated by elevation of the limb above the level of the

heart, was undesirable in arterial injuries for number of reasons: It disrupted

tissue and predisposed to fibrosis. It compressed and occluded small vessels.

It increased the barrier to the transport of metabolic products to and from the

blood. The edem» which occurred in battle injuries was therefore as undesirable

as edema always is, but it was the result, in part at least, of ischemia which

would be increased and not reduced by elevation of the limb above heart level.

When confronted with this choice it therefore seemed more reasonable to

maintain the extremity in slightly dependent position, or possibly at heart

level, and to regard the edema as the lesser of two evils. Alternate raising and

lowering of the limb for brief periods was suggested as solution of the problem,

but careful judgment was essential to be certain that elevation did not do

more harm than good by increasing the period of ischemia.

4S See footnote 22 (1), p. 70.

Essential Technical Medical Data from Overseas Forces, Hq NATOUSA, 23 Dec 43. HD: 350.05. 47 See footnote 28, p. 81.
98 VASCULAR SURGERY IN WORLD WAR II

Some authorities were not in agreement with this point of view. Cohen, 48

for instance, advocated elevation of the limb on the ground that this position

does not empty the arterial tree and cause capillary anoxia. He stated that

elevation by diminishing venous pressure and increasing lymph flow prevents

edema which will compress the capillaries. The experience of American surgeons, however, confirmed the desirability of placing the extremity in slightly

dependent position.

Physiologic rest of the injured limb was essential both to reduce to

minimum the nutritional needs of the tissues and to limit infection and absorption of toxic by-products. These objectives were best accomplished by placing

the extremity in well-padded posterior plaster shell made by splitting long

tubular plaster cast. The limb could then be lowered onto support off the

side of the bed or kept in dependent position by some other means.

Oxygen Therapy. Since lack of available oxygen is one of the factors responsible for death of tissue after vascular occlusion, oxygen inhalation seemed

reasonable method of supplying the lack in acute vascular injuries. An increase

in the oxygen saturation of the blood could be easily effected by this means

when oxygenation was impaired by thoracic wounds or similar causes. Under

normal respiratory conditions, however, the increase in the partial pressure of

oxygen in the inspired air had little effect upon the oxygen content of the

blood. The slight increase (15 percent) was made possible by an increase in

the amount of oxygen dissolved in the plasma. Whether or not this increase

resulted in sufficient increase in the oxygen gradient between capillary blood

and the rest of the tissues to affect the outcome in arterial injuries seemed

doubtful, especially in view of the difficulties inherent in the use of the method

under combat conditions. It was the consensus that better results would be

achieved by devoting the same amount of effort to correction of oligemia and

anemia with the objective of improving the oxygen-carrying capacity of the

circulating blood.

Anticoagulant Therapy. Anticoagulant therapy, in spite of its value in

selected vascular surgery cases in civilian practice, had an extremely limited

application in the military setup in overseas theaters. Its use, as already

pointed out, was impractical immediately after wounding because the criteria

of its employment, close clinical observation and repeated laboratory studies,

could not usually be met. Mere arrival of the patient at hospital did not

meet these criteria. For one thing, the vascular injury had to be the only injury;

the use of an anticoagulant agent if the patient had other injuries was contraindicated for obvious reasons. Moreover, while it may be theoretically possible

in civilian hospital or Zone of Interior installation to employ heparin or

some similar agent before operation and to control the clotting time during the

procedure, this could not be regarded as either practical or safe in an overseas

forward area.

49 Cohen, S. M.: Traumatic arterial spasm. Lancet 1:1-6,1 Jan 44.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 99

Another, and perhaps the chief, reason for not employing anticoagulant

therapy in most combat-incurred vascular injuries was that by the time the

patient could be transported to hospital equipped to administer it, too much

time had elapsed for the measure to be of any benefit. Thrombosis usually

had occurred, and the distal portion of the extremity had been deprived of

blood for too long period for the pathologic changes which follow in the

absence of circulation to be reversible.

In spite of these obstacles to its routine employment, in few cases of

battle injuries in which anticoagulant therapy was indicated and in which

conditions permitted careful, continuous observation and adequate laboratory

checks, the method had definite field of usefulness and was employed.

Data are not available as to how often anticoagulant therapy was used in

vascular wounds by American surgeons in World War II, although it is known

that it was employed only rarely. In sample of 12 cases in which it was

instituted (it was usually administered in Pitkin’s menstruum) 49 as early as was

considered feasible under the military conditions and in which careful studies

were made, no significant advantages were observed from its use. 50 Langley 51

suggested continuous saline drip as more effective mode of administration

than intermittent intravenous injection. He also regarded the generally

accepted dosage as insufficient.

The Use of Refrigeration. The concept of reducing the metabolism of an

injured part by cooling to make metabolic activity commensurate with whatever circulation remains in the limb is theoretically sound and had attracted

some attention before World War II. 52 On the other hand, the wisdom of

actual refrigeration of limb in which the circulation is for any reason impaired

is still open to question unless the objective is to control infection and diminish

lymphatic absorption prior to amputation, or to permit amputation without

anesthesia in an aged and debilitated subject, 53

Bruneau and Heinbecker 54 showed that under experimental conditions the

clinical application of cold (6° C.) to infected tissues was of no therapeutic value

per se, and when the application was continued for periods of 24 to 96 hours,

there were definite changes in tissue hydration, pronounced vasodilatation,

and decrease in the growth-resisting action of the tissues toward bacterial

Loewe, L., Rosenblatt, P., and Lederer, M.: new method of administering heparin. Proc. Soc. Exper. Biol.

Med. 50; 53-65, May 1942. 80 Simeone, F.: Wounds of the arteries of the extremities. Report to the Surgeon, Mediterranean Theater of Operations, Aug 1945. HD: 350.05. 81 Langley, O. F.: Repair of ruptured popliteal artery, with note on heparin therapy after arterial suture. Brit. J.

Surg. 31; 161-165, Oct 1943. 81 (1) Blalock, A.; Effects of lowering temperature of injuredextremityto which tourniquethas beenapplied. Arch.

Surg. 46: 167-170, Feb 1943.

(2) Freeman, N. E.: Influence of temperature on development of gangrene in peripheral vascular disease. Arch.

Surg. 40: 326-333, Feb 1940. 88 (1) De Takats, G., and Miller, D. S.: Use of direct heat and indirect heat to increase blood flow to the extremities.

War Med. 2: 429-436, May 1942.

(2) Richards, V.: Refrigeration anesthesia in surgery. Ann. Surg. 119: 178-200, Feb 1944. 88 Bruneau, J., and Heinbecker, P.: Effects of cooling on experimentally infected tissues. Ann. Surg. 120: 716-726,

Nov 1944.
100 VASCULAR SURGERY IN WORLD WAR II

organisms. These changes became more severe as the period of refrigeration

was prolonged. They concluded their article by stating: “While the exact

clinical limitations of the procedure remain to be determined, this would contraindicate, except for brief periods, the cooling to levels around 6° C. of infected limbs which one aims to save by conservative measures.” Large and

Heinbecker 55 noted in 1944, asBrooks and Duncan 58 had previously noted, that

healing progressed less satisfactorily after refrigeration, and they also called

attention to the possibility of nerve injury following prolonged cooling of an

extremity.

Throughout the war some observers continued to advocate the refrigeration

of the wounded extremity. They argued that application of ice packs would

gradually produce anesthesia in the injured part and allow painless transportation of the wounded soldier which is considerable factor in the prevention of

secondary collapse from continued pain, bacterial growth would be inhibited

by refrigeration therapy because of decreased oxidation, and enzymes and

toxins would be temporarily inactivated. dirty wound would, therefore, be

maintained in stationary condition until debridement could be carried out.

It was also pointed out that when refrigeration was continued following definitive treatment because of irreparable vascular damage it had to be continued

until the collateral circulation was reestablished, vasospasm was overcome,

thrombosed vessels recanalized, or until failure was evident. In any event,

it had to be withdrawn slowly to prevent the rapid spread of gangrene or

infection.

Regardless of the logic or the fallacy of this line ofreasoning, refrigeration,

as already pointed out, was only occasionally practical procedure in hospitals

of combat zone, while the transportation of wounded soldier through

channels of evacuation with repeated replacement of ice packs on his wounded

limb was concept which no experienced military surgeon could possibly

contemplate.

Refrigeration was employed in cases in the Mediterranean theater in which circumstances were favorable for trial of this method. The femoral

artery was the site of the wound in case and the popliteal in cases. Amputation was required in all instances. These poor results are in accord with

those reported by Auster, 57 and by Ottaway and Foote, 58 who gave the method

trial in naval casualties in the South Pacific, and by Snyder, 59 who used it

in the Mediterranean and European theaters. While the amputations necessary in these cannot be attributed to the method (it was employed with great

58 Large, A., and Heinbecker, P.: Nerve degeneration following prolonged cooling of an extremity. Ann. Surg. 120:

742-749, Nov 1944. 56 Brooks, B., and Duncan, Q.: The influence of temperature on wounds. Ann. Surg. 114: 1069-1075, Dec 1941. 87 Auster, L. S.: Combat injuries in the South Pacific. U. S. Nav. M. Bull. 42: 1009-1018, May 1944. 89 Ottaway, J. P., and Foote, J. J.: Refrigeration of wounded extremities. U. S. Nav. M. Bull. 43: 1041-1043,

Nov 1944. 89 Snyder, J.M.: Vascularwounds; report of series of 108cases encountered in forward evacuationhospital. Surgery

21; 77-85, Jan 1947.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 101

caution and careful observation) no evidence exists that this method has saved

limbs after wounds of the major arteries. Indeed its prolonged use, as has

already been indicated, can lead to damage of the tissues that it is expected

to preserve.

While the direct application of cold to the injured limb was not advocated, itwas recommended that the temperature of an extremity to which tourniquet

had been applied should be lowered as much as was feasible short of actual

freezing.

The Use of Heat. While the application of cold to an injured limb was

considered unwise and ineffective, the direct application of heat was also considered to be contraindicated. The direct use of heat had several undesirable

effects: It speeded up local tissue metabolism in part in which the circulation was already inadequate for the demands upon it. Since the heat could

not be carried away by the vessels which were damaged, its effect was cumulative, and the possibility of damage to the tissues was increased. Finally, heat

increased capillary stasis and thereby increased local edema and delayed wound

healing. For these reasons it was the practice to leave the injured limb uncovered and exposed to room temperature. If the patient complained of cold

the limb could be lightly covered with wool or cotton cover, but it was never

placed under bed covering.

Conservation of the body heat was, on the other hand, an important part

of treatment. This was accomplished by the use of blankets, or an electric

cradle, or hot water bottles. Warming was frequently necessary because of

exposure or as part of the treatment of shock, but, in addition, it had beneficial effect on the wounded limb in that it relaxed the peripheral vessels,

favored the development of collateral circulation, and encouraged the relaxation of vasospasm.

SURGICAL MEASURES Debridement

There was every reason for not omitting debridement in most battleincurred wounds. No matter how innocent the wound might look from the

outside, there might be considerable shattering and destruction of tissue in its

depths which could be visualized only through adequate incisions in the skin

and fascial planes. When wound was thus explored it was common to find

beneath even small wound of entrance foreign bodies, bits of clothing, devitalized muscles, hematomas, and major vascular damage. The surgical excision of devitalized tissue was part of the resuscitative program; it minimized

the incidence of gas bacillus and other infections, and it had favorable effect

on vasospasm of any degree which might be present in an injured artery which

had not lost its integrity. This was first pointed out in Circular Letter No. 178,

Office of The Surgeon General, dated 23 October 1943, and was reiterated at

intervals thereafter until the end of the war.
102 VASCULAR SURGERY IN WORLD WAR II

Arterial Ligation

The affected artery had to be ligated in the majority of the vascular injuries which came under the military surgeon’s observation in World War II.

It was never the procedure of choice, but one of stern necessity required by

the location, type, size, and character of the wound.

Not great deal need be said about the optimal site of ligation. In World War II, when wound infection was usually controllable complication

and secondary hemorrhage was not the factor of risk which it was in World

War I, there was seldom any justification for proximal ligation. While it is

desirable theoretically to ligate the vessel at such level as to avoid the creation

of blind pouch, the deliberate effort to do so frequently involves extensive

dissection and may still further jeopardize the circulation of the injured limb.

Ligation in continuity was not favored in World War II. 60 Instead, nonabsorbable sutures were placed well above and well below the site of injury

or thrombosis and the damaged intervening segment was excised. This technique eliminated the dangers of secondary hemorrhage, thrombosis, and vasoconstrictor influences. Division permitted the ends of the vessel to retract

and suppressed generalized vasospasm. Embolism at the site of ligature was

also less likely to take place in divided vessel.

On the other hand, when it was possible to tie the artery just below

large branch rather than leave blind end to which the blood flowed with each

pulse beat, it was best to do so. Rogers 61 emphasized that there was less

interference with the hand and fingers when the brachial artery was tied just

distal to the origin of the superior profunda. Rogers also advised the rapid

transfusion of 800 to 1,200 cc. of blood during ligation to increase the blood

pressure and force the capillaries open.

All the experience of World War II suggested that the best results were

achieved in vascular injuries in which ligation was required if the operation

could be delayed for at least several days. In selected cases the possible

development of an aneurysm was therefore accepted as calculated risk if

delay could thus be achieved.

Ligation of the Concomitant Vein. The chief difference in the technique

of arterial ligation as it was performed in the two World Wars concerns the

ligation of the concomitant vein along with the injured artery. The amount

of space devoted in the literature to the discussion of this procedure and the

emphasis put upon it in World War and in the early years of World War II are curiously out of proportion to its value. 62

60 See footnotes 22 (1), and (3), p. 70; and 29, p. 81. 81 Rogers, L.: Physiological considerations In vascularsurgery; ligatureof main arteries to the limbs, M. J. Australia

1: 517-518, 19 May 45.

See footnotes 22 (1), p. 70; and 23, p. 71.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 103

Therapeutic venous ligation has been known since the time of Hippocrates,

as Brooks 83 points out in his review of the subject, and has always been widely

practiced for venous disease. Makins seems to have been the first to suggest

that it be part of the treatment of acute traumatic arterial lesions. His experiences in the South African War convinced him that the incidence of gangrene following surgery for traumatic arteriovenous fistula was less when both

artery and vein were ligated than when only arterial ligation was done, but he

did not record the observation until his Bradshaw Lecture in 1913.64 Moreover, in his extensive article on vascular injuries of warfare published in 1916 65

he dismissed the procedure rather casually, with the remark; “With regard to

the question of the danger of simultaneous ligature of the artery and vein, it

may be added that this was done in one of the successful cases.”

In the Hunterian Oration, however, which was delivered in 1917 88 he

advocated the deliberate ligature of the uninjured concomitant vein in cases

of arterial occlusion, and at this time, as well as in his monograph 87 published

after the war, he set forth the evidence on which he based his advocacy. This

evidence may be briefly summarized as follows:

1. The demonstration in varicose veins of the ease with which compensatory balance is attained when blood is diverted from the larger channels.

2. The absence of permanent vascular difficulties when the jugular and

other large veins are ligated to prevent the diffusion of septic emboli.

3. The possibility of survival after occlusion of the vena cava.

4. Personal experience with arteriovenous fistula to the effect that quadruple ligation and excision are less dangerous than simple arterial ligation.

5. Von Oppel’s good results 88 with this technique in cases of senile gangrene resulting from occlusion of the popliteal artery. (Von Oppel used this

method because of his observation of the occasional good results which followed arteriovenous anastomosis in this condition and which he attributed to

control of the venous circulation and consequent rise in the blood pressure of

the limb.)

83 Brooks, B.: Surgical applications of therapeutic venous obstruction. Arch. Surg. 19; 1-23, Jul 1929. 64 Makins, O. H.; The Bradshaw Lecture on gunshot Injuries of the arteries. Lancet 2: 1743-1752, 20 Dec 13. Also

Brit. M. J. 2: 1569-1577, 20 Dec 13. 85 Makins, G. H.: On the vascular lesions produced by gunshot injuries and their results. Brit. J. Surg. 3: 353-421,

Jan 1916.

88 Makins. Q. H.: The Hunterian Oration on the influence exerted by the military experience of John Hunter on himself and the military surgeon of today. Lancet 1: 249-251,17 Feb 17. 8T See footnote 12, p. 64. 88 (1) Von Oppel, W. A.: Zur operatlven Behandlung der arteriovenOson Aneurysmen. Arch. f. din. Chir. 86;

31-52. 1908.

(2) Von Oppel, W. A.: Reduzierte Blutkrelslauf. International Congress of Medicine, 1913. London, Oxford

University Press, 1913, pt 1, p. 189. (3) Von Oppel, W. A.: Wietlng’s Operation und der reduzierte Blutkreislauf (Wratschebnaja Qaz. 1913, No.

9). Zentralbl. f. Chir. 40: 1241, Aug 13.

(4) Von Oppel, W. A.: Die Theorie des umgekehrten und perversen Blutlaufs in den Extremitftten (Russki

Wratsch 1913, No. 15). Zentralbl. f. Chir. 40: 1242, Aug 13.

330323 O—55
104 VASCULAR SURGERY IN WORLD WAR II

6. Drummond’s experimental demonstration 69 that gangrene follows

ligation of the mesenteric artery but does not follow ligation of the mesenteric

artery and vein.

7. Van Kend’s experimental studies 70 which showed local rise of blood

pressure in the affected limb when the concomitant vein was ligated subsequent

to occlusion of the artery.

This was the evidence on which Makins based his observations, and he

advanced, in addition, two other reasons why ligation of the concomitant vein

was of distinct advantage:

1. The capacious main vein affords too ready channel of exit for the

diminished arterial supply, as well as an undesirable reservoir of stagnation.

2. As the result of combined arteriovenous ligation, the smaller amount

of blood supplied by the collateral arterial circulation is maintained for

longer time within the limb, with the result that there is an improvement in

the conditions necessary to preserve its vitality.

Aside from Makins’ statistics, not great deal of evidence for or against

ligation of the concomitant vein can be found in the literature of World War I.

In 1916 (that is, before Makins’ observations were published), Sehrt 71 reported

that when the artery alone was ligated the incidence of gangrene in the upper

extremity was 7.8 percent, but when the concomitant vein was also ligated

there was no incidence of gangrene. The corresponding figures for the lower

extremity were 20.4 percent and 9.0 percent. On the basis of this experience,

the author concluded that ligation of the concomitant vein was of distinct

value and that the “impounding of venous blood in the extremity” was beneficial. It is not clear on how many cases his observations were based. Propping 72 in 1917 attempted to provide experimental evidence to support the

opinion that concomitant vein ligation is beneficial, and while the experiment

was rather naive he concluded from it that ligation of the concomitant vein

was beneficial since gangrene of the limb after ligation of an artery is the result

of an imbalance between the amount of blood entering the extremity and the

amount leaving it through the veins.

The whole matter was fully discussed at the Inter-Allied Conference of

Surgeons held in Paris in May of 1917, and on the basis of Makins’ statistics

(Chart 13) it was agreed that the concomitant vein should be ligated whenever

major artery was ligated, even if the vein itself was not injured. 73

••

Drummond, Hamilton: Quoted by Makins (footnote 12, p. 64).

T0 VnaKend: Sur lesblessures des'vaisseaux, 6° Stance, 17May 17.Arch, deM6d. et dePharm. mil. 68:348-349, Jul-Aug-Sep, 1917.

71 Sehrt, E.: ttber die kdnstliche Blutleere von Qliedmassen und unterer K6rperhftlfte, sowie iiber die Ursache der

OangrSn des Gliedes nach Unterbindung der Arterien allein. Med. Klin. 12:1338-1341, 17 Dec 16. 71 Propping, Karl: ttber die Ursache der Oangrftn nach Unterbindung grosser Arterien. Miinchen. med. Wchnschr.

64: 698-599, May 17. 73 (1) Depage, A.: Blessures desVaisseaux. Comptes-Rendus de la Conference Chirurgicale Interallied pour 1’etude

des plaies de guerre, 5® Stance, 16 May 17. Arch, de Med. et de Pharm. mil. 68: 324-328, Jul-Aug-Sep 1917.

(2) Jacob: Blessures des Vaisseaux. Comptes-Rendus de la Conference Chirurgicale Interalli6e pour I’etude

des plaies de guerre, 5® Seance, 16 May 17. Arch, de M6d. et de Pharm. mil. 68: 328-340, Jul-Aug-Sep 1917. (3) Makins, G. H.: Blessures des Vaisseaux. Comptes-Rendus de la Conference Chirurgicale Interalli6e pour

1’etude des plaies de guerre, 6® Seance, 17 May 17. Arch, de Med. et de Pharm. mil. 68: 341-348, Jul-Aug-Sep 1917.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 105

Chart 13. Results of ligation of comparable arteries with and without ligation of concomitan

veins in British casualties in World War I. These data include only those cases where

for the same artery, there were examples with and without concomitant vein ligation.

This conclusion was complete reversal of the attitude which had prevailed before World War when the current opinion seemed to be that the prognosis for survival of limb after interruption of major artery was worse when

the concomitant vein was injured and had to be ligated simultaneously. Under

these circumstances, Jacobson 74 wrote, “Leave should be gotten at once for

amputation,” while Matas 75 declared that “the danger of peripheral gangrene

is always made doubly worse by the simultaneous injury of the accompanying or satellite vein.”

Even after World War I, all surgeons did not accept the new point of

view unreservedly. In 1921 Punin 76 on the basis of 64 personal and 1,057

collected cases of arterial injury concluded that the incidence of gangrene was

no less after the combined procedure than it was when ligation of the vein was

omitted. In the same year Maurer 77 stated guardedly that concomitant

i* Jacobson, W. H. A.: The Operations of Surgery, 6th edition by R. P. Rowlands Philip Turner. London, J.

A. Churchill, 1915, vol 1, p. 843, 894. 75 Matas, Surgery of the vascular system. In Keen, William W.: Surgery—Its Principles and Practice, by

Various Authors. Philadelphia and London, W. B. Saunders Company, 1921, vol 5, pp. 17-350. 79 Punin: Cited by Franz (footnote 17, p. 64).

77 See footnote 14, p. 64.
106 VASCULAR SURGERY IN WORLD WAR II

vein ligation is not harmful and might be advantageous (in 1939 78 he was even

less enthusiastic). The weight of Makins’ prestige, however, was so great

that his point of view was usually accepted without question, and the practice

of ligation of the concomitant vein became the rule when certain arteries, at

least, had to be ligated.

Brooks, 79 in 1929, in his extensive review of the subject decided on the basis

of clinical and experimental evidence 80 that the concomitant vein should be

ligated when the popliteal or axillary arteries were injured but when the common

femoral artery was injured he believed it wiser to close the wound without

ligating the vein and to watch the extremity carefully for signs of impending

gangrene. The vein should be ligated only if such signs became evident.

When the femoral and brachial arteries were damaged he believed that it made

little difference whether or not ligation of the concomitant vein was done.

In 1933 Wilson 81 published an article which controverted the opinion that

ligation of the concomitant vein diminished the incidence of gangrene following

ligation of the main artery. If venous ligation was done at higher level than

the arterial ligation, he concluded, both the incidence and extent of tissue death

would be increased. This study received indirect support from the observations which Montgomery 82 had published in 1929 which showed that the perminute flow of blood to the extremity was stillfurther reduced ifthe concomitant

vein was ligated in an extremity in which the artery had previously been

ligated. Then, in 1934, Brooks 83 and his co-workers published an article on

their results of an experimental study of 220 rabbits which showed that massive

gangrene of the extremity was 14.5 times less frequent after arterial and venous

ligation than after arterial ligation alone.

While the experimental evidence for and against ligation of the concomitant

vein is thus rather inconsistent, there seems no doubt, as Wilson 84 pointed out, that Makins’ reasoning in favor of the procedure was not based upon sound

physiologic concepts. Moreover, Makins’ frequently quoted statistics,85 when

they are carefully examined, do not seem to warrant the sweeping conclusions

78 Maurer, A.: Note sur les plaies vasculaires rGcentes et leur traitement d’aprfis 444 observations. M6m. Acad, de

chir. 66; 1156-1164, 25 Oct-8 Nov 39. 78 See footnote 63, p. 103. 80 (1) Brooks, B., and Martin, K. A.: Simultaneous ligation of vein and artery; an experimental study. J. A. M. A.

80: 1678-1681, Jun 23.

(2) Holman, E., and Edwards, M. E.: new principle in the surgery of the large vessels; ligation of vein proximal

tosite of ligation of artery; an experimental study. J. A. M. A. 88: 909-911,19 Mar 27. (3) Pearse, H. E., Jr.: new explanation of the improvedresults following ligation of both artery and vein. Ann.

Surg. 86: 850-854, Dec 1927. (4) Theis, F. V.: Ligation ofartery and concomitant vein in operationson large blood vessels. Arch. Surg. 17; 244-

258, Aug 1928. 81 Wilson, W. C.; Occlusion of the main artery and main vein of limb. Brit. J. Surg. 20: 393-411, Jan 1933.

88 Montgomery, M. L.: Effect of therapeutic venous ligation on blood flow in cases ofarterial occlusion. Proc. Soc.

Exper. Biol. Med. 27:178-179, Nov 1929. 83 Brooks, B.; Johnson, Q. S., and Kirtley, J. A., Jr.: Simultaneous vein ligation; an experimental study of the effect

of ligationof the concomitant vein on the incidence of gangrenefollowing arterial obstruction. Surg., Qynec. Obst. 59:

496-500, Sep 1934. 84 See footnote 81, above. 88 See footnotes 3, p. 60; and 12, p. 64.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 107

which have been drawn from them. For one thing, it is not possible to separate

the cases of acute arterial injury from the cases of arteriovenous fistula, nor is

it possible to determine the proportions of aneurysms in the two groups of cases. For another, the difference between the incidence of amputations in the series

in which only arterial ligation was done and the series in which the concomitant

vein was ligated also is not statistically significant. Finally, the incidence of

amputations in the whole group of wounds of arteries in Makins’ collected

World War series (Chart 13) is actually less than the incidence of amputations

in the comparable series in which the concomitant vein was ligated, though the

former series, on the basis of his theories, should provide the larger number (or

at least an equal number) of poor results.

Makins’ concepts were undoubtedly responsible for the persistence into

World War II of the idea that concomitant venous ligation was useful in arterial

injuries. Hoche, 86 in 1940, warned against ligation of certain arteries, such as

the popliteal and the femoral artery above the branching off of the deep femoral,

without simultaneous ligation of the concomitant vein on the ground that disturbances resulting from arterial injury and ligation seemed to result not so

much from failure of the collateral circulation as from disparity between the

collateral arterial inflow and the venous discharge. Decker, 87 in 1941, recommended ligation of the jugular and popliteal veins when the corresponding

arteries were ligated. He suggested, however, when other vessels were concerned, that temporary pressure be applied to the vein after the artery had

been ligated and that the subsequent procedure depend upon developments:

If after few minutes the peripheral circulation was found to be favorably

affected by this maneuver, ligation of the appropriate vein should be done,

while if no effects were observed it should not be done.

Although ligation of the concomitant vein was recommended in circular

letters and other material issued to American medical officers in World War II

as late as D-day in Europe, 88 the American experience with the method was not

extensive (Chart 14). The majority of surgeons did not use it routinely, if at

all, and the experience of no single surgeon was large enough to permit valid

conclusions. The collected figures seem to indicate that ligation of the concomitant vein does not in any way increase the chance of survival of the limb.

The difference between the incidence of amputations in the cases in which the

vein was ligated and in the cases in which it was not ligated is not statistically

significant. As in the British figures for World War I, the incidence of amputation in the total group of arterial wounds was considerably less than it was

in the comparable group in which concomitant vein ligation was done. The

difference, in fact, is statistically significant, although if the procedure were of

86 Hoche, O.: Die wehrehirurgische Behandlung der Verwundeten. Die Blutung und ihre Behandlung. Med.

Klin. 36: 919-922, 16 Aug 40.

87 Decker, P.: L’hfimostase d’urgence en chirurpie de guerre. Helvet. med. acta 8: 3-21, Apr 1941.

88 See footnote 23. p. 71.
108 VASCULAR SURGERY IN WORLD WAR II

Chart 14 Results of ligation of comparable arteries with and without ligation of concomitant

veins among British casualties in World War and American casualties in World War II. These data include only those cases where, for the same artery, there were examples with and

without concomitant vein ligation.

definite value one would expect the results of venous ligation to be at least as

good, if not better.

The conclusion therefore seems warranted that ligation of the concomitant

vein in combat-incurred arterial wounds furnishes no protection whatsoever

against the development of gangrene after acute arterial occlusion treated by

ligation.

Primary Amputation

Circular letters and directives issued in the Mediterranean and other

overseas theaters 89 and information disseminated from the Surgeon General’s

Office 90 limited primary amputation to cases in which the extremity was irreparably damaged or devoid of circulation. Primary amputation was also

permitted in an occasional case for the control of hemorrhage or as the first

88 (1) See-footnote 23, p. 71.

(2) Cir Ltr 101, Off of Chief Surg ETO, 30 Jul 44, sub: Care of battle casualties.

(3) Cir Ltr 23, Off of Chief Surg ETO, 17 Mar 45, sub: Care of battle casualties. 81 See footnotes 28 and 29, p. 81.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 109

step of treating traumatic amputation which is not complete. The site of

amputation was the lowest possible level of viable tissue regardless of the

utility of the stump. The warning was frequently issued that the line of

demarcation in an infected extremity which was the site of vascular occlusion

did not mark the level at which an amputation stump could be maintained, since circulation sufficient only to maintain tissue viability could not cope with

infection.

When amputation was necessary the entirely proper desire to delay it in

order to permit the establishment of an adequate collateral circulation had to

be weighed against the possible systemic reaction, the local evidence of infection, and the practicability of keeping the patient under observation. In an

active theater of war the latter consideration was of great importance. At

echelons in which evacuation might be necessary on short notice, it was sometimes better to amputate limb in which gangrene had developed as promptly

as possible rather than risk complications during the time of evacuation when

the patient was not being closely observed.

Suture Repair

World War I. On theoretical grounds, repair of damaged artery by

suture offers the chief hope of survival of the limb but practically, as has been

pointed out, reparative measures are seldom applicable in military surgery.

The value of suture was recognized during World War but, as in World War

II, the number of cases to which it could be applied was very small. It is the

only method, Makins 91 stated, which provides ideal results, but he added that

it is applicable only in the primary state of vascular injuries and only if infection can be avoided. He regarded lateral wounds of the carotid, femoral, and

popliteal arteries as the most suitable sites for its performance and placed the

axillary and brachial arteries in the next category. Sencert 92 also wrote that

ligature is the method par excellence for the arrest of hemorrhage from recent

vascular wounds, but he added, like Makins, that the indications for its performance are few.

Bernheim’s experiences 93 in World War were illuminating. He had

enthusiastically practiced the Carrel 94 method of suture in his civilian practice

and went to France with elaborate personal equipment in order to use the

method in military surgery. In nearly years overseas, however, he never

saw any other surgeon suture an artery and he himself discontinued it in the

few cases in which he attempted it because of loss of supporting tissue as the

result of necessary debridement, and because of the unjustifiable amount of

time which the operation required. Even in cases in which infection was

91 See footnote 3, p. 60. 92 See footnote 33, p. 84. 93 (1) Bemheim, B. M.: Blood-vessel surgery in the war. Surg., Gynec. Obst. 30: 564-567, Jun 1920.

(2) Bernheim, B. M.: Symposium on emergency treatment; management of vascular injuries. S. Clin. North

America 22: 1417-1426, Oct 1942. 94 Carrel, A.: Surgery of blood vessels. Bull. Johns Hopkins Htsp. 18: 18-28, Jan 1907.
110 VASCULAR SURGERY IN WORLD WAR II

absent he thought that military circumstances were unpropitious for vascular

suture, while “only foolhardy man,” he remarked, “would have assayed

suture of arterial or venous trunks in the presence of infections such as were

the rule in almost all the injured.”

Goodman’s experience 95 with vascular suture made him, like Bernheim,

enthusiastic about the method, and after months stay on the British Front

in 1917, he felt “enabled to refute the deductions made by the other surgeons

present,” these being that the risk of gangrene after arterial ligation was sufficient to justify immediate amputation in injuries of the femoral and popliteal

arteries, and even the posterior tibial artery. Goodman’s personal experience

with vascular suture, however, was limited to cases, in of which amputation

was later required because of gangrene. In addition to his own cases, he collected number of others, but the large proportion of aneurysms included

limits their values for comparative purposes. Many cases in the collection

were of German origin and there is no doubt that German surgeons used suture

more frequently than either British or American surgeons in World War I,

though many series, such as that reported by von Haberer,90 consisted entirely

or chiefly of aneurysms. Makins 97 was able to collect only 39 cases of arterial

suture from the British experience. Three patients died, all from infection,

and ideal to good results were obtained in about one-half of the remaining cases,

the results being “in no way inferior to those of ligature,” which seems somewhat faint praise. Gnilorybov,98 writing in 1944, stated that during World

War he had performed vascular suture in number of cases (he did not cite

exact figures) and that he saw no instance of gangrene after its use, in contrast

to ligation, after which half of his patients developed gangrene.

Decker 99 furnishes an interesting and probably correct interpretation of

why arterial suture was practiced in the early part of World War by the

surgeons of the Central Powers but infrequently during the second half. This

was not the result of the tactical situation, although mobile warfare gave way

to stationary trench warfare during the course of the war, but of change in

the character of the missiles used. At the beginning of World War projectile

wounds were usually inflicted from distance, the explosive effect in the tissues

was minimal and vascular injuries were therefore frequently suitable for repar85 (1) Goodman, C.: histological study of the circular suture of the blood vessels. Ann. Surg. 65: 693-703, Jun 1917.

(2) Goodman, C.: Suture of blood-vessel injuries from projectiles of war. Surg., Gynec. Obst. 27: 528-529,

Nov 1918.

(3) Goodman, C.: Surgery of the Heart; Blood Vessels, Thrombosis and Embolismand Blood Transfusion. Cinq.

Cong, de Soc. Internat. de Chin, Paris, 19-23 Jul 20, p. 244-263. Brussels, M. Hayez, 1921. (4) Goodman, C.: Suture repair of war injuries to the blood vessels. J. Internat. Coll. Surgeons 6: 127-131, MarApr 1943.

88 (1) Von Haberer, H.: Diagnose und Behandlung der GefSssverletzungen. Miinchen. meci. Wchnschr. 65; 363-367;

idem, ibid.: 405-409, Apr 1918. (2) Von Haberer, H.: Surgery of the blood vessels in wartime. Miinchen. med. Wchnschr. 87: 849-851, Aug 40.

Abstn, Internat. S. Digest 31: 21-24, Jan 1941. 87 See footnotes 3, p. 60; and 12, p. 64. 88 Gnilorybov, T. E.: One Hundred and Thirty Operations on the Blood Vessels. Khirurgiya No, 8, 40-35 (lie),

1942. Moscow. Abstn, Bull. War Med. 452-4.53, Apr 1944. 89 See footnote 87, p. 107.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 111

ative surgery. Later in the war when bombs, mines, and similar weapons prevailed and were discharged at close range, this favorable circumstance ceased

to exist.

World War II. In World War II the circumstances were propitious for

trial of arterial suture in that thorough debridement, supplemented by chemotherapy and antibiotic therapy, greatly reduced the risk of infection. Nevertheless, this method was not very widely employed. One reason was that it is

not technique suitable for all types of wounds. Although it can be employed

in lateral injuries of some size, or in incomplete or complete transections, the

most favorable type of injury is the small lateral wound. second reason was

the frequently uncontrollable length of the time between wounding and treatment, an unavoidable military circumstance.

Case 7. soldier who was wounded by enemy shell fragments in Italy, January, incurred wound of the right popliteal fossa with laceration of the popliteal area. There

was no fracture. The laceration was sutured on January at an evacuation hospital and

right lumbar sympathetic block was done.

Between 11 January and 20 January four different operations were performed on the

patient for local excision of gangrenous skin and muscle. On February, at general hospital,

guillotine-type of amputation was done for infection and loss of tissue caused by ischemia.

Comment. The details are lacking in this case, the history of which was

secured from proceedings of disposition board, but the most significant fact

is known, that arterial suture was done more than 24 hours after wounding.

This is well past the optimum time period for repair and good result could

scarcely have been expected.

Arterial suture was performed in only 81 of the 2,471 arterial wounds analyzed in this chapter (Chart 15). Included in the group are end-to-end anastomoses, which were performed on the common femoral, femoral, and popliteal

arteries. Most of the other wounds were small lateral lacerations, involving

third or less of the circumference of the vessel. One was wound inflicted

accidentally with bayonet, type ideally suited for suture because the

incision is clean and there is no great loss of tissue.

The results of suture in these 81 cases are significantly better than the

results of ligation and vein graft and probably better than the results of tube

anastomosis (Chart 15). That fact, however, does not offer any great encouragement, for these 81 cases were highly selective group of minimal wounds

without extensive tissue destruction. It would not be possible to duplicate, or

even approach, these results in the usual run of arterial wounds.

Killian’s observations 100 on arterial suture in the German Army during

World War II are not helpful in this connection because, while it was performed

in 52 of 72 surgical cases, an unspecified number of these were aneurysms.

Recovery occurred in 50 cases, in only of which amputation was necessary.

The favorable results in these instances of arterial suture and early operation

for aneurysms showed, according to Killian, that suture is method which can

100 Killian, H.: tiber die Indikation zur Frflhoperation von OefSssverletzungen und Aneurysmen. Arch. f. kiln.

Chlr. 204 355-410, 26 Mar 43.
112 VASCULAR SURGERY IN WORLD WAR II

Chart 16. Results of various therapeutic measures on incidence of amputation in arterial

wounds of the extremities in American battle casualties in World War II, with special

reference to the type of arterial repair. The data depicted are based on selected group for which the necessary information was available. They do not include all arterial wounds during World War II. Detailed treatment of the remaining 697 American cases shown in

Table consisted of amputation as primary procedure, or is unknown.

be practiced by the field surgeon at the battiefront. Unfortunately, he does

not define his terms, and this fact, together with the apparently large proportion of aneurysms included in the series, makes his observation oflittle value.

Complications. Thrombosis and embolism are immediate, but infrequent,

complications of arterial suture. They did not appear in this series nor did any

patient present signs of either arterial stricture or aneurysm during the period

he was under observation. The most important immediate complication of

arterial suture is hemorrhage. The records are incomplete on this point but it

is known to have occurred in of 24 cases in which it was possible to determine

its presence or absence. It usually occurs to days after operation by which

time collateral circulation has developed and ligation can be done with much

less risk than when it is primary procedure. In the following case the hemorrhage which occurred shortly after operation can be considered complication

of heparinization rather than of the arterial suture.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 113

Case 8. soldier wounded by enemy mortar shell fragments in Italy, 17 April 1945, incurred penetrating wounds of the face, both thighs, and the right inguinal region. The

latter wound caused laceration of the common femoral artery, to mm. long, at the

junction of the femoral and profunda femoris arteries and near the origin of the circumflex

iliac artery. There were no fractures. Sulfanilamide powder was dusted into the wounds

and compression bandages were applied. When the patient reached an evacuation hospital

about 4}i hours after wounding, penicillin was administered promptly (25,000 units intramuscularly at 3-hour intervals).

The operation was performed, using drop-ether anesthesia, 10 hours after wounding

and lasted hours. The blood pressure was normal throughout and the pulse rate varied

between 100 and 120 beats per minute. Debridement and exploration of the right groin

revealed large hematoma and the laceration of the femoral artery already described. It

was sutured with fine silk. During the procedure hemorrhage was controlled by means of

pressure supplemented by tape placed under the common femoral artery above Poupart’s

ligament and kept in place for about an hour. The patient received 1,000 cc. of whole blood

before operation and another 1,000 cc. during operation. The soldier had been wounded before, but had never received transfusion. plaster spica was applied with pressure

over the wound. At the end of the operation the dorsalis pedis and posterior tibial pulses

were good.

Heparin in Pitkin’s menstruum, cc., 200 mg. heparin, was given hours after operation

and later at an unrecorded hour cc. was given. The following day it was given in 2-cc.

amounts at 0200 and again at 0900 hours. transfusion of 1,000 cc. of whole blood was

started 5}i hours after operation and completed after midnight. Heparin was discontinued when bleeding occurred from the wound in the evening of the day after operation.

The urine voided on the day of operation was described as clear, but was not examined.

Thirty-one hours after operation, however, the patient voided bloody urine (Table 5).

Urinalysis at 0900 and 1000revealed protein to be present to which 4+ rating was ascribed.

When the patient was questioned he stated that he had never been ill in the past, but he

thought that during the past year he might have had “kidney trouble” because he had suffered from lumbar pain and nocturia. Examination of the urine showed no urobilinogen

or urobilin. The serum urea was 98 mg. per 100 cc. and the urea nitrogen 46 mg. per 100

cubic centimeters. The blood pressure was 120 mm. of mercury systolic and 90 diastolic. The third day after operation (20 April) the blood pressure was 130 mm. of mercury

systolic and 84 diastolic. The patient was drowsy but was easily aroused. The urine

voided was clear (Table 5). Circulation in the right foot was normal.

Recovery thereafter was smooth. Transfusions of 500 cc. each were given without

incident on 21 and 22 April. On 27 April the wounds were sutured. When the patient

was evacuated to the Zone of Interior 29 May, his wounds were well healed and the circulation in the right leg appeared entirely normal.

Comment. It was stated in this case that at no time, before, during, or after operationwas

it ever impossible to feel pulsations in the dorsalis pedis and posterior tibial arteries. There

seems no doubt that suture of the lacerated artery was efficacious. Of special interest are

the appearance of probable myoglobin in the urine and the transient azotemia (Table 5).

Sutured Vein Grafts

The extensive loss of substance caused by the extremely destructive

weapons used in World War II meant that in certain of the few vascular injuries

in which arterial ligation did not seem to be immediately indicated and in which

suture repair was clearly impossible, some method of bridging sizeable gap

in the wounded artery had to be used in order to reestablish continuity of the

artery.
114 VASCULAR SURGERY IN WORLD WAR II

Table 6. Special Laboratory Studies (Case 8)

Urinalyses

Time of determination

pH Benzidine-positive substance Myoglobin

Date Hour

19 April 0900

1000

1630

2000

0030

0130

0930

1030

6.

5.

6.

5.

7.

8.

8.

8.

Mg. per 100 ce.

244

Mg. per 100 ee.

203

19 April 82 54

19 April 9.

19 April Trace

20 April Faint ti•ace..

20 April

20 April

20 April

Blood Chemistry

Date Van den

Bergh

reaction

Magnesium

Bromsulfaleln re- tention

Nonprotein

nitrogen Creatinine

19 April

Mg. of bi- lirubin per 100 ee.

3. 57

1. 81

2. 16

Mo. per 100 ee.

2.

2.

2.

Percent

6. 17

18.

Mg. per

100 ce.

64

53

40

Mg. per

100 ee.

1. 48

1. 09

0. 94

20 April

22 April

Other Studies

Date Plasma protein Hematocrit value Icteric Index

26 April

Om. per 100ce. of plasma

7.

6.

6.

Ce. cells per 100 cc. of blood

33

44

41

28 April

15 May

16 May

Determined by Medical Board to study the treatment of the severely wounded, MTOUSA.

Five milligrams of the dye were injected intravenouslyper kilogram ofbody weight and theretention was measured

45 minutes later.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 115

Sutured, as opposed to nonsutured, vein grafts had been used with considerable success both experimentally 101 and clinically 102 before World War

and the method was used with surprisingly good results for traumatic aneurysms

in that war, 103 though apparently it was not used for acute arterial occlusion.

The operation was successful in 40 of the 47 traumatic aneurysms reported

by Warthmuller, 104 though, as Matas 105 emphasized, there was small reason for

its use in aneurysms in the light of the successful results achieved by his own

technically simpler procedure. Suture vein grafts do not seem to have been

used by American surgeons in World War II but few successful cases (chiefly

aneurysms) were reported by Helm, 106 Murray, 107 Killian, 108 Schneider and Batzner, 109 and Khenkin. 110

Maintenance of the Main Arterial

Channel by Prosthetic Devices

Bridging of the arterial gap by intubation to provide for temporary maintenance of the blood flow seems first to have been employed clinically in 1915

by Tuffier. 111 He had used silver tubes in performing direct blood transfusion

and, on the basis of his experience with them, proposed their use for bridging

arterial defects. He later reported number of successful cases. Makins 112

mi (1) See footnote 95 (1), p. 110.

(2) Guthrie, C. C.: End-results of arterial restitution with devitalized tissue. J. A. M. A. 73:186-187, 19 Jul 19.

(3) Moure, P.: Technique des grefles vasculalres appllqutes au rfitabllssement de la continuity des arteres. J. de

chir. Paris 641-560, 1912.

(4) Moure, P.: Qrefle vasculalre; preuve de la vitality du greffon par une double greffe. Bull, et m6m. Soc. anat.

de Paris 88 489-492, 1913. 1W (1) Lexer, E.: Die Ideale Operation des arterlellen und des arterlell-venosen Aneurysma. Arch. f. kiln. Chlr. 83:

459-477, 1907.

(2) Warthmiiller, Hans, ttber die Blsherlgen Erfolge der QefUsstransp antatlon am Menschen. Jena, G. Neuen

bann, 1917, p. 39. 1M (i) Alessandrl, R.: Chlrurgla del cuore Del Qrossl Vasl. Cinq. Cong, de Soc. Internat. de Chlr., Paris, 19-23

Juillet 1920, p. 139-241. Brussels, M. Hayez, 1921.

(2) V6n Bonin, Q.: Aneurysmen durch Schussverletzungen und ihreBehandlung. Beltr. z. kiln. Chlr. (Kreigschir. Hefte 2) 97: 146-176, 1915.

(3) Hotz, O.; Zur Chlrurgle derBlutgefasse. Beltr. z. kiln. Chir. 97: 177-188, 1915.

(4) Renaux, L.: Reconstruction of Popliteal Artery. Brazll-med. 34: 509, Aug 20. Abstract J. A. M. A. 75:

1756, 18 Dec 20. (5) Sencert,L.: La Chlrurgledes gros valsseaux: 1. Les Blessures des valsseaux. Clnq.Cong.deSoc.Internat.de

Chir., Paris, 19-23 Juillet 1920, p. 77-137. Brussels, M. Hayez, 1921.

(6) Zahradnlcky, F.; Die Behandlung der unechten Aneurysmen. Weln. kiln. Wchnschr. 28: 999-1007, 1915.

(7) See also footnotes 95 (1) and (4), p. 110; and 102 (2), above. 1M See footnote 102 (2), above..

1M Matas, Rudolph: Military surgery of the vascularsystem. In Keen, W. W.: Surgery—Its Principles and Practice,

by Various Authors. Philadelphia and London, W. B. Saunders Company, 1921, vol 7, p. 713-819. I0 (1) Rehn, E.; Das Aneurysma derArteria subclavia durch Schussverletzung und seine Ideal Operation mit freier

Veneniiberpflanzung. Zentralbl. f. Chir. 69: 1262-1275, Aug 42. Abstr., Bull. War Med. 3: 264, Jan 1943.

(2) Rehn, E.: Orundsatzliche Bemerkungen zur rekonstruktiven Chlrurgle des Schussaneurysma. Zentralbl.

f. Chir. 70; 957-965, Jul 43. 107 Murray, G. D. W.: Heparin in thrombosis and embolism. Brit. J. Surg. 27 667-598, Jan 1940. los See footnote 100, p. 111. If Schneider, H., and Batzner, K.: Die Behandlung der Aneurysmen der Arteriapoplitea und ihrer Aste. Zentralbl.

f. Chir. 70: 965-975, Jul 43.

110 Khenkin, V. L.: Experience in treatment of injuries of blood vessels in the forward area and at the rear. Khlrurgiya,

Moscow 2; 50-57, Oct 1944. Abstr., Bull. War Med. 6: 75, 1945-46. 111 Tuffier: De 1’lntubationdans les plaies des grosses artSres. Bull. Acad, de mfed., Paris 74: 455-460, Oct 1915.

111 See footnote 3, p. 60.

104 See footnote 102 (2), above..
116 VASCULAR SURGERY IN WORLD WAR II

reported 12 operations by this technique in 1922, of which were nonacute

lesions. One patient died of sepsis and another of gas gangrene, but results

in the other cases were good. Makins also mentioned in this report Cowell’s

case, in which, when signs of gangrene followed ligature of completely divided

femoral artery, the limb was saved by removal of the ligatures and the use of

Tuffier tube. number of other observers during this period reported favorable

results with this method.113

Early in World War II British and Canadian surgeons attempted the use

of glass tubes for arterial injuries, but their results are not known, 114 Their

potential clinical value was indicated by the successful experience of Murray

and Janes 118 in their experiments with heparin on dogs.

Plastic tubes were similarly used by American surgeons, though the

results in the 14 cases in this series were not outstanding (Chart 15). Plastic

prostheses have certain advantages over other prostheses in that they are

apparently well tolerated by the tissues and can be altered in size and shape

to fit the necessities of the special case merely by soaking the basic material

in warm water. supply of various sizes therefore need not be kept on hand.

The technique of repair is simpler than when vitallium tubes are used, though

the possibility of thrombosis is theoretically greater than when vein grafts

are used.

Whether or not permanent circulation is maintained through these

tubes is not matter of extreme importance if in the interim collateral

circulation has developed, since gradual occlusion of vascular channel is

always less deleterious than abrupt occlusion. This result cannot be achieved, however, unless operation is performed early, and the timelag offers an obstacle

to this desideratum in most combat-incurred vascular injuries. The importance of some form of bridging of the arterial defect to permit at least minimal

circulation while collateral vessels are developing is illustrated by the following

case report. Collaterals were adequate by the time the nonsuture graft

thrombosed.

Case 9. This soldier, wounded by an enemy bomb fragment on shipboard off Southern France 18 August 1944, incurred perforating wound of the right popliteal space with

laceration of the popliteal artery at its bifurcation into the anterior and posterior tibial

arteries. He also received penetrating wounds of the right thigh and hand. There was no

fracture. First aid consisted of morphine, tetanus toxoid, dusting of the wound with

sulfanilamide powder, and the administration of sulfadiazine by mouth (2 gm. at once and

gm. every hours). The following day, after the patient was transferred to hospital

ship, penicillin therapy was begun.

115 (1) Donati, M.; Ferlte del vasi sanguigni degli artl. Chir. d. organ, d. mov. Bologna 1: 191-254.1917. (2) Tuffier: proposdes plaies des artSres. Bull, et mfim. Soc. de chir. de Paris 43: 1469-1741,1917.

(3) Tuffier: French surgery in 1915. Brit. J. Surg. 4; 420-432, Jan 1917. (4) See also footnotes 3, p. 60; 13, p. 64; 95 (3), p. 110; and 103 (3), p. 115,

114 Matheson, N. M., and Murray, O.; Recent advances and experimental work in conservative vascular surgery. In

Bailey, Hamilton: Surgery of Modern Warfare. Baltimore, Williams and Wilkins Co., 1941, vol 1, p. 324-327.

118 Murray, O., and Janes, J. M.: Prevention ofacute failure of circulation following injuries to large arteries; experiments with glass cannulae kept patent by administrationofheparin. Brit. M. J. 2:6-7, Jul 40.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 117

When he was admitted to general hospital in the base on 21 August his right leg was

nearly twice normal size and the calf was tense. The toes and ankles were discolored and

mottled. The foot was numb, cold to touch, and motionless as far as the ankle. The skin

of the foot was mottled but blanched fairly easily. No pulsations could be felt in the leg

or foot. There was moderate pain in the leg. The popliteal space was full but soft. Aus- cultation revealed systolic bruit in this area; diastole was clear. The hematocrit value

was 30 percent and the total plasma protein concentration 7.15 gm. per 100 cubic centimeters.

transfusion of 1,000 cc. of whole blood was given and conservative treatment was

decided upon for the time being.

The following day (22 August) there was sudden, brisk hemorrhage from the small

lateral wound behind the head of the fibula at the knee with an estimated loss of about 1,000 cc. of blood. Shock was moderate. Bleeding was controlled by the application of

temporary tourniquet which stopped the bleeding in 25 minutes. Seven hours after the

hemorrhage the foot was ice cold, the mottled areas were more prominent, and it was

apparent that in all likelihood the limb would not survive. The bruit in the popliteal space

could no longer be heard. The hematocrit value was 35 percent and the plasma protein

concentration 7.5 gm. per 100 cubic centimeters.

The vascular operation was preceded by lumbar ganglionectomy, with resection of the

second, third, and fourth lumbar ganglia. When the right popliteal space was explored

the gastrocnemius muscle herniated through the incision in the fascia. The fibers of the

heads of the muscle were separated, very pale, and putty-like in consistency. Hematoma

formation was evident beneath the heads. The tibial nerve appeared contused, but was

intact. The popliteal vein had been severed, and the popliteal artery was also severed

except for narrow strand of the wall on the deep aspect which kept the ends from retracting.

The artery was open for distance of about l}i inches, including the area of its bifurcation.

thrombus was aspirated from the posterior tibial artery. The severed popliteal vein

was ligated at each end, and nonsuture anastomosis was done between the popliteal and

posterior tibial arteries bridging gap of about inches. segment of the left saphenous

vein was used. The foot was warmer and of better color after operation than before.

Heparin was not available.

The day after operation the entire right leg was edematous and there was some redness

in the upper half of the leg. Both foot and leg were warm and blanched fairly well. The

patient’s temperature was 102° F. and his general condition was fair. transfusion of

1,000 cc. of whole blood was given.

By 30 August, the sixth day after operation, the acute edema of the leg had subsided

and the foot was warm. On the external lateral aspect of the heel was small round area

of discoloration. All sutures were removed from the right flank and left thigh. The wounds

of the right popliteal space and right space were sutured. There was still small amount of

slough on the surface of the lateral head of the gastrocnemius, but beneath it was normallooking muscle. The skin edges came together easily.

On September an arteriogram with diodrast revealed no flow through the anastomosis

but an excellent collateral circulation was demonstrable (Fig. 5). On September faradic

stimulation of the leg muscles was done. Reactions were obtained only from the gastrocnemius and posterior tibial muscles, but edema still present in the leg made interpretation of the

negative results uncertain. On September all sutures were removed. Healing was

satisfactory. The foot was warm, pink, and dry. The small round spot of necrosis on the

heel was thought to be the result of pressure while the posterior plaster shell was in place.

On 17 September the right calf was still indurated and enlarged. There was no motion

in the toes but the patient had begun to feel tingling in the dorsum of the foot. There was

anesthesia to inches above the lateral malleolus and inches above the medial malleolus.

No further observations were possible after this date.
118 VASCULAR SURGERY IN WORLD WAR II

Figure 5. Laceration of popliteal artery treated by nonsuture anastomosis. Arteriogram

days after operation showing excellent collateral circulation. Thrombosis now blocks the

anastomosis, which may have been patent earlier, however.

Comment. In this case ischemia which had been only partial for days

after wounding suddenly became complete and it seemed that the limb would

not survive. The circulation improved following nonsuture anastomosis

(vitallium tubes and vein segment), though an arteriogram 11 days after operation showed thrombosis of the anastomosis. It is quite possible, however, that

the anastomosis was open earlier and that the temporary circulation which it

afforded, together with the fact that for the initial 3-day period the ischemia

was only partial, allowed the development of collateral circulation which was

sufficient to ensure survival of the limb.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 119

Nonsuture Anastomosis

The principle of nonsuture anastomosis originally developed by Payr in 1900 116 was tested experimentally by Hbpfner in 1903 117 and was successfully

applied clinically by Lexer in 1907.118 Jeger, in 1913, 119 advocated this method

for military surgery but it does not seem to have been employed in World War I. In 1942 Blakemore, Lord, and Stefko 120 in effect revived the technique

of these earlier investigators as method of restoring the blood flow through

severed arteries. They used vitallium tubes, instead of the magnesium alloy

tubes which Payr and Hbpfner had used, lined them with vein grafts, and tied

the cut ends of the artery over the ends of the connecting cannula. Somewhat

later they modified their method, so that it resembled Hbpfner’s technique, by

using two tubes bridged by vein graft.

The results secured by Blakemore and his associates 121 with this technique

were so encouraging that hope was expressed that the method would be equally

effective in military surgery. The vitallium tubes required became available

in the Mediterranean theater in August 1944. 122 They were in limited supply

and therefore were used only in carefully selected critical cases cared for by

experienced vascular surgeons. 123 It is known that the double-tube-vein-graft

technique was employed in 40 cases (Chart 15).

Case 10. When this soldier was wounded by enemy machine pistol bullets 11 March

1945 near Lucia, Italy, he incurred penetrating wounds of the right upper arm, compound

comminuted fracture of the right humerus, perforating wound of the right forearm with

compound comminuted fracture of the ulna, and perforating wound of the right thigh where

the femoral artery and vein were both divided in the adductor canal by the missile. The

sciatic nerve was partially divided. The femur was not fractured. First aid consisted of

sulfanilamide powder and dressings applied to the wound, 4.0 gm. of sulfadiazine given

orally during evacuation, and units of plasma. No tourniquet was applied. The patient

reached an evacuation hospital hours after injury. As preparation for operation he received

unit of plasma and 2,000 cc. of whole blood. At the conclusion of resuscitation the hematocrit value was 40.5 percent and the blood volume, determined by the T-1824 dye method,

was high normal (6,160 cc. for body weight of 68 kg.). The blood pressure was 144 mm. of

mercury systolic and 100 diastolic.

in Payr. E.; BeitrSge sur Technlk der Blutgefasse und Nervennaht nebst Mittheilungen (iber die Verwendung eines

resorbirbaren Metalles in der Chirurgie. Arch. f. klin. Chir. 62: 67-93, 1900.

117 Hopfner, E.: Uber Oefiissnaht, GefSsstransplantationenund Replantation von amputirten Extremitaten. Arch,

f. klin. Chir. 70: 417-454, 1903.

118 See footnote 102 (1), p. 115, 118 Jeger, Ernst: Die Chirurgie der Blutgefaesse und des Herzens. Berlin, Hirschwald Co., 1913. 180 Blakemore, A. H.; Lord, J. W., Jr., and Stefko, P. L.; The severed primary artery in the war wounded; nonsuture

method of bridging arterial defects. Surgery 12: 488-508, Sep 1942. 1,1 (1) Blakemore, A. H.; Lord, J. W., Jr., and Stefko, P. L.; Restoration of blood flow in damaged arteries; further

studies on nonsuture method ofblood vessel anastomosis. Ann. Surg. 117: 481-497, Apr 1943.

(2) Blakemore, A. H., and Lord. J. W., Jr.: nonsuture method of blood vessel anastomosis; review of experimental study; report of clinical cases. Ann. Surg. 121: 435-453, Apr 1945.

(3) Blakemore, A. H., and Lord, J. W., Jr.: nonsuture methodof bloodvessel anastomosis; experimentaland clinical study. J.A.M.A. 127: 685-691; idem, ibid.: 748-753, Mar 1945. 182 Later, an ordnance company copied the tubes in stainless steel and they were used with great satisfaction at the

8th Evacuation Hospital.

123 See footnote 50, p. 99.

330323 0—55
120 VASCULAR SURGERY IN WORLD WAR II

The operation, which was performed with the patient under ether-oxygen anesthesia

with thiopental sodium induction, lasted hours and 15 minutes. primary incision was

made in the femoral triangle and tape was passed under the common femoral artery to

permit emergency control of hemorrhage. All wounds were debrided. The femoral vein

was ligated in the adductor canal. Anastomosis of the severed femoral artery was accomplished by means of stainless steel tubes fashioned after those described by Blakemore and

his associates. segment of the right long saphenous vein was used to bridge the gap.

Before the anastomosis was completed clot was detected in the end of the artery just

above the proximal tube. Heparin was injected subcutaneously (2 cc. in Pitkin’s menstruum)

and when the clotting time (determined by the Lee and White method) was 10 minutes, the

clot was removed and the anastomosis was completed. Good pulsation was noted in the

femoral artery distally, beyond the lower tube. The primary incision was closed, but the

other wounds were left open for later delayed primary suture. No untoward effects followed

procaine hydrochloride block of the third and fourth lumbar ganglia.

The patient’s general condition during operation was satisfactory. The systolic blood

pressure remained in the neighborhood of 120 and the diastolic between 70 and 80 mm. of

mercury. The pulse rate ranged between 110 and 120 beats per minute. In the course of

the operation the patient received 500 cc. of whole blood, 1,000 cc. of 2-percent sodium

bicarbonate, and 1,000 cc. of 5-percent glucose in physiologic saline solution.

On 12 March, the day after the operation, the patient received 500 cc. of 2-percent

sodium bicarbonate by vein and 1,000 cc. of whole blood. He was also given, subcutaneously,

cc. (200 mg.) of heparin in Pitkin’s menstruum. Examinations of the urine showed

to 4+ reaction for benzidine-positive substance but no other abnormality. The sympathetic

block was repeated.

The right foot was cooler than the left; the capillary circulation in the right foot was

sluggish. There was neither sensation in the toes nor motor power in the left foot. When the

effect of spinal anesthesia on the circulation of the leg was tested, the level of anesthesia

reached the crest of the ilium. There was no immediate change in the temperature of the

right foot.

posterior fasciotomy was done from the popliteal space to just above the ankle. The

gastrocnemius and soleus group of muscles bulged through the incision. They appeared

edematous. There were areas of pallor in the gastrocnemius muscle but some pulsating

vessels were seen in it. The soleus muscle was relatively more anemic. small fasciotomy

incision over the anterior tibial group of muscles revealed normal muscles with no bulging.

After the posterior fasciotomy the foot appeared much improved in color; it was also warmer

and the capillary circulation was better.

On 13 March the patient received units of plasma and 1,000 cc. of whole blood. The

foot was warm, the capillary circulation normal, and the posterior tibial pulse palpable and

forceful. The dorsalis pedis pulse was not palpable. There was moderate amount of serous

drainage from the calf.

The patient received units of plasma and 500 cc. of whole blood on 14 March. Two

2-cc. doses of heparin in Pitkin’s menstruum (200 mg.) were given subcutaneously at 11-hour

intervals. The foot and leg were edematous to the knee. The anterior tibial group of muscles,

though rather tense, was resilient. Exudate continued to drain from the fasciotomy wound.

The foot of the cot was elevated at half-hour intervals for 30-minute periods.

On 15 March the patient received unit of plasma and 1,000 cc. of whole blood, together

with dose of heparin (2 cc.). Hepaiin thereafter was discontinued because the supply was

exhausted. unit of plasma and 500 cc. of whole blood were given the following day. Weak

pulsation was felt in the posterior tibial artery and edema began to subside. Exudation from

the fasciotomy wound also began to decrease. Two days later (18 March) both posterior

tibial and dorsalis pedis arteries were readily palpable. Penicillin, which had been given

daily in the amount of 200,000 units, and sulfadiazine, which had been given in 6-gm.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 121

amounts, were discontinued. On 15 March the urine was free of benzidine-positive substance which had been present in small amounts since it first appeared 12 March. By 16 March the

phenolsulfonphthalein excretory capacity of the patient was greatly improved. It had been

50 percent below normal on 12 March.

The patient was transferred to general hospital on 19 March. When the dressings

were changed in the operating room 22 March the gastrocnemius and soleus muscles showed

some separating slough. All wounds were closed except the wound on the posterior thigh

and the fasciotomy wound.

The hip spica was changed on April and the sutures were removed. The fasciotomy

wound showed superficial suppuration and small amount of slough was still found separating

from the gastrocnemius-soleus group of muscles near the tendinous portions. The right foot

was warm, though not as warm as the left. The sole of the foot and the toes were anesthetic

and hypesthetic. No motion was detectable in the toes or the ankle. An arteriogram showed

complete patency of the anastomosis (Fig. 6A, B). When the patient was evacuated to the

Zone of Interior 13 April he stated that he was beginning to “feel” little motion in the toes

and ankle, though none could be detected objectively.

Figure 6. {Case 10.) Laceration of femoral artery and vein treated by nonsuture anastomosis.

A. Roentgenogram 25 days after operation, before injection of diodrast. B. Arteriogram

after injection of diodrast into common femoral artery.

Comment. The result in this case would probably not have been as

satisfactory if the severed blood vessel had not been repaired by anastomosis.

The appearance of benzidine-positive substance (probably myoglobin) in

the urine for several days after the operation is of interest in that it may indicate

relief of ischemia. It is physiologic fact that this substance does not appear

in the blood and urine until the circulation has become reestablished.
122 VASCULAR SURGERY IN WORLD WAR II

The proportion of amputations for the double-tube-vein-graft technique

was significantly higher than for suture repair. However, the difference was

not considered to be due to the techniques used but to the different characteristics of the injury for which the type of treatment was selected.

Case 11. When this 22-year-old soldier was wounded by enemy rifle fire 19 September

1944 in Italy, he incurred severe wound of the left knee with compound comminuted

fracture of the left femur extending into the knee joint. The popliteal artery and vein were

completely transected in the midpopliteal space. When the patient was admitted to an

evacuation hospital 20 September, 9}i hours after wounding, the blood pressure was unmeasurable. He had already received units of plasma. Three hours later, after resuscitation with whole blood and plasma, the blood pressure was 104 mm. of mercury systolic and

58 diastolic.

The operation was performed 14}£ hours after injury with the patient under thiopental

sodium anesthesia. The wound was debrided, the popliteal vein ligated, and the popliteal

artery suture-ligated. lumbar sympathetic block was done at the conclusion of the operation and was repeated 8}4 hours later (1.5-percent procaine hydrochloride was used). No

improvement was noted after either block.

On 21 September the left foot and leg were cold up to the level of the tibial tubercle.

Areas of purple discoloration on the dorsum of the foot and in and around the great toe did

not blanche. No pulsations could be felt in the foot or at the ankle. No oscillations were

observed in the calf. The foot was anesthetic to justabove the ankle. There was no motion

in the toes. Although little hope was felt for of the extremity it was decided,

as last resort, to do nonsuture anastomosis with the hope of improving the circulation

sufficiently to save part of the leg. After transfusion of 500 cc. of whole blood left lumbar

ganglionectomy was done, with excision of the second, third, and fourth ganglia. The ends

of the popliteal artery were exposed and anastomosis by the nonsuture technique was performed (Fig. 7A). Vitallium tubes and segment of the right long saphenous vein were used.

gap inches long was thus bridged (Fig. 7B). posterolateral fasciotomy was done in

the calf. bivalved cast was applied, using only the posterior half. Intravenous administration of heparin was begun at once at the rate of 600 mg. every 24 hours, and the foot was

kept in dependent position.

The day after operation there was no edema of the foot; the foot was, however, cold and

anesthetic to just above the ankle. There was no motion in the toes or at the ankle. The

calf was swollen to almost twice normal size. transfusion of 1,000 cc. of whole blood was

given. On 24 September the appearance of the left calf was unchanged. During the previous

48 hours the area from the level of the tibial tubercle to about inches above the malleoli

became warmer. The foot was cold and dusky and the terminal phalanges of the toes were

purple. The following day the foot was cold but the calf was warm to within inches of the

malleoli. The clotting time (by the capillary tube method) was 22 minutes.

By 27 September, the seventh day after injury, when no improvement in the condition

of the limb had occurred (Fig. 7C), amputation was recommended. It was carried out the

following day, with the patient under ether anesthesia. An attempt was made to perform

the amputation at the midleg, but at this level, while there was bleeding from the skin, there

was none from the muscles. Upon examination the muscles proved to be pale and nonviable (Fig. 7D). Amputation was therefore done at the supracondylar level. Recovery was

uneventful.

Comment. When the anastomosis was exposed in the amputated specimen both the cuffs

were found in place but the artery was thrombosed proximal to the anastomosis. Thrombosis extended distally into the leg and the venous segment was filled with blood clot. The

anastomosis in this case was probably of no value because it was done after extensive thrombosis had occurred in the leg.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 123

Figure 7. A. Details of nonsuture technique, a. Method of making anastomosis, this is

essentially the technique described by Blakemore, Lord, and Stefko, except that the vein is

not ligated onto the tube. Note that one of the ties is looser than the other and that the direction of the valves in the vein is reversed, b. Completed anastomosis.
124 VASCULAR SURGERY IN WORLD WAR II

Figure —Continued. B. Transection of popliteal artery treated by nonsuture technique. The

arterial injury was complicated by severe compoundfracture of the tibia and the dislocated

tibialfragments are stillattached inthe wound. C. Appearance offoot days after anastomosis.

D. Dissection of amputated leg. The muscles were pale and swollen and the subcutaneous

tissues were edematous.

In of 13 cases observed in Italy (9 of which one of us personally operated

on) amputation was necessary later, in instance limited to the toes, in

through the lower leg, and in through the thigh. All of these patients had

severe injuries and it is doubtful that the limbs could have been saved under

any method of treatment. The cases were deliberately selected for trial because the use of this method under battle conditions was considered purely

experimental and therefore justified only in critical cases.

All of the patients in this series, as just noted, had severe injuries. In

of the cases in which amputation had to be done above the knee, severance

of the popliteal artery was complicated by compound fracture of the knee

joint. While it must be granted that this is the type of case in which experience has shown that survival of the limb is unlikely, it must also be emphasized
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 125

that this is exactly the type of case in which it was hoped that nonsuture

anastomosis would improve the results if it could be done early enough for

diffuse thrombosis and infection not to have become established.

Failure in cases in the series just mentioned could be attributed to

technical errors. In instance re-anastomosis after bleeding from tiny

venule had become apparent was not successful because peripheral thrombosis

had already developed. In the other case the edge of the vitallium tube cut

through the arterial wall on the 11th day after operation. When the anastomosis was performed there had been good deal of difficulty in inserting the

tube into the lumen of the vessel.

What is more important from the standpoint of military surgery than the

exact results secured in this series is the character of the technique. The ease

or difficulty with which an operation can be performed is an important consideration in military surgery, and the experience in World War II suggested that

nonsuture anastomosis is neither as simple nor as easy as its proponents, whose

extensive experience with the method was confined to civilian practice, indicated that it was. One operation in Italy, for instance, performed by betterthan-average surgeon, took 3% hours; in the course of the procedure the ligature twice slipped off the tube and had to be tediously reapplied. forward

hospital, when casualties are heavy, is not the place for such time-consuming

surgery if it produces no better results than can be secured by other, simpler

methods. It is not known how many times the method was attempted and

failed, though this is known to have happened times in series of 23 cases.

Another possible disadvantage of the method is that when it is not successful

it may result in the destruction of additional arterial substance. This is

particularly undesirable result and the sacrifice of functional collateral arteries

was felt to be definite contraindication to the use of the method in any case

in which there was not reasonable chance of success.

It must be granted that although these operations were done by capable

surgeons, they involved new technique, and better results can probably be

expected as experience increases.

The various series of reparative operations performed for acute arterial

injuries in World War II were all too small to permit definite statements concerning the value of any one of these methods as compared with other methods

(Charts 15, 16). In individual cases it is possible to say that one method or

another was responsible for the saving of all or part of limb, but the overall

figures permit no such conclusions. It must be emphasized again, however,

that most of the cases in these series were cases in which, because of the size

of the defect, suture repair was not practical, in which the proportion of

critical vessels was high, and in which the prognosis was always grave.

Sympathectomy was usually performed when major artery of the lower

extremity had been treated by nonsuture anastomosis.
126 VASCULAR SURGERY IN WORLD WAR II

Chart 16. Incidence of amputation in arterial wounds in American battle casualties in World

War II according to method of management. The data depicted are based on selected

group for which the necessary information was available. They do not include all arterial

wounds during World War II. The difference between total cases and breakdown in this

chart represents 670 cases for which therapeutic measures could not be determined or are not

included in the two categories. Type of repair was not known in cases, of which involved

amputation, and these are not included in the types of repair shown in Chart 15.

COMPLICATIONS OF ACUTE ARTERIAL INJURIES

Ischemia

As the war progressed disastrous effects of circulatory constrictions, no

matter what the cause, became recognized more and more. Constriction

might be caused by action of the missile itself, by bacterial toxins and proteolysis, by vasospasm, and by effect of compound fractures or multiple injuries

which impaired circulation directly or indirectly. Unwisely applied emergency

measures were an unfortunately frequent cause. They included application

of tight bandages, tight packs (particularly in deep wounds), tourniquets, and

plaster casts. Plaster casts were particularly dangerous when applied under

conditions which did not permit close observation of the patient afterward or

when the cast had not been bivalved to allow for subsequent swelling of tissues.

Dangerous ischemia could follow either localized or homogeneous compression.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 127

circular bandage inside cast could give rise to dangerous ischemia and simple

linear incision of circular cast did not provide sufficient safeguard against

edema of the limb and embarrassment of the circulation. Even prolonged

elevation of limb with vascular injury might hasten ischemia which was

impending or accentuate the condition if it had already developed.

Exactly why, when all circumstances seemed comparable, some wounds

healed without complications, and in others local infection and gas gangrene

developed, was never clearly understood. What was understood, however,

was that certain factors favored the growth of clostridia and enhanced the

development of infection, and that loss or impairment of circulation in the

involved tissues was the most important of these causes.

Eventually these dangers were warned against in directives issued in the

Mediterranean 124 and European theaters, 125 and the Office of The Surgeon

General. 126 One of the precautions against the development of serious ischemic

complications was retention of patient with an injured extremity at the

evacuation hospital whenever the blood supply seemed to be jeopardized. He

was not permitted to be evacuated further until it was clear that the collateral

circulation was adequate or until amputation had been performed.

Pulsating Hematoma

Although aneurysms and arteriovenous fistulas seldom required treatment

in forward hospitals, false aneurysms (pulsating hematomas) were in different

category. 127 Many surgeons took the position that the risk of hemorrhage or

rupture was so great in this type of lesion that evacuation to the Zone of

Interior was unsafe until operation had been performed. In theory, this was

complication which could be prevented by proper treatment of vascular injuries.

In practice, planned repair of the arterial defect was often not possible because

of the circumstances of war. Frequently, extensive damage to muscles, nerves,

and bones did not even permit an exact determination of the vascular damage.

Pulsating hematomas were usually encountered in cases in which it was

not possible to ligate the main vessels securely and immediate hemorrhage had

to be controlled by packing. They were also encountered in cases in which,

because the wound was small and there was little external loss of blood, massive

hemorrhage into the tissues had occurred and had been overlooked. In some

cases infection and necrosis produced secondary hemorrhage into the limb,

which was not obvious externally. In all such cases the blood extravasated

into the part and clotted. Later, if the condition was not remedied, true

endothelial sac was partially or completely organized. Expansile pulsation

could be observed as long as blood continued to enter the mass. When the

area had become over-distended and no further blood could enter the sac, all

■*< See footnote 22 (3), p. 70. 1,4 See footnote 89 (3), p. 108.

124 (1) Gas gangrene prophylaxis. Bull. U. S. Army M. Dept. 75: 26-28, Apr 1944.

(2) See also footnote 29, p. 81. 127 See footnotes 22 (3), p. 70; 23, p. 71; 29, p. 81; and 89 (2), p. 108.
128 VASCULAR SURGERY IN WORLD WAR II

pulsation ceased. This was the time during which the blood supply to the

limb could be totally occluded both by an intraluminal clot and by secondary

compression of the artery. As result the part below the lesion began to swell

and the patient complained of pain, or of more pain if pain had already been

feature of his clinical course.

While pulsating hematoma could develop at any time following injury,

it most often became evident within the first to weeks. It was also particularly easy to overlook it during this period because the patient was being

transported to the rear, and examinations along the way were apt to be superficial. If the limb was in cast, examination was frequently omitted.

The diagnosis of pulsating hematoma usually was not difficult if it was

remembered that it was possibility in any instance of penetrating trauma in

the vicinity of large arteries, and that the possibility was strong if there was

history of initial profuse hemorrhage, or if an initial hemorrhage had had to be

controlled by packing. When the packing was removed, cavity often remained

which was an ideal site for the escape of blood. Undue swelling of the part and

pain and discomfort, especially after change of cast, were always indications

for careful local examination. Characteristically, the pain was out of proportion to that previously experienced. Sometimes mass was not palpable,

but if hemorrhage had occurred recently, or if rupture was impending, it

usually was present and might be of considerable size. If the sac was well

developed, pulsations could be seen and were likely to be associated with

systolic bruit.

Differentiation of pulsating hematoma from an abscess offered the chief

diagnostic problem. If the hematoma was well developed and presented the

classical signs there was seldom any difficulty. Otherwise, the differentiation

had to be made on the basis of the systemic manifestations likely to be present

in abscess formation. It was sound rule not to incise fluctuant mass near

blood vessel, even though evidence of infection was present, until the possibility

of pulsating hematoma had been eliminated.

In small pulsating hematomas which had become infected, an occasional

spontaneous cure followed the occlusion of the affected vessel by the so-called

currant-jelly clot and subsequent fibrosis:

Case 12. 36-year-old soldier wounded by aerial bomb fragments at Anzio, Italy

28 January 1944, incurred multiple penetrating wounds of the left hand, left wrist, and both thighs. The right femoral artery was involved in the wound on that side. The wounds

were debrided at an evacuation hospital the same day, and foreign body was removed

from the left thigh.

Roentgenograms taken at general hospital February showed metallic fragments

in the upper third of the right thigh; there was an incomplete fracture of the femur in the

same area. moderately low-pitched bruit (systolic) and an expansile pulsation could

be demonstrated justproximal to the middle of the right thigh medially. The bruit did not

have “machinery” quality. There was no evidence of nerve damage and the pulses in

the right foot were normal. The erythrocytes numbered 3,280,000 and the leukocytes

19,600 per cubic millimeter of blood. Transfusions of 500 cc. of whole blood were given

February and February.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 129

On 11 February all wounds were closed secondarily, and subsequent healing was satisfactory. At this time the patient was complaining of periods of numbness in the dorsum

of the right foot. The following day the systolic bruit over the left femoral artery was

recorded as softer and less shrill. It was still present on 14 February, but on 15 February

when the patient was shown to surgical consultant to secure advice concerning the management of the aneurysm, there were no signs of the lesion nor was there any further evidence

of its presence during the week the patient subsequently remained under observation.

Comment. The case demonstrates one of the advantages of delaying the

surgical treatment of traumatic aneurysms and similar lesions, for sometimes,

as in this instance, they disappear spontaneously.

In most cases of pulsating hematoma observed in World War II, surgery

was necessary, though it was best postponed for to months if pain or evidence of impending rupture did not furnish indications for immediate operation. The longer an operation could be postponed, the more likely was the

collateral circulation to be adequate. It was also desirable that the external

wound be well healed and that dormant infection be excluded before operation was undertaken, but this was not always possible in the absence of wellorganized sac. When such sac was not present, copious bleeding often followed necrosis or slough of extensive soft-tissue wounds and even disruption

of recently sutured wounds. In these cases, when pallor of the limb, absence

of pulsations distal to the lesion, swelling of the part, or lowering of the surface temperature indicated that the blood supply to the extremity was reduced,

it was not safe to postpone operation.

The most important technical step in operations for pulsating hematoma

was control of bleeding from above; dry operative field was imperative.

Frequently this could be achieved with properly applied tourniquet, though

in wounds of the upper thigh this was not possible. safer method in all

cases was to expose the main vessels above the lesion and to ligate them temporarily with rubber bands or tape. An approach through the original wound

was usually complicated and unsatisfactory. True arteriorrhaphy or endoaneurysmorrhaphy was not always the wisest procedure, or, indeed, feasible

procedure. The rent in the vessel was frequently too extensive and the separation of the ends too great. Segmental defects in the wall were also frequent.

The best plan, after evacuation of the sac, was occlusion of the proximal and

distal portions by interrupted silk sutures carefully placed in the ends of the

vessel, or by ligation. The temporary bands occluding the blood supply were

then loosened to make sure that occlusion was complete. The cavity was

lightly packed with gauze and adequate drainage was provided in all cases

since most of the wounds were infected. Primary closure was always contraindicated if the operation was done on the indication of rupture or threatened

rupture.

Secondary Hemorrhage

Secondary hemorrhage was relatively frequent complication of arterial

injuries in World War I. In series of 10,000 patients with wounds in which
130 VASCULAR SURGERY IN WORLD WAR II

the long bones were involved, Waugh 128 observed an incidence of 14 percent

in year and of percent in the following year. He attributed the improvement in the second year to “improved arrangements for the early excision of

wounds.” Tuffier, 129 in commenting upon secondary hemorrhage from arterial

wounds during the First World War, also related the incidence of the complication to the incidence of infected wounds.

In World War II the incidence of secondary hemorrhage was strikingly

reduced because of improvements in the technique of debridement and immobilization, and the availability of chemotherapeutic and antibiotic agents.

Of these reasons, improvement in debridement and the use of chemotherapeutic

and antibiotic agents were probably the most important because of their

beneficial effect on the incidence of wound infection. The problem was still

important, however, because of the disastrous consequences which might follow

severe bleeding.

In all theaters the practice of delay in operation for aneurysm and arteriovenous fistula probably had much to do with reducing the incidence of

secondary hemorrhage. It was generally taught that secondary hemorrhage

was possibility, even if remote one, when arterial or venous ligature was

undertaken, and it was recommended that tourniquet be kept in position

about the limb to be tightened immediately if hemorrhage should arise which

could not be controlled by simpler measures. In an occasional case the

loosening of thrombi several weeks after their original formation resulted in

secondary hemorrhage.

In the North African Theater of Operations not single secondary hemorrhage was encountered in forward hospitals in the Sicilian campaign, perhaps because the patients were seldom kept long enough for it to occur. On

the other hand, the basic reason probably was that the wounds were not

particularly extensive.

The secondary hemorrhages encountered in the Italian campaign and

studied by Capt. J. T. Coyle and Maj. W. D. Thompson 130 were of two types.

The first and more frequent type occurred from large muscle areas when

thin layer of necrotic material sloughed en masse. It was readily controlled

in every instance by thoroughly cleaning out the slough tissue and applying

hot, moist sponges. Petrolatum impregnated dressings were not satisfactory;

dry gauze fluffs, removed after 48 hours, worked well. The second type of

hemorrhage occurred from large wounds of the calf after sloughing of the wall

of the posterior or anterior tibial artery. It was controlled by ligation of the

involved artery and no circulatory disturbances were noted subsequently in

any of these patients.

128 Waugh, W. Grant: Secondary hemorrhage. In Bailey, Hamilton: Surgery of Modern Warfare. Baltimore.

Williams Wilkins Co., 1941,vol 1, p. 328-332. 128 See footnote 113 (3), p. 116. uo Coyle, J. T., and Thompson, W. D., Jr.: Fractures in battle casualties. Bull. U. S. Army M. Dept. 86: 57-63,

Mar 1945.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 131

The experience reported by Lt. Col. Norman E. Freeman 131 at the 20th

General Hospital at Assam, India, may be taken as typical of the World War II

experience with secondary hemorrhage. This complication was observed in 23

of 2,168 patients treated in the course of year for gunshot or shell wounds of

the extremities and neck. In of these patients bleeding was from small vessels

and was readily controlled by packing or by simple ligation of the bleeding vessel in the wound. In the other 15 patients hemorrhage was from major vessel

and was serious problem. Freeman personally operated on 12 of the 15

patients and supervised the treatment of others, which makes the report of

this particular experience of unusual value.

Clinical Observations. In every instance in Freeman’s series the wound

was located in the immediate proximity of the vessel from which the hemorrhage

occurred, circumstance which naturally simplified the diagnosis. As in

Waugh’s series, 132 compound fractures were present in more than two-thirds of

the cases. Another observation of major importance, though its significance

was not always realized, was that the patients in whom secondary hemorrhage

occurred had (1) previous clear-cut story of massive hemorrhage or recurrent

bleeding while in the forward area, or (2) condition of severe anemia at the

time of admission to the hospital. Eventually it was realized that injury to

large vessel should always be suspected when heavy loss of blood was evident.

In patients one or more episodes of bleeding occurred before the final massive

hemorrhage. Failure to heed this “red signal” was responsible for the death of

patient (Case 13) and would have been responsible for death in others except

for the skilled intervention of ward personnel (Case 14). As emphasized by

Waugh “a small initial hemorrhage occurs in more than half the total cases and

constitutes an inexorable indication for exploration of the wound.” This lesson

was eventually learned in World War II and ward personnel were instructed to

report immediately any bleeding, however small.

Case 13. 27-year-old Chinese soldier was struck just below the left shoulder by

bullet from .25 caliber pistol on March 1944. The wound of entrance was over the

lateral surface of the left arm below the acromion and the bullet came to rest in the soft

tissues of the axilla. compound fracture of the humerus was present in addition to the

soft-tissue injuries. Debridement had been performed in the forward area and plaster

encasement applied to the left shoulder with the arm in abduction. When the patient

reached the 20th General Hospital the radial pulse was normal, normal sensation and motion

were present in the fingers, and there was no edema of the extremity. The value for hemoglobin was 8.8 gm. per 100 cc. of blood. When the cast was changed 14 March the wound

appeared clean and there had been nothing in the patient’s progress to suggest subsequent

difficulties. hanging plaster encasement was applied to the forearm for traction and

separate spica was applied to cover the wound.

On 17 March the Officer of the Day noted on the patient’s record at 0700 that some

bleeding had occurred for few minutes under the encasement while the man was brushing

his teeth, but that it had stopped and his condition was good though he would probably

131 Freeman, N. E.: Secondary hemorrhage arising from gunshot woundsof the peripheralblood vessels. Ann. Surg.

122: 631-640, Oct 1945.

132 See footnote 128, p. 130.
132 VASCULAR SURGERY IN WORLD WAR II

need new encasement. Six hours later the ward officer noted that there had been no

further bleeding, that the patient’s condition was satisfactory, and that it could be seen

under the encasement that the wound was dry. Two and one-half hours later there was

second small episode of bleeding and the patient vomited and fainted. When the ward

officer removed the encasement, the wound was dry. corpsman reported that he had

seen the patient “picking at the wound with his chopsticks,” and it was assumed that this

action had caused some bleeding from the granulations.

For the next 10 days progress was completely satisfactory except that, for the first

time, the patient had higher than normal temperature. There was no bleeding and the

alignment of the fracture was satisfactory. On 27 March, 27 days after wounding and 10

days after the episodes of bleeding, the patient suddenly screamed. He was found sitting

up in bed in pool of blood and death occurred while the encasement was being cut off and

efforts were being made to start transfusion.

Case 14- Chinese soldier sustained shell fragment wound just below the angle of

the left mandible 18 March 1944. The missile lodged in the transverse process of the first

cervical vertebra. Debridement was performed in the forward area and was accompanied,

according to the operative note, by “much bleeding.” Three days after the patient’s

admission to the 20th General Hospital, and days after he had been injured, swelling

was noted below the left mandible which continued to increase in size and to cause severe

pain. His temperature was normal. On 30 March, 12 days after the original injury, with

preoperative diagnosis of cervical abscess the mass was incised. The “rush of blood”

which ensued was controlled with difficulty by suture of the skin and pressure dressing.

On April, days later, pulsating tumor with palpable thrill and continuous murmur

was found below the lobe of the left ear. The wound was healing but serous fluid was

weeping from the skin edges. The anterior jugular vein was distended when the patient

was recumbent but collapsed when he sat up. The pulse rate dropped from 72 to 60 beats

per minute when pressure over the carotid artery was sufficient to abolish the murmur.

diagnosis of arteriovenous fistula was made.

In this case it was considered desirable, if possible, to allow complete healing to occur

before the fistula was excised. The delay was regarded as safe since hemorrhage from an

arteriovenous fistula is rare because of the free communication with the venous side of the

circulation and the resultant low pressure within the aneurysmal sac. tight bandage

was applied over the lesion, procedure which, in retrospect, was realized to be mistake

since compression of the tissues, if it achieved anything, was likely to raise the pressure in

the aneurysm because of pressure on the venous outlet.

The day after the bandage was applied, the nurse on the ward heard the patient cry

out. When she went to him she found him sitting up in bed with blood streaming from his

neck. She immediately applied digital pressure, thus controlling the bleeding and saving

his life. As soon as possible he was transported to the operating room where, with the aid

of local analgesia, the external carotid artery was exposed below the digastricus. The circulation was temporarily occluded by rubber tube. The arteriovenous fistula was then

opened and excised with quadruple ligation of the component arteries and veins. The

hemorrhage had originated from the external maxillary artery and the temperomaxillary vein.

It is noteworthy that hemorrhage was sometimes preceded by minor

activity such as brushing the teeth or moving the arms; however, in other

instances it occurred without warning. In any event, such warnings as did

occur were often so slight that they were ignored; moreover, the cessation of

the initial hemorrhage induced an unwarranted sense of security.

In of Freeman’s patients bleeding into cast hindered both diagnosis

and treatment. Plaster encasement was an essential form of treatment in
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 133

both fractures and extensive soft-tissue injuries, but care was not always taken

to exclude injuries of major blood vessels before immobilization was instituted. In World War secondary hemorrhage most often occurred between the

10th and 16th days after injury. In Freeman’s series the range was from

days to months. In 10 of the 15 cases he cited, the bleeding occurred within

the first weeks after wounding.

When these cases were reviewed it was found that physical examination

at the time the patients were admitted to the hospital had not been helpful.

Although all of the patients had lacerations of major arteries, as their clinical

course later proved, the peripheral pulses were absent in only and were

diminished in only others. Most of the patients presented peripheral edema

or complained of sense of numbness of the distal part of the affected extremity.

In patients, although the fingers were warm and the radial pulses palpable,

tissue damage had obviously occurred and could have been caused only by

severe ischemia of long duration. Since the circulation was adequate at the

time of admittance, the observation pointed to serious arterial injury for

which compensation had been provided either by resumption of the blood flow

through the injured vessel or by development of collateral circulation.

In instances hematoma was present over the injured vessel, but

systolic bruit was audible in only of these cases. In other cases, although

the initial examination was conducted with the possibility of an arterial lesion

in mind, no bruit could be heard.

Character of Injuries. In 14 of the 15 cases in Freeman’s series the arterial

injury was laceration. In the 15th case the vessel was only partially divided.

Injuries of this type are much more likely to lead to severe bleeding than is

complete severance in which retraction of the severed ends is physiologic

means of controlling hemorrhage. Waugh, 133 in his study of secondary hemorrhage in World War I, cited Makins to the effect that in every secondary

hemorrhage an incomplete injury of blood vessel is preexistent. These cases

help to prove that thesis.

Therapy. In hemorrhage from minor vessels, as already noted, packing

of the wound with dry gauze, the application of pressure, or ligation of the

bleeding vessel in the wound was sufficient for control. Immediate arrest

of bleeding, by one means or another, was the proper method of treatment in

all cases and management included immediate replacement of the blood loss

and arrangements for immediate operation. In the meantime the bleeding

was controlled by emergency methods, with tourniquet the last resort. In

small wounds of the neck digital compression might be the only possible

method of temporary control.

The first principle of surgery was that the incision be long enough for

adequate exposure, since circulation through the afferent artery had to be

controlled before the bleeding point could be found. There was never any

133 See footnote 128, p. 130.
134 VASCULAR SURGERY IN WORLD WAR II

hesitation in opening and exposing the original wound. It was sometimes

difficult to find the laceration when the bleeding had been checked by temporary

measures, for the laceration was often sealed again by clot formation, and the

circulation was depressed from loss of blood. In of the 15 cases cited by

Freeman manipulation was necessary to produce bleeding before the injury

could be identified. It was essential to be quite certain that the precise source

of the bleeding had been found. In patient small arterial branch of the

popliteal artery was thought to be responsible, but recurrent hemorrhage after

transfusion necessitated second exploration and disclosed laceration of the

popliteal artery itself.

In patient proximal ligation through separate incision was performed

for secondary hemorrhage after previous ligation of the femoral artery. After

the vessel had been exposed, bleeding was controlled by rubber tubes placed

proximally and distally and the bleeding point was then sought, in dry field,

without danger of injury to accompanying nerves and other structures.

Suture of the laceration was attempted twice but was successful in only

case. In the other, ruptured false aneurysm of the femoral artery, amputation was required days later for ischemic gangrene. In all the other cases

the vessel was ligated and divided.

Case 16. In this case shell-fragment wound, 11 July 1944,resulted in supracondylar

fracture of the left femur with little hemorrhage. When the patient was examined at the

20th General Hospital 12 July, the left foot was warm and the dorsalis pedis pulse was

palpable. Skeletal traction was applied. Infection of the wound followed and was asso- ciated with intermittent fever. Pitting edema of the foot was noted about weeks after

injury. On 15 September, months after injury, about 100 cc. of serosanguineous material containing some small clots was discharged from the wound immediately after the

patient had used bed pan. Distortion of the thigh was noted and roentgenograms confirmed the clinical impression of displacement at the fracture site. The ankle pulses were

normal, motion and sensation were present in the toes, and there was no pulsation, thrill,

or bruit over the femoral vessels just above the knee. One week later an accumulation of

pus on the posterolateral aspect of the lower thigh was drained. Slight amounts of blood

continued to appear on the dressings. The medial wound was now almost healed.

On October, almost months after the original injury, brisk hemorrhage occurred

from the posterolateral wound. It was controlled by packing until the patient could be

taken to the operating room. Then, with the aid of spinal analgesia, the femoral artery

was exposed in the adductor canal, the circulation was controlled, and the site of bleeding

was sought. It proved to be ruptured false aneurysm. Release of the distal end of the

artery allowed no back bleeding. The laceration in the femoral artery was sutured since

it was felt that the collateral circulation was insufficient. Pulsation of the artery below

the line of suture took place after release of the upper rubber tubing applied to control the

blood supply. After operation there was marked ischemia of the tissues below the knee.

Although the lower leg was refrigerated for days, no improvement was evident and

amputation through the fracture site had to be performed 14 October. Dissection of the

arteries of the leg revealed that thrombosis had occurred below the point of suture.

Although Reid 134 had condemned chromic catgut for these purposes,

especially when wound infection was present because its absorbable properties

1M Reid, M. R.: Partial occlusion of the aorta with silk sutures, and complete occlusion with fascial plugs; effects of

ligature on the arterial wall. J. Exper. Med. 40: 293-299, Sep 1924.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 135

made rapid disintegration likely, it was used in the series reported by Freeman

without any untoward results. The factors of safety were probably adequate

drainage and the use of sulfonamide drugs.

After operation alcohol was injected into the region of the paravertebral

sympathetic ganglia in patients with good results. In fifth patient, procaine

was injected repeatedly. In the case just described in which ischemic gangrene

required secondary amputation, alcohol injection was not employed.

Vasospasm

Vasospasm is well known in civilian practice as accompanying wounds

or manipulations of the arteries. It is, in fact, natural response to any form

of trauma which directly or indirectly affects the vascular structures. It was

therefore common occurrence in the arterial injuries observed in World War

as well as in those observed in World War II. Depending upon number of

factors it might involve only small part of vessel (as in arterial concussion),

might spread to neighboring vessels, or might become sufficiently generalized

to involve the entire limb and even larger areas of the body. Although

vasospasm could under certain conditions be considered compensatory

mechanism, prolonged vasospasm could lead to serious consequences. When

it was minimal, amounting merely to localized area of constriction, the

resulting ischemia was minimal and the limb was seldom placed in jeopardy.

When it was more extensive, and especially when the collateral circulation was

involved, ischemia was often sufficient to produce localised gangrene. When

it occurred in cases in which trauma to the tissues had already seriously

impaired their vitality, vasospasm was often the factor which determined

whether the limb would survive or die. An additional factor of danger was

that the results of ischemia might cause development of gas bacillus infection. In the category of spasm are included the few cases of contusion recorded

as such in American battle casualties in World War II because this condition,

if it was recognized at all, was not infrequently accompanied by spastic

phenomena. This type oflesion was usually slight and its inclusion in tabulated series therefore alters the results favorably. (This is perhaps one reason

why Makins’ statistics, in which contusions were included, are so much more

favorable than other statistics from which they are omitted.) Some doubt

is felt about the incidence of amputation (25 percent) reported in the 28 cases

of spasm in this series (Chart 12). That the figures are weighted is suggested

by the fact that in sample of cases, there were instances of gangrene.

This is so contrary to the usual experience as to suggest that the diagnosis of

spasm was probably not correct in or more cases in the group. Furthermore,

most cases of spasm were notrecorded at all and reports therefore included only

those which developed complications.

Vasospasm, as the following cases show, might be transient or might be

of long duration.

330323 0—55 10
136 VASCULAR SURGERY IN WORLD WAR II

Case 16. soldier wounded in Tunisia 31 March 1943, incurred perforating shellfragment wound of the right leg. When he was admitted to an evacuation hospital the

following day the wound was described as located to cm. below the anteromedial lip of

the tibia, midway between the tibia and the fibula. The wound of exit, which was small,

was located in the calf posteriorly. The leg was warm and of good color but was markedly

edematous. Pulsation could not be felt in the dorsalis pedis.

Exploration was undertaken April, 32 hours after wounding. The missile track

passed through the opening above the interosseous membrane in close proximity to the anterior tibial artery. The peroneal nerve was not injured. There was no visible injury to

the vessel wall, but the vessel was in complete spasm for distance of at least 10 cm. distally.

Three hours after operation pulsation still could not be felt in the dorsalis pedis artery, but

hours later pulsation was easily felt and the volume improved progressively thereafter.

Edema also subsided progressively until the patient was evacuated on the fourth postoperative day.

Comment. This case is an illustration of short-lived arterial vasospasm

caused by wound close to the vessel which did not, however, directly involve

it. If lumbar sympathetic block had been done promptly after operation,

improvement might have occurred even more rapidly.

Case 17. 26-year-old soldier wounded near Cassino, Italy, incurred shell-fragment

wounds of the right leg in the upper third and of the right thigh in the lower third. The

wounds were debrided at an evacuation hospital 15 hours later. shell fragment was removed from the right leg through an elective incision along the head of the fibula. Exploration of the posterior tibial artery showed it to be in complete spasm but pulsations were felt in the popliteal artery. The dorsalis pedis pulse could not be felt and the foot was cold.

Lumbar sympathetic block was done promptly after operation and was repeated three times

in the next several days. The results were not recorded.

When the patient was admitted to general hospital 13 days after wounding, the right

foot was slightly swollen and was colder than the left. There was some question about

whether peripheral pulses were detectable. Two days after admission secondary closure

of the wounds was done and paravertebral procaine hydrochloride block was repeated because the foot was cyanotic and clammy. The wounds healed normally but the foot continued as described except immediately after sympathetic block; then it was transiently

warm and pink. Eight blocks were carried out over 14-day period. Femoral pulsations

continued to be normal, but the popliteal, dorsalis pedis, and posterior tibial pulses were

never palpable. lumbar ganglionectomy was therefore done on the 30th day after wounding. Eight hours later the foot was described as flushed and warm, and all the peripheral

pulses became palpable and so remained.

Comment. In contrast to the preceding patient (Case 16) the arterial

vasospasm in this patient persisted for an unusually long period of time. The

indications for ganglionectomy were sound and its performance clearly contributed to the good results.

Therapy. Treatment in vasospasm is always based upon an attempt to

counteract the condition and to produce maximum vasodilatation in the involved extremity. This was the objective in such cases in World War II.

few attempts were made to induce and maintain vasodilatation by the use of

such vasodilating agent as whiskey, but in general, chemical or surgical means

were preferred. The logic of these methods is evident: Since the disturbance

is apparently the result of vasomotor reflex initiated in the traumatized

tissues, and since vasoconstrictor impulses are transmitted by way of the
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 137

sympathetic nerve fibers, interruption of these impulses by the means suggested

is the proper mode of treatment.

Interruption of sympathetic impulses, usually by paravertebral injection

of 1-percent procaine hydrochloride solution, was widely practiced by American

surgeons in World War II, but in the material available for analysis it was

possible to determine definitely in only 280 cases that the procedure had or

had not been performed. The results (Chart 17) provide no substantial evidence that the method was of any value. The incidence of amputation in the

group in which sympathetic block was performed was only slightly less than

the incidence for the group as whole, while the incidence in the cases in which

ganglionectomy (which was preferred to repeated nerve blocks) was performed

was greater than for the entire series.

Familiarity with the clinical material permits different and more accurate

interpretation of results than the figures on sympathectomy might suggest.

Actually, sympathectomy was used only as last resort when it had already

become apparent that the limb would not survive. Sympathetic block was

Chart 17. Results of sympathectomy and sympathetic block in comparable arterial wounds in

American battle casualties in World War II. The data depicted are based on selected

group for which the necessary information was available. They do not include all arterial

wounds during World War II. Only those cases where, for the same artery, there were

examples of management with sympathectomy and sympathetic block, and also examples

where neither had been used, are included in this chart.
138 VASCULAR SURGERY IN WORLD WAR II

more frequently instituted as part of the immediate postoperative routine and

was continued until the outcome in respect to survival or death of the limb

became obvious.

When these facts are known, the apparently poor results of sympathectomy

and the apparently better results of sympathetic block are more readily understood.

It should also be emphasized that it is extremely difficult to evaluate such

procedures as these on purely statistical basis. First, it was not always possible to determine from the records that the block had been performed effectively. Second, proper objective methods to determine the efficacy of the

procedure are lacking, and suitable controls upon which to base an evaluation

of results are also lacking. Survival or death of the limb is not critically

objective test; the outcome does not permit clear decision whether the

therapeutic measures employed in given case have influenced the results and

it can serve as criterion only when sufficiently large numbers of cases are

available for statistical evaluation. Third, and perhaps most important of all,

the ultimate viability or death of the part was established in most cases at

the time of wounding, and the margin within which improvement could be

demonstrated was therefore so small that great numbers of cases would be

required to establish the efficacy of any single procedure on statistical basis.

Despite the lack of statistical proof, there is much clinical evidence in favor

of sympathectomy and sympathetic block. The personal testimony of numbers

of surgeons indicates the usefulness of these procedures. In case after case

moderate degrees of tense swelling and muscle pain characteristic of ischemia

were observed to regress and the temperature of the limb was observed to rise

following their use. Most American surgeons who worked in forward areas

regarded interruption of the sympathetic system when practicable as perhaps

the most useful adjunct method of treatment available to them.

Cohen 135 was among the few experienced observers unwilling to accept the

theory that arterial spasm is influenced by local or distant autonomic reflexes,

his position being that it is myogenic in origin. He also cited evidence to indicate that blockage of the vasomotor control of wounded limb was dangerous

because vasodilatation of the skin was not accompanied by vasodilatation in

the muscles, and harm was done by diverting blood from the muscles into the

skin. For this reason he deprecated the use of sympathetic block or sympathectomy as therapeutic measure to combat traumatic vasospasm associated with

direct injury. His reasoning, however, seems inconsistent since he was willing

to use sympathectomy to control vasospasm associated with crushing injury

or following the prolonged application of tourniquet, on the ground that the

vasospasm observed under these circumstances is of reflex nature. It seems

highly unreasonable to assume that vasospasm can be initiated reflexly by one

type of trauma and not by another, especially since the end results of both

13# See footnote 48, p. 98.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 139

varieties take the form of ischemia from tissue damage. It seems equally

unreasonable to assume that sympathetic block or sympathectomy can be

injurious in one of the varieties of vasospasm and beneficial in the other.

Aneurysms and Arteriovenous Fistulas

As has been pointed out, the nature of the missiles employed in World War

II altered in many respects the character of the wounds produced by them.

This was particularly true of vascular injuries. In addition to wounds caused

by machinegun and rifle bullets and high explosive shells, multiple injuries

were frequently caused by fragmentation of land mines and grenades. It was

not uncommon to find as many as hundred small, separate wounds scattered

over the surface of the body, none of them serious enough to cause death but

many of them capable of producing aneurysms. The incidence of aneurysms

and of multiple aneurysms was therefore greater in World War II than it had

been in any previous war. The same was true of the incidence of arteriovenous

fistulas.

Since, as will be pointed out shortly, the policy of management of aneurysms

and arteriovenous fistulas was entirely conservative, the majority of patients

with these conditions received their definitive treatment in Zone of Interior

vascular centers. (See Chapter IV.) As matter of fact, when these complications were seen overseas it was almost without exception in hospital installations of the base sector. They usually took weeks to become manifest and

would scarcely have had time to develop in field and evacuation hospitals of

corps and army areas. The diagnosis was probably missed in some cases overseas, but in many others the lesions still had not developed when the patients

were evacuated. Not uncommonly their presence was first detected by the

patients themselves who days or weeks after the injury noticed “buzzing” in

the region of the wound. Traumatic aneurysms and arteriovenous fistulas were

practically always observed in injuries which caused only partial interruption

of the flow of blood through the vessel.

The plan of management of arterial aneurysms and arteriovenous fistulas

was basically conservative for several reasons: (1) Delay permitted whatever

infection might be present from the original wound to subside completely.

(2) Delay lessened the chances of secondary infection when operation was done.

(3) Delay diminished the chances of secondary hemorrhage which was possibility in any case in which there was extravasation of blood into the tissues.

(4) Delay provided for the occasional case in which traumatic aneurysm might

heal spontaneously. (5) Delay allowed time for an adequate collateral circulation to develop.

Of all the reasons listed in favor of conservative treatment of aneurysms

and arteriovenous fistulas the last-named was the most valid. Major vessels

could not be ligated and divided with safety until such circulation had developed. In the natural course of events when the blood flow through the main

artery of limb was impeded or partially diverted by trauma, collateral cir-
140 VASCULAR SURGERY IN WORLD WAR II

dilation developed and took over the function of supplying the limb with blood.

This development, however, was matter of weeks, not of days. It was thought

to reach its maximum not less than 10 weeks, and more often not less than 12

to 16 weeks, after the need for it first arose. It was therefore the established

policy in all theaters of operations that in the absence of indications to the

contrary, surgery for traumatic aneurysms and arteriovenous fistulas should

be deferred for to months after injury and should be carried out preferably

in vascular center in the Zone of Interior.

In certain number of cases, operation for arterial aneurysms and arteriovenous fistulas had to be undertaken in overseas theaters because the circumstances did not permit delay. Surgery was then more or less an emergency

matter. The chief indications were impending rupture, hemorrhage, infection,

threatened gangrene of the extremity because of circulatory deficiency, increase

in the size of the mass, signs of pressure on neighboring vessels and nerves,

severe pain, and evidences of strain on the cardiovascular system. These

indications were more likely to appear in pulsating hematomas (false aneurysms)

than in true aneurysms and arteriovenous fistulas. As the following cases

show, more than one indication was frequently present in single case.

Case 18. 22-year-old soldier was wounded accidentally in Italy by bullet from

.45 caliber pistol 20 September 1943. The bullet entered just beneath the middle third of

the left clavicle and emerged from the thorax through the left scapula. The subclavian artery was damaged. The wounds of entrance and exit were debrided in an evacuation hospital

about 3}i hours after injury. It was noted that the pulse was less strong in the left wrist

than in the right, which suggested that the subclavian artery was in spasm. Roentgenograms revealed fragmentation of the scapula but no injuries of the thorax.

The day after operation examination showed paralysis of the left arm, forearm, and

hand except for slight deltoid, triceps, and supinator action. Sensation was present in the

axillary area and in the area supplied by the medial and dorsal antebrachial cutaneous

nerves. It was concluded that the injury involved the inner cord of the brachial plexus

completely and at least half of the posterior cord below the level of the axillary nerve.

On 23 September, when the patient was examined at general hospital to which he

had been evacuated by air, the left arm was found flushed and slightly edematous throughout

its length. By 26 September the edema had subsided to considerable degree but the

radial pulse remained weaker in the left arm than in the right. On 28 September, when he

sat up for breakfast, about an ounce of blood oozed through the dressing over the left clavicularregion. Examination showed edema of the entire left arm with distention of the veins.

The palm of the left hand was moist but no voluntary motor activity could be elicited. Operation was undertaken 48 hours later because of the complaint of pain and the continuing

evidence of compression of the brachial plexus by the aneurysm. The aneurysm arose from

the first portion of the axillary artery. After rather difficult operation the subclavian and

axillary arteries were ligated in continuity proximal to the origin of the subscapular artery.

transfusion of 1,000 cc. of whole blood was given during the procedure.

At the end of the operation the hand was warm and of good color. Recovery was uncomplicated and the patient was in good condition when he was evacuated farther to the

rear 26 October.

Case 19. 23-year-old soldier was wounded in action by enemy shell fragments on the

Anzio beachhead 20 February 1944. He incurred multiple wounds of the left buttock, the

left thigh and leg posteriorly, and the left popliteal area. There were no fractures. He was

given first aid, including unit of plasma, within 3}£ hours after wounding and was admitted
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 141

to an evacuation hospital shortly afterward where all his wounds were debrided. Roentgenograms showed foreign bodies beneath the base of the left fifth metatarsal and in the left

thigh medially and also medial to the lesser trochanter.

When the patient was received at general hospital in the base 23 February after

evacuation by hospital ship, examination showed impending gangrene in the toes of the left

foot which was slightly edematous. He complained of pain in the foot which he said was

“worse” at night. The calf was swollen and tense. The skin over the lateral aspect of the

leg was hot and reddened. No pulsations were felt in the popliteal space or below it. The

site of the arterial lesion responsible for the vascular insufficiency was not determined.

After two lumbar sympathetic blocks with procaine hydrochloride, pain lessened and swelling decreased in both the leg and the foot.

On 25 February edema of the extremity was more prominent. The first four left

lumbar sympathetic ganglia were blocked with procaine hydrochloride. On 27 February the

toes were dark, the calf was tense, and the foot was edematous. The patient was able to

move the ankle and toes. By March the foot was still swollen and there was definite

gangrene of the great toe and the fourth and fifth toes. The following day the erythrocytes

numbered 2,570,000 and the leukocytes 11,900 per cubic millimeter. By March all of the

toes of the left foot were undergoing the changes of dry gangrene and there was gross discoloration of the skin of the distal half of the foot. On March the erythrocytes numbered

3,410,000 and the leukocytes 12,500per cubic millimeter; gangrenous changes (dry) continued

to progress slowly proximally on the foot. Pain was limited to the foot.

On 14 March the patient himself noted peculiar sensation in the thigh near the left

inguinal region. Examination showed the characteristic “machinery” murmur of an arteriovenous fistula. The blood pressure in the arm was essentially unchanged when the aneurysm was occluded. On 17 March an electrocardiogram was reported as being normal.

The pulse rate was 120 beats per minute before the arteriovenous fistula was occluded by

pressure and 96 and 100 beats per minute while it was occluded. firm, diffuse, tense

swelling appeared in the peroneal group of muscles and was progressive.

By 30 March the dry gangrene in the foot was well demarcated. On the sole it extended

almost to the heel. On April left lumbar sympathectomy was performed with the aid of

spinal analgesia. By April there was noticeable improvement in the circulation of the

left leg and the tense swelling of the peroneal group of muscles had somewhat receded.

On April the arteriovenous fistula, which was located about cm. below Poupart’s

ligament, was excised. Thereafter there was continued improvement in the circulation.

Before the patient was evacuated to the Zone of Interior in May (the exact date is not

known) guillotine amputation was done just above the ankle.

Comment. The cause of the early vascular insufficiency in this case is not

clear. It may have been caused by arterial spasm, or it may have been the

result of small arteriovenous fistula. The outcome might have been different

if it had been recognized earlier and if the circulation had been aided promptly

by sympathetic block or sympathectomy. When the aneurysm was clearly

established, weeks after wounding, the pathologic changes in the leg had

become progressive. The course in this case seemed to furnish an indication

for excision of the aneurysm rather than for temporizing measures.

Case 20. This 25-year-old soldier was wounded by shell fragments in Italy December

1943. He incurred multiple wounds of the abdomen, chest, and extremities. The following

day in field hospital all wounds were debrided, colostomy was established because the

colon was the site of several injuries, and “a diffuse axillary hematoma was drained through

stab wound in the axilla.” This hematoma was related to an anterior wound of the right

shoulder.
142 VASCULAR SURGERY IN WORLD WAR II

When the patient was evacuated to general hospital 16 days after wounding, mass was

palpable on the right side in the subpectoral region. Three days later the mass suddenly

increased in size and the patient complained of severe, burning pain which involved the right

upper extremity. Examination showed the mass to be expansile. systolic bruit was

heard over it. The right arm was weak and there was hypesthesia over the radial and

median nerve distribution. The blood pressure was 104 mm. of mercury systolic and 26

diastolic on the right side, and 130 mm. of mercury systolic and 78 diastolic on the left.

Because of the increase in the size of the mass and the pain, which was difficult to control

even with morphine, operation was carried out 31 December. The first portion of the axillary

artery was exposed by division of the clavicle and was controlled by means of rubber tubing

passed under it. The aneurysm was then approached through separate incision. It was opened and cleared of blood clot. The arterial wound was at the level of the anterior

circumflex humeral branch which was ligated. The axillary artery was then ligated and

divided across the wounded area. The lesion was thoughtto be proximal to the subscapularis

artery. The missile had also lacerated small trunk of the median fasciculus of the brachial

plexus as it lay anterior to the axillary artery. The circulation appeared satisfactory at

the conclusion of the operation, in the course of which the patient received 1,500 cc. of whole

blood.

The day after operation the function of the right hand was better than it had been

before operation. The right hand was cooler than the left. The radial and ulnar pulses

were not palpable but there was good capillary circulation. The sympathetic nerve supply

of the right arm was blocked twice with procaine hydrochloride.

When the patient was evacuated 46 days after operation he was showing satisfactory

progress. The function in the right hand had improved progressively though there was

still no radial pulse.

It was usually simple matter to determine the status of the circulation

in the limb. When interruption of the blood flow was only partial, the limb

was cool but not cold. The muscles distal to the wound were essentially

normal and were not tense or swollen. Oscillations were detectable with

standard oscillometer or with sphygmomanometer. Vascular spasm was

likely to be present in these cases and to respond well to repeated sympathetic

block with 1-percent procaine hydrochloride. When emergency operation was

necessary sympathectomy was frequently performed either before or after

operation to assure maximum vasodilatation and thus increase of circulation

in the involved part. The results of surgery for arterial aneurysms and arteriovenous fistulas, whether the operation was done overseas or in the Zone

of Interior, were generally excellent.

Other Complications

Volkmann’s Ischemic Contracture. In many cases of vascular injury

curious phenomenon became evident after interruption of the blood supply,

sometimes as soon as 12 hours afterward, in the form of tense, hard swelling

of the muscles (Fig. 8). It was particularly likely to occur after wounds of the

popliteal artery, but also occurred after wounds of the brachial and femoral

arteries. When the femoral artery was injured the swelling was likely to be

limited to groups of muscles in the leg, such as those in the anterior tibial compartment. The involved extremity became progressively larger, the maximum

size being reached in 36 to 48 hours. It was characteristically hard and tense
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 143

Figure 8. Tense swelling of muscles of calf, without significant subcutaneous edema, 12 hours

after transection of popliteal artery. Fasciotomy, useful in some cases of this kind, was not

successful in wounds involving the popliteal artery in this experience.

on palpation. Subcutaneous edema eventually appeared, but was often absent

at first and might not appear until to days after injury.

The nature of this brawny swelling in an ischemic extremity was never

entirely clarified. An occasional biopsy specimen showed no evidence of extracellular edema or infection. The swelling was sometimes compared to the

changes observed in rigor mortis, but the comparison was actually not valid

since in ischemic swelling the muscles always appeared to be contained under

considerable pressure by the enveloping fascia. It was sometimes explained

as the result of generalized intracellular edema of the ischemic muscle cells,

while the subcutaneous edema which appeared later was explained as the result

of venous stasis and of inflammatory changes in the leg. More probably the

chain of events was as follows: When the main arterial supply to the muscles

of the affected extremity was suddenly interrupted, vicious circle promptly

developed in which impairment of the capillary circulation was increased by

swelling of the muscular tissue and the pressure of the enveloping fascia. The

swelling and pressure, in turn, were increased with increasing impairment of

the capillary circulation until stage was eventually reached at which the circulation ceased entirely.
144 VASCULAR SURGERY IN WORLD WAR II

On the basis of these assumptions, fasciotomy 136 was recommended in

these cases, both for those in which the condition seemed incipient and progression likely and for those in which the patient was not seen until it had become

fully developed. Longitudinal incisions were used for both upper and lower

extremities. In the leg the incision was made posteromedially to decompress

the muscles of the gastrocnemius-soleus group, and anterolaterally to decompress the anterior tibial compartment. In the forearm the incision was made

on the volar aspect. When the fascia was incised, it spread widely and the

pale underlying muscles bulged forcibly through the incision.

Fasciotomy was open to the criticism that the incision might destroy the

collateral circulation from the skin and thus further compromise the regional

circulation by introducing the risk of infection. On more theoretical grounds,

however, these objections were superseded by the consideration that the operation might permit the reestablishment of circulation through the ischemic

musculature. Certain British surgeons 137 in the Mediterranean theater were

enthusiastic advocates of fasciotomy and reported excellent results with it.

American surgeons in the area were much less favorably impressed by its

possibilities. In the limited number of cases in which it is known to have been

used, results were occasionally good (Cases 10, 21) but they were uniformly

poor in wounds of the popliteal artery (Case 11).

Case 21. 25-year-old soldier incurred an accidental wound of the right arm 21 November when two carbine bullets perforated the arm through the biceps and lodged in the

cervical region and the superior mediastinum. The brachial artery and vein were severed

and the median nerve was partially severed and badly traumatized. There were no fractures. tourniquet was applied to the right upper arm minutes after wounding and was

released and reapplied in about an hour.

When the patient was admitted to station hospital hour and 45 minutes after the

accident there was large, tense hematoma in the right arm extending into the axilla. The

arm was cold and limp and was without sensation. There was no sensation in the forearm;

its muscles were soft and relaxed. Radial and ulnar pulses were absent.

Operation was performed at once with the patient under thiopental sodium anesthesia.

The incision was made over the medial edge of the biceps muscle. Clotted blood was

evacuated. The brachial artery and vein were ligated above the profunda branch. The

ulnar nerve was not identified.

Ice bags were applied to the arm and forearm as soon as the operation was concluded. About 11 hours later swelling and stony hardness were observed in the uninjured forearm,

and it was also noted that the superficial veins were dilated. No pulses were palpable at

the wrist. The wrist and fingers were held stiff in flexion. When the ice bags were discontinued 12 hours after operation the patient said that the arm had been more comfortable when they were in place. No other effects were noted from their use.

Twenty-four hours after the first operation (about 26)4 hours after wounding), with

the patient under thiopental sodium anesthesia, the forearm was decompressed by incisions, dorsal and ventral, which were carried throughout the length of the arm and

through the deep fascia. The surgeon described the tissues as “wet.” Shortly after the

I3# See footnotes 22, p. 70 and 126 (1), p. 127. 137 (1) Clark, R.: Forwardsurgery of injuries to major blood vessels. Proc. Cong. C. M. F. Army Surgeons, Rome,

12-19 Feb 45, p. 107-111.

(2) See also footnote 42 (1), p. 95.
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 145

operation had been completed, the wrist and fingers which had been held in flexion could be

extended passively. The forearm and hand were put up in plaster splint with the hand

in the position of function.

Recovery was uneventful. On 28 November, although the pulses were still not palpable at the wrist, the fingers were warm. By December the swelling of the forearm was

less, but the tissues were still not soft to palpation. There was beginning ability to extend

the wrist and some return of sensation in the radial nerve distribution on the hand, but the

median and ulnar nerves showed no return of motor or sensory power. The patient was

not observed after this date.

Comment. It is doubtful that the brief refrigeration served any useful

purpose in this case. On the other hand, there seems little doubt that the arm

would have been lost if fasciotomy had not been performed promptly.

The condition just described may be classified as an early phase of the

type of contracture known in civilian practice as Volkmann’s ischemic contracture and usually observed in injuries associated with fractures. Contractures involving the forearm and hand, and less frequently the leg and foot,

constituted one of the most crippling sequels of acute ischemia consequent

upon arterial wounds. They apparently developed as result of severe

ischemia which stopped just short of causing actual gangrene. The incidence

of this complication in World War II is not known, but it was apparently

relatively infrequent. In series of 35 arterial injuries observed at vascular

center in the Zone of Interior there were instances of contractures, and in

another series of 77 injuries there were 20 instances. These figures are, of

course, weighted: Patients who were hospitalized in vascular centers were sent

there because of complications.

The management of these contractures was not very satisfactory. In

spite of every effort to improve the circulation, including sympathectomy, the

results were only moderately good at best. Other attacks upon the problem

took the direction of orthopedic plastic operations and physiotherapeutic

measures designed to make the best use of whatever functioning muscle tissue

might remain.

Causalgia. Causalgia was not frequent complication of the vascular

injuries observed in World War II. If only the figures from vascular centers

are considered this observation might seem to be incorrect; there were 17

instances in series of 77 cases observed at vascular center. As just pointed

out these figures are weighted in that they include only patients in whom

complications required their reference to the vascular centers. In series of

75 cases of causalgia reported by Ulmer and Mayfield, 138 the etiologic factor

in no instance was an arterial injury. In the cases observed at the vascular

centers the incidence of causalgia was always higher when nerve injuries were

associated with the vascular injuries.

The great majority of patients with causalgia responded well to sympathetic block and sympathectomy.

1,8 Ulmer, J. L., and Mayfield, F. H.: Causalgia; study of 75 cases. Proc. Neuropsychiat. Conf., Sixth Serv. Command, 179-184, Jul 1945.
146 VASCULAR SURGERY IN WORLD WAR II

Circulatory Insufficiency. Clinical evidences of circulatory insufficiency

were seldom apparent soon after wounding in the army areas or even in the

communications zone. They became manifest when the wounded became

ambulatory and were rehabilitated for either return to duty or discharge from

the Service. Since detailed discussion is given in Chapter XV, only brief

mention is necessary here. Clinical manifestations included color changes,

intermittent claudication, and, in the more severe cases, partial paralysis.

Some patients experienced only mild discomfort even after exertion, while

others had pain even when resting. Similar observations had been made

during World War and have been described by numerous observers in civilian

practice.139

No accurate data are available concerning the exact incidence of this

clinical manifestation of acute arterial injuries in World War II. In one

sample of 88 cases, however, vascular insufficiency severe enough to be manifested clinically was observed in 68 percent. Two patients had had early

sympathectomy and in 49 the operation was done late. With the exception

of patient, all were definitely improved.

The concept of sympathectomy in the management of these cases was

developed by Leriche 140 in World War and this procedure apparently provided

the best results reported in the management of this condition in World War II,

though it was, of course, not always successful.

Case 22. This 23-year-old private in the Infantry was accidentally shot by another

soldier 15 May 1944 on the Anzio beachhead. The wound was debrided at field hospital

hours after wounding. The left femoral artery and vein were ligated in the midthigh

distal to the profunda femoris branch. Sulfadiazine therapy was instituted and lumbar

sympathetic procaine hydrochloride injections were done daily for days. On 23 May

the wounds were closed and healing progressed satisfactorily.

When the patient was evacuated to general hospital 26 May, examination revealed

the left foot to be colder than the right. No pulsations could be felt in it. The foot was

not swollen and the color was good. Both feet were sweaty. Two days later transfusion

of 1,000 cc. of whole blood was given.

On 20 June, which was cold day, both feet were cold and moist. The left foot was

slightly cyanotic and no pulses were demonstrable. On July the posterior tibial pulse

could be felt without difficulty. The dorsalis pedis pulse was weak. The temperature of

both feet was about the same; both were cold and sweaty. The patient could walk about

400 yards slowly and without pain, but climbing two flights of stairs at moderate speed

caused pain in the left calf. On 31 July (a cool day) the left foot was cooler than the right;

139 (1) Burrows, H.; Paralysis following arterial Injuries. Brit. M. J. 1: 199-203, 16 Feb 18.

(2) Lerlche, R.: De la sympathectomle p6rl-art6rlelle et de ses rSsultats. Presse mM Paris 25: 513-515, Sep 1917.

(3) Lerlche, RenS: La Chirurgle de la Douleur. Paris, Masson et Cie, 1940. (4) Lerlche, Ren6: Physiologic Pathologique et Chirurgle desartferes. Prlnclpes et methodsde la Chirurgle Art6-

rielle. Paris, Masson etCie, 1943.

(5) Lerlche, R., and Heltz, L: Rfeultats de la sympathectomlep6rl-artferlelle dans la traitement des troubles nerveux post-traumatlques d’ordre rfiflexe (type Bablnski-Froment). Lyon Chlrurg. 14: 754-792, Jul-Aug 1917.

(6) Lerlche, R., and Werquin, M. Q.: Effects ofarterial ligature on the vasomotor system. Lancet 2: 296-297,

Sep 40.

(7) Mltchiner, P. H.: Injuries of blood vessels and their treatment. St. Thomas’s Hosp. Qaz. 38: 92-96, Jul 1940. (8) Mltchiner, P. H.; Treatment of wounds of blood vessels. Post-Grad. M. J. 16:157-161, May 1940.

(9) See also footnotes 12, p. 64; 38, p. 84; 103 (5), p. 115; 113 (2), and (3), p. 116.

140 See footnotes 139 (2) and (5).
ACUTE BATTLE-INCURRED ARTERIAL INJURIES 147

both were sweaty. At this time, 2)4 months after injury, the patient could walk only 200

to 300 yards at moderate speed without complaining of pain in the left calf.

On 10 August left lumbar sympathectomy was performed, with the aid of spinal analgesia, through an anterior muscle-splitting extra peritoneal approach. The second and

third lumbar ganglia and the connecting sympathetic trunk were excised. By 26 August,

16 days after operation, the patient could walk at least 10 times the distance he could walk

prior to sympathectomy at the same rate of speed without cramping the calf. On 20

September, 41 days after sympathectomy, he walked 1)4 miles without pain. The foot and

leg were warm and dry, and the left foot was now warmer than the right. It was not swollen.

The posterior tibial pulse was fairly strong.

As of this date the patient returned to limited duty in the Mediterranean theater. Case 23. This 28-year-old Infantry sergeant was wounded in action in Southern France 19 August. He received penetrating wounds of the left hip and thigh and right heel, and

lacerations of the right femoral artery and vein. The wounds were debrided at field hospital (apparently soon after wounding, though the exact hour is not available) and the

femoral vessels were ligated at the site of injury below the profunda femoris branch.

Penicillin therapy was begun immediately after operation and lumbar sympathetic

injection of procaine hydrochloride was done daily for days. When the patient was evacuated to general hospital in Italy 25 August, he was quite pale. The plasma protein

concentration was 6.7 gm. per 100 cc., the hemoglobin 8.2 gm. per 100 cc., and the hematocrit value was 24.1 percent. The right foot was pale, slightly cyanotic, and cooler than the

left foot, but was not swollen. No pulses could be felt in it.

The patient was given 1,000 cc. of whole blood 26 August. When he had received

about 100 cc. of second transfusion the following day he had severe reaction with back

pain, numbness, tingling of the extremities, dyspnea, and cyanosis. The symptoms were promptly relieved with adrenalin. When the blood was rechecked it was found compatible

and the reason for the reaction could not be determined.

Secondary closure of the wounds was done 27 August. transfusion of 1,000 cc. of

whole blood was given during the operation. Healing was satisfactory.

On October, months after injury, the patient complained of cramping pain in the

right calf after walking 500 to 600 yards at moderate speed. The pulses were now palpable,

although weak. The foot was cold and pale on cold days. On 28 October right lumbar

sympathectomy was done, with the aid of spinal analgesia, through an extraperitoneal

muscle-splitting anterior abdominal incision. The second and third lumbar ganglia and

the connecting trunk were excised. Soon after operation the right foot was found to be

dry and to be warmer than the left foot. By November the pulses in the foot were of

fairly good volume. week later the patient was able to take daily walks without cramping in the calf. By 25 November, months after injury and month after sympathectomy,

he could walk miles at moderate speed without pain in the calf. The right foot was dry, not

edematous, and warmer than the left. The color was good and the pulses of good volume.

Soon afterward the patient was returned to limited duty in the Mediterranean theater.

Case 24. 22-year-old soldier was accidentally wounded when one of his own chemical

mortar shells exploded prematurely in Italy 23 November. The shell fragment caused

complete interruption of the right femoral artery and vein. There were no fractures.

tourniquet was applied promptly above the wound and firm dressings were used. He was

admitted to field hospital platoon hours after injury. Resuscitation was accomplished

with units of plasma (in addition to unit of plasma previously given in the first aid

station) and 1,000 cc. of whole blood.

Operation was performed with the patient under ether anesthesia 5)4 hours after injury.

The foreign body was removed and the severed femoral artery and vein were ligated.

right lumbar ganglionectomy was then done with removal of the second, third, and fourth
148 VASCULAR SURGERY IN WORLD WAR II

lumbar ganglia. Four units of plasma and 1,000 cc. of whole blood were given during

operation and gas gangrene antitoxin was given immediately afterward. well-padded

circular cast was applied and bivalved.

On 24 December, the day after operation, the right leg was warm to inches below the

knee. The remainder of the leg and the foot were cool. On 27 December the circulation

in the right leg was good and it was warm down to the junction of the middle and lower

thirds. Below this level the leg was cyanotic and cold (Fig. 9). It was thought that demarcation would take place low enough to save the knee.

No particular change was noted in the extremity until January. The muscles continued to be tense and on this date pitting edema was first observed. The following day,

although there were no systemic signs or symptoms, supracondylar amputation of the leg

was decided on because of the absence of apparent improvement in the foot and leg. Amputation was done above the knee because of poor circulation in the muscle of the leg.

Figure 9. (Case 24-) Complete severance of right femoral artery and vein treated by ligation

below profunda femoris. Dry gangrene of tips of great toe and second toe days after operation with line of demarcation at junction of middle and lower third of leg. Supracondylar amputation was required in this case because of muscular ischemia.

Comment. This is case in which sympathectomy failed to achieve the

desired results. It also illustrates the possible discrepancy between the

appearance of the skin and the condition of the underlying muscles. The

appearance of the skin, and the apparently excellent circulation and healthy

subcutaneous tissues, suggested that the muscles would be in equally good

condition. Actually, although the skin was viable, the muscles, as frequently

happens in this type of case, were found to be necrotic. In retrospect, it would

have been wiser to delay amputation as long as there was no evidence of toxicity

from the ischemic leg in the hope of saving the stump below the knee.
CHAPTER IV

Arterial Aneurysms and Arteriovenous Fistulas

General Considerations

Daniel C. Elkin, M. D.

and

Harris B. Shumacker, Jr., A4. D.*

For descriptive purposes, battle-incurred vascular injuries may be divided

into:

1. Wounds in which the blood vessel is completely severed or in which

vasospasm exists to such an extent as torender the blood supply so impoverished

that death of the part or useless fibrotic tissue results.

2. Wounds in which the damaged vessel is only partially severed, producing false aneurysm or arteriovenous fistula.

3. Wounds which result in activation of previously existing blood vessel

disorders, including vascular tumors.

In numerous instances of complete vascular severance, death inevitably

occurred promptly on the battlefield because of excessive loss of blood. In

patients who survived, ligation of the vessel above the point of injury was often

the only feasible procedure. Early repair of the vessel while theoretically

possible and always desirable was not usually practicable under existing

conditions. Sometimes, particularly when small arteries were injured, clotformation and retraction of the severed ends occurred, the process probably being

facilitated bj the lowered vascular tension associated with wounding. Late

complications were not usual in this type of vascular injury. They were also

the exception in injuries superimposed on preexisting cardiovascular or peripheral

vascular disease, very few of which were observed because physical examination

at induction centers was sufficiently thorough to prevent the induction of

individuals with such conditions. The situation was quite different, however,

when vascular injury resulted in incomplete severance of the affected vessel.

Late complications were then relatively frequent.

The number of aneurysms and arteriovenous fistulas of traumatic

origin observed in vascular centers in the Zone of Interior in World War II

far exceeded any similar series ever recorded. This increase may be attributed

to the introduction of higher velocity projectiles. In addition to the ordinary

‘Professor of Surgery and Chairman of the Department. Indiana University Medical Center. Formerly Lt. Colonel,

MC, AUS.
150 VASCULAR SURGERY IN WORLD WAR II

wounds caused by machineguns, rifle bullets, and shell fragments, great many

multiple injuries were produced by fragmentation of land mines, grenades, and

aerial bombs. These last-named produced great many small individual

wounds—thus increasing the incidence of trauma to the blood vessels.

Numerous additional factors figured in the development of arterial aneurysms and arteriovenous fistulas after vascular injuries in World War II. The

majority of these would likewise be operative in noncombat-incurred injuries.

They included (1) the particular artery involved; (2) the size and other

characteristics of the injury to the vascular wall; (3) the size and direction of the

channel which served as an exit for the hemorrhage, that is, the path of the

missile; (4) the nature of the surrounding tissue, which determined the possibilities of controlling hemorrhage; (5) the level of arterial tension; (6) the

degree of pressure applied to control hemorrhage; (7) the adequacy of splinting;

(8) the method of transportation; and (9) the speed with which definitive

treatment was supplied.

The wide variety of possible causes of vascular injuries, combined with the

inconspicuousness of many combat-incurred wounds caused by minute fragments of exploding missiles, made it inevitable that in the press of evacuating

large numbers of casualties in theaters of operations some vascular injuries

were initially overlooked, and the subsequent discovery of arterial aneurysms

and arteriovenous fistulas entirely unexpected. Openings in blood vessels

produced by small missiles frequently caused no early symptoms and it was

natural that these should be overlooked, or their significance not appreciated.

This was particularly true if more extensive injuries distracted the surgeon’s

attention from them. It was also understandable that under combat conditions

an incomplete, or even an incorrect, diagnosis might be carried by wounded

soldier for considerable period of time.

One reason that these lesions were often overlooked was failure to bear

in mind the fact that blood vessels are usually accompanied by nerves. The

manifestations of nerve injuries were frequently so striking that they overshadowed other damage in the same area.

During World War II it was repeatedly demonstrated that arterial

aneurysms and arteriovenous fistulas could easily be missed unless every wound

was examined from the standpoint of possible vascular injury, and unless

auscultation was part of the routine examination. Furthermore, arteriovenous

fistulas present from the onset of injury could be overlooked unless examination

was repeated after edema had subsided and hemorrhage into the tissues absorbed.

PATHOGENESIS OF ARTERIAL ANEURYSMS

AND ARTERIOVENOUS FISTULAS

To understand the development of traumatic arterial aneurysms and

arteriovenous fistulas it is necessary to discuss what may occur as result of

penetrating wound of the blood vessels.
ANEURYSMS AND FISTULAS—GENERAL CONSIDERATIONS 151

When an artery is completely severed both ends retract. Hemorrhage

may be severe at first but will stop either spontaneously or with the application

of pressure, although the artery may require ligation or some attempt at repair.

When the vessel is only partially severed an entirely different chain of events

ensues. The wound tends to enlarge in the long axis of the vessel as the result

of retraction, and hemorrhage is likely to be profuse. If the wound in the

soft tissues overlying the vessel is of sufficient size, hemorrhage occurs externally and the indications for immediate control are clear. If the wound is small,

the imbrication of muscle, fascia, and skin planes can prevent the escape of

blood externally. Blood passes out through the rent in the arterial wall into

adjacent tissues where its collection is limited in size and determined in contour

by the nature of the surrounding structures, the extent of traumatic damage to

these, also the size of the injured artery and of the tear in its wall, as well as

by such factors as arterial pressure and effectiveness of the clotting mechanism.

This results in the formation of hematoma which is likely to become false

aneurysm.

As the clot becomes organized, it tends, as has just been intimated, to

lose the characteristics of hematoma and assume the characteristics of an

arterial aneurysm. wall composed of fibrous tissue and supported by surrounding structures becomes evident. The flattened innermost layer of fibroblasts may be suggestive of endothelial cells, and roentgenologic examination

sometimes reveals deposits of calcium, but the characteristic elements which

compose the wall of true aneurysm formed by dilatation of an arterial wall

are always lacking. The laminated clot continues to undergo organization,

but the natural tendency toward spontaneous cure is seldom completely attained and, in the absence of surgical correction, rupture and extension are

always possibilities.

When an aneurysm results from the sudden giving way of diseased arterial

wall, the sac which forms may immediately become filled with thrombus.

Like the thrombus in the sac of traumatic aneurysm, this thrombus also

tends to be compressed against the sac wall, to adhere to it completely or in

part, and to become well organized with the passage of time. Frequently

aneurysms which develop by the giving way of diseased arterial wall are not

filled with thrombus. This is particularly true when the aneurysm is of the

fusiform type.

In instances in which the external wound is small and the vein injured

simultaneously with the artery, groundwork is laid for the formation of an

arteriovenous fistula, the artery and vein communicating with each other

directly or through the medium of false sac. It was characteristic of arteriovenous fistulas brought about by combat injuries that they resulted from penetration of shell fragments of small size, just as in civilian practice they frequently

followed wounds made by knives and ice picks, injuries accidentally produced

in the course of phlebotomy, or the application of transfixion sutures or of

330323 0—55 11
152 VASCULAR SURGERY IN WORLD WAR II

pins for skeletal fixation. direct shunt of blood from artery to vein could

result if these vessels were injured laterally by missile which passed between

them or through them. In through-and-through wounds blood could be

shunted directly from the artery to the vein only if the lateral wounds became

sealed. Arteriovenous fistulas were particularly likely to develop by this

mechanism if the affected vessels were enclosed in common sheath. Femoral

and carotid vessels were for this reason particularly frequent sites of arteriovenous communications. Some arteriovenous lesions followed blows with

blunt instruments, no external wound being present.

False aneurysms were sometimes found in association with arteriovenous

fistulas. They sometimes lay between the vein and artery and sometimes

projected from the site of injury of one vessel or the other. From notes made

at the time of operation and from examination of the excised specimens, an

analysis was made of the presence or absence of aneurysm and the type when

present in 195 patients with arteriovenous fistulas observed at the vascular

center of Mayo General Hospital. In Figure 10 some of the types of fistulas

and associated aneurysms studied have been diagrammatically represented.

Of the 195 cases analyzed, 78 (40 percent) had no aneurysm—there was only

direct communication between artery and vein—(Fig. 10A), 117 (60 percent)

had or more aneurysms present (Fig. 10B through J).

In 89 of the 117 patients with or more aneurysms, the artery and vein

communicated by means of an interposed saccular aneurysm, or to aneurysms arose from the fistula itself. (Fig. 10B through D.) In 13 patients

there were or separate arterial aneurysms in addition to direct fistula; in 10 of these 13 there was single aneurysm and in double arterial aneurysm.

(Fig. 10E and F.) In 10 patients there was an aneurysm arising from the vein

and direct fistula. (Fig. 10G.) In patient there was an arterial aneurysm

and the artery and vein communicated through second aneurysm (Fig. 10H);

in another there was an aneurysm arising from the vein as well as through

which the vessels communicated (Fig. 101); and in there were aneurysms

both of the artery and vein (Fig, 10J). The aneurysms varied in size from

mass cm. in diameter to an ovoid mass about 22 cm. long and 15 cm. in

diameter.

When developed in these locations true aneurysms differed in two respects

from the false which arose independently: (1) laminated clot was likely to

be present in the sac; and (2) they were usually smaller, the tendency toward

expansion being controlled by the decompression afforded by the vein.

Early signs of combat-incurred arteriovenous fistula varied and depended

upon the location of the lesion and its size. After injury the patient might become aware of the presence of pulsating mass or discover the thrill characteristic of the condition. On the other hand, he might notice neither mass nor

thrill, in which case the fistula could have been overlooked unless routine search

was made because ofthe existence of circumstances under which it might develop.
ANEURYSMS AND FISTULAS—GENERAL CONSIDERATIONS 153

Figure 10. Diagrammatic representation of various types of arteriovenous fistulas and

associated aneurysms. Symbols: A, artery; V, vein; S, sac.

Regardless of the site of the fistula, the local clinical evidences of its presence were always the same. The most common sign was bruit or murmur

which could be heard in the region of the lesion. The murmur, in contrast to

the murmur of an arterial aneurysm which is purely systolic, was always continuous and lasted through both systole and diastole, the systolic accentuation

of this sound providing the distinguishing characteristic of fistulas. Although

in general, the larger the fistula the louder the murmur, this was not always true; small fistulas sometimes produced loud murmurs. The murmur of fistula,

like cardiac murmur, might be transmitted for considerable distance from
154 VASCULAR SURGERY IN WORLD WAR II

the site of origin. Invariably the chief cause of failure to hear the murmur of

an arteriovenous fistula was failure to listen for it.

When the murmur was of sufficient intensity, thrill might be felt. Again,

although somewhat indicative of the size of the fistula the intensity of the thrill

was not completely reliable evidence of this, since it might be modified by the

position of the fistula and by the structures which overlay it. The thrill of an

arteriovenous fistula was less well transmitted than the murmur associated with

it and was always limited to an area near the lesion.

Differential Diagnosis

Differentiation between false arterial aneurysm and an arteriovenous

fistula was frequently difficult, but was always important since the sequelae, the

general and local effects, and the treatment of the two conditions were altogether different. The points of differentiation were the same as those employed

in civilian practice: (1) As rule an arteriovenous communication is characterized

by continuous vibratory thrill and loud, rough continuous murmur with

systolic intensification. In false aneurysm, although murmur is also present,

there is distinct pause between the systolic and the diastolic phase and the

murmur is often heard only in systole. (2) In an arteriovenous communication

the murmur is usually transmitted for some distance on either side of the lesion

along the course of the vessels, while in false aneurysm the murmur is only

occasionally heard beyond the confines of the dilatation. (3) In an arteriovenous

communication, although the presence of false sac may cause tumor of considerable size, swelling is not usually pronounced. In false aneurysm definite pulsating mass is usually demonstrable. (4) The dilatation of cutaneous

veins in the region of an arteriovenous fistula, and the slowing of the pulse on

temporary occlusion of the lesion are additional points of differentiation since

neither of these signs is associated with the presence of false arterial aneurysm.

(5) While coincident cardiac disease may, of course, be present, the heart is not

affected by the presence of an arterial aneurysm. In large arteriovenous fistulas, on the other hand, and in those which persist over period of time,

cardiac dilatation with subsequent cardiac failure is likely to develop.

INCIDENCE

The staffs of the three vascular centers established in the Zone of Interior

by The Surgeon General cared for and studied large numbers of soldiers with

traumatic arterial aneurysms and arteriovenous fistulas. Two hundred twentyone arterial aneurysms and 593 arteriovenous fistulas were treated in these

centers during World War II (Table 6), but it must not be assumed that these

figures represent the total number of such lesions which occurred in patients in

the United States or in patients evacuated from overseas theaters to the United

States during the course of the war.
ANEURYSMS AND FISTULAS—GENERAL CONSIDERATIONS 155

Table 6. Distribution of 814 Arterial Aneurysms and Arteriovenous Fistulas

Location

Arterial

aneurysms Arteriovenous

fistulas Total cases

Number Percent Number Percent Number Percent

Upper extremity:

Axillary. 36 16. 33 5.

5.

69

84

8.

Brachial 54 24. 30 10.

Cervical, transverse 0.

Humeral, posterior circumflex 0.

Interosseous, common 0.

Radial 12 5. 0. 14 1.

Scapular, transverse 0. 0. Subclavian __ 15 6. 19 3. 34

Ulnar 3. 1. 16 2.

Total 124 56. 99 16. 223 27.

Lower extremity:

Calf, to muscles of 0. 0.

Circumflex, lateral 0. 0.

Femoral 18 8. 144 24. 162 19

Gastrocnemius, muscle branch 0. 0.

Geniculate 0. 0.

Gluteal, inferior 0. 0.

superior 0. 0.

Peroneal 0. 25 4. 27 3.

Plantar 1. 0.

Popliteal 23 10. 102 17. 125 15.

Profunda femoris.. ___ 2. 19 3. 25 3. branch._ 0. 0. 0.

TibiaL. 87 14. 107 13.

anterior 2.

posterior 15 6.

Total 72 32. 399 67. 471 57.

Head and neck:

Carotid 13 5. 48 8. 61 7.

Cervical, deep.. 0. 0.

Cirsoid 1. 1.

Lingual. 0. 0.

Occipital __ 0. 0.

Temporal, superficial 0. 0. 0.

Vertebral 13 2. 13 1.

Total 16 7. 77 12. 93 11.
156 VASCULAR SURGERY IN WORLD WAR II

Table 6. Distribution of 814 Arterial Aneurysms and Arteriovenous Fistulas

Continued

While these figures do not depict the Army incidence, they do represent

large proportion of these complications. Not included are some operations

that were performed overseas either because of urgent indications or in violation of the directives issued by The Surgeon General which provided that

Army personnel with specified types of vascular diseases and injuries would be

transported to the vascular centers in the Zone of Interior. Furthermore, the

sequelae of vascular injuries are not always immediately apparent (sometimes

considerable length of time elapses before they are detectable) and data

concerning these late developments are naturally not part of this analysis.

Notwithstanding, these statistics can be assumed to be reasonably complete

and certainly representative of the special sequelae of vascular injuries as they

were observed in the vascular centers in the Zone of Interior.

The disparity in numbers between 221 arterial aneurysms and 593 arteriovenous fistulas observed is immediately apparent. The most logical explanation for this unequal distribution is that arterial aneurysms more often present

acute surgical emergencies than do arteriovenous fistulas. By their very

nature aneurysms tend to become progressively larger and therefore subject to

rupture. On many of them, then, surgery could not be delayed sufficient

length of time to permit the patient to be evacuated to the Zone of Interior.

(1) Interview, M. D. Historians with Ma] Gen Norman T. Kirk, 29 Nov 51. HD; 000.71.

(2) Interview, M. D. Historians with Maj Gen Paul R. Hawley, 18 Apr 50. HD: 000.71.

(1) Ltr, Surg ETO, 19 Mar 44, sub: List of medical conditions which make it advisable to return personnel for

hospitalization in Zone of Interior. HD; .008 Policy (ETO Professional Service File).

(2) Cir Ltr 101, OS Surg ETO, 30 Jul 44, sub: Care of battle casualties.

Location

Arterial

aneurysms

Arteriovenous

fistulas Total cases

Number Percent Number Percent Number Percent

Trunk:

Aorta-vena cava 0. 0.

Gluteal, superior __ 0. 0.

Hypogastric 0. 0.

Iliac 1. 1. 13 1.

Innominate __0. 0. 0.

Mammary, internal 0. 0.

Obturator-iliac vein __

0. 0.

Subscapular ___

0. 0.

Thoracic, lateral 0. 0.

Thoracoacromial ____ 0. 0. 0.

Total ______ 4. 18 3. 27 3.

TOTAL 221 100. 593 100. 814 100.
ANEURYSMS AND FISTULAS—GENERAL CONSIDERATIONS 157

While statistics are not available, experience of surgeons in foreign theaters

points to the fact that numerous patients with aneurysms were operated on

because of rupture or to forestall rupture.

In most patients with arteriovenous fistulas, surgery could be delayed

until the patient could be transported to the Zone of Interior, for an arteriovenous fistula has no tendency to bleed externally. The very nature of this

lesion, which is actually hemorrhage from artery to vein, acts as safety valve

to prevent loss of blood and seldom presents an acute surgical emergency.

These figures, therefore, do not reflect the frequency with which such

lesions occurred and cannot be used for comparative statistics. The fact that

there were 593 arteriovenous fistulas and only 221 arterial aneurysms in this

analysis is not an indication that the former occurred, roughly, three times

more frequently.

Site and Regional Frequency

Concerning the sites of the arterial aneurysms and arteriovenous fistulas

observed in the vascular centers in the Zone of Interior during World War II,

no extended comment is necessary. They were identified in practically every

blood vessel in the body (Table 6) but were most frequent in the axillary,

brachial, and subclavian vessels in the upper extremity; in the femoral, popliteal, and tibial vessels in the lower extremity; and in the carotid and vertebral

vessels in the head and neck. The largest number in any single vessel occurred

in the femoral artery.

Aneurysms and arteriovenous fistulas of the vessels of the trunk were

uncommon; wounds of the aorta, the renal artery, and other large and deepseated vessels of the abdomen usually precipitated immediate death.

DIAGNOSIS

As rule the diagnosis of aneurysms and arteriovenous fistulas resulting

from battle injuries offered few difficulties; the chief problem in such cases was

to demonstrate physical signs of their presence. If the lesion lay deep under

heavy musculature, the characteristic pulsating mass was sometimes neither

visible nor palpable but other signs which clarified the clinical picture were

usually present. When proper survey of the whole body was carried out

after wounding, the diagnosis of combat-incurred arterial aneurysms and

arteriovenous fistulas offered no greater difficulties in military practice than

do similar lesions encountered in civilian practice.

Occasionally, especially when associated nerve injuries existed, the question arose whether the lesion was an arterial aneurysm or an abscess, and in

at least one such case actual incision of the mass was undertaken before the

error was realized. Occasionally, too, an arterial aneurysm or arteriovenous

fistula was suspected to exist when it did not, though the following ca&e in

which this difficulty was particularly confusing is believed to be unique:
158 VASCULAR SURGERY IN WORLD WAR II

Case 1. 30-year-old soldier was wounded in France on August 1944 by shell fragments. He received penetrating wounds of the soft tissue in the left parietal region of the

scalp and in the left trapezius area. There was little bleeding at the time of wounding.

The wounds were debrided in an evacuation hospital and on August he was admitted to

general hospital where an abnormal pulsation and bruit were noted in the left infraclavicular

region. Secondary closure of the wounds was carried out on 15 August. Healing was

satisfactory. diagnosis of arteriovenous fistula was made and the patient transferred to

the vascular center at Mayo General Hospital, Zone of Interior.

When first seen at this center, 24 October 1944, the patient denied numbness, paralysis,

pain, excessive sweating, knew of no color or temperature changes, and had not observed

any dilated veins, edema, or trophic lesions. He thought he had noted some swelling in the

left clavicular area. He stated his health prior to wounding had always been good.

Examination revealed number of dilated veins in the left pectoral and left infraclavicular areas, but otherwise inspection of the left clavicular area revealed nothing unusual.

There was no visible mass, and no abnormal pulsation could be detected. There was, however, strong pulsation palpable just beneath the midportion of the left calvicle, which was

not present on the contralateral side. No thrill could be palpated but loud systolic bruit was heard in this area. The unusually well-developed muscles in both shoulders and arms

made it impossible to compress the subclavian artery above the clavicle or the axillary

artery beneath it, and tests for collateral circulation therefore could not be carried out.

No color changes, edema, abnormal sweating, trophic, or neurologic changes were

present in either hands or feet. The peripheral arteries were neither thickened nor tortuous.

The radial, ulnar, and brachial pulses were normal and equal in the two extremities, and the venous filling time was the same (3 seconds) in both hands. Skin temperature studies

revealed no significant unilateral differences.

The result of the Kahn test was negative. Roentgenograms revealed several metallic

fragments in the left parietal scalp, the left side of the neck, and the left supraclavicular

region.

diagnosis of traumatic arterial aneurysm was made, either of the distal end of the left subclavian artery or of the proximal end of the axillary artery. Since it had been impossible,

for the reason stated, to test the collateral circulation there was naturally feeling of insecurity concerning its adequacy and as precaution preganglionic upper dorsal sympathectomy was carried out 31 October 1944.

The vascular operation was performed 30 December. The entire extent of the axillary

artery was visualized by dividing the fibers of the pectoralis major and minor muscles but

no aneurysm was found in the artery or in any of its branches. The axillary vein was bifid

and somewhat dilated just distal to the point at which it passed beneath the clavicle, and at

which the two branches joined. The clavicle could be elevated sufficiently to permit

visualization and digital exploration of the subclavian vessels beneath, but neither in this

area nor above the clavicle was there evidence of aneurysm or of constriction of the vessel by

scar tissue. No foreign bodies were observed. The muscles were resutured and the wound

closed in layers with fine black silk. No bruit was audible at the close of the procedure.

Recovery from both sympathectomy and the vascular operations was uneventful. It

was noted postoperatively that the bruit was sometimes loudly audible though at other times

it was absent. The prominent pulsation beneath the left clavicle persisted. The patient

had full range of motion in the left shoulder and continued to have no complaints referable

to the upper extremities. Eventually observations were made which were thought to offer an adequate explanation

for these findings: The bruit was found to be present, or absent, or altered in character,

according to the position of the patient and his method of breathing. It was present and

intense when he stood with shoulders unsupported. It was absent when he was recumbent.

When he sat with elbows resting on the arms of chair single short bruit was heard with
ANEURYSMS AND FISTULAS—GENERAL CONSIDERATIONS 159

each inspiration and expiration but none was audible when respiration was held either in

inspiration or expiration. When he stood or sat with his arms unsupported and hanging by

his side, the bruit ceased completely during full inspiration and at the same time all arterial

pulsations in the left upper extremity disappeared. Downward traction on the shoulders

had no influence upon pulsation, bruit, or radial pulse. The various positions of abduction

and hyperabduction, with the extremity in the plane of the body, likewise did not influence

these manifestations regardless of whether the body was bent forward or backward. Similarly, strong backward thrusting of the shoulders, with the head turned to one side or the

other, had no effect upon them. When the patient attempted to elevate the left shoulder

against downward traction on the arm, the bruit often disappeared.

Oscillometric readings were within normal range in both arms (Table 7) except during

deep inspiration when the patient was seated with his arms hanging unsupported by his

sides; then oscillations ceased completely in the left arm. They also ceased when he stood

with his arms hanging unsupported. When he was recumbent there was no change in the

readings during forced inspiration.

Table 7. Oscillometric Variations in the Two Arms at Different Positions During Normal Breathing and Deep Inspiration

Case of Costoclavicular Compression of Left Subclavian Artery

The blood pressure was 128 mm. of mercury systolic and 78 diastolic in the right arm

and 120 mm. of mercury systolic and 80 diastolic in the left. When the patient was standing,

the venous pressure in the cephalic veins in the antecubital fossae varied from 48 to 60 cm.

of water. With deep inspiration there was rise of cm. of water or more on the left side

and drop of approximately cm. of water on the right.

Regardless of position, the left hand was of somewhat better color than the right.

The radial and ulnar pulses were full at both wrists. In room in which the temperature

was 22° C., the skin temperature in the fingers on the right hand varied from 17.5° to 20°

Centigrade. On the left side the range of variation was from 32.5° to 33.5° Centigrade.

The left side of the face and the left upper extremity did not perspire; on the right side the

same areas perspired normally. Ergometric studies, repeated on several occasions, revealed

no essential differences in the fatigability of the two hands. Roentgenograms taken in

position of lordosis revealed some narrowing of the space between the clavicle and the first

rib on the left with inspiration, but the interpretations were inconclusive.

From these various observations it was decided that the physical signs which this

patient presented could be explained by compression of the subclavian vessels on the left

between the first rib and the clavicle. When he stood with arms unsupported, partial

compression of the vessels occurred and there was resulting loud systolic bruit. When he

was recumbent, compression did not occur and there was no bruit. Full inspiration in the

Right Left

Position of extremity Normal

breathing*

Deep

inspiration*

Normal

breathing*

Deep

inspiration*

Hanging, adducted,_ _________

Hanging, shoulder thrust backward, head turned to

opposite side .. .. 5.

Abducted 90°.. ..

Hyperabducted over head

*A11 oscillometricreadings were maximal at pressure of 110mm. of mercury.
160 VASCULAR SURGERY IN WORLD WAR II

standing or sitting position caused sufficient compression of the vessels to shut off completely

all flow of blood to the left upper extremity. With normal respiration this phenomenon

did not occur.

Since the patient had no complaints and had ample circulation under ordinary conditions,

further operative interference was not thought justified and he was returned to duty.

Comment. For number of years it has been well known that certain

vascular and neurologic symptoms in the upper extremity may result from

structural abnormalities or be associated with positional changes. Particularly

well known are the scalenus anticus syndrome and the clinical pictures associated with cervical ribs and with tendinous or cartilaginous bands extending from rudimentary cervical ribs or transverse processes. Also well known are

the symptoms resulting from compression of the subclavian vessels and the

brachial plexus between the first rib and the clavicle, and neurovascular complaints resulting from the relatively normal obliteration of arterial pulsation

in the upper extremity in various positions of hyperabduction when they are

maintained for any length of time.

The case just described differs from previously reported cases of costoclavicular compression. Although the patient had no subjective complaints,

he presented physical findings which pointed to the diagnosis of aneurysm.

Prior to operation, in fact, no doubt existed concerning the diagnosis, partly

because the patient had sustained wound which might have injured the

subclavian or axillary artery and partly because of the signs present. Furthermore, aneurysms of considerable size in this area may exist in the absence of

pulsating mass, without thrill, and with only moderately strong pulsations and

moderately intense bruits. In this case there was no mass and no thrill could

be felt, but pulsation was prominent and the bruit was intense.

It is unfortunate that because of diagnostic error this patient was subjected to two unnecessary surgical procedures, but under the circumstances

it is difficult to see how they could have been avoided since, so far as can be

determined, this particular syndrome had never before been reported and

therefore was not suspected. The excessive development of the arm and

shoulder muscles prevented testing of the collateral circulation, and preoperative sympathectomy was regarded as desirable for two reasons: First, arterial

aneurysms, in contrast to arteriovenous fistulas, provide notoriously poor

stimuli for the development of collateral circulation. Second, the possibility

that surgical cure of an aneurysm will entail ligation of the involved artery

always exists when an operation of this type is undertaken. It is true that the

subclavian and axillary arteries can often be severed with relative impunity,

but it is equally true that gangrene may follow such procedure.

Since the question might be raised as to whether the clinical picture was

the same before and after the operation, it can be said that nothing was done

during the exploratory operation which could have altered the regional anatomy

and physiology, and that the postoperative findings offer adequate explanation

of the picture presented before operation.
ANEURYSMS AND FISTULAS—GENERAL CONSIDERATIONS 161

THERAPY

In large number of the arterial aneurysms and arteriovenous fistulas observed at the vascular centers during World War II operative cure (Tables

8-9) was possible, partly because of the very considerable number of these

lesions from which cases for this procedure could be selected, partly because

of deliberate effort to increase the number of indications for operation, and

partly because competent vascular surgeons had been chosen to head these centers and carry out the delicate and difficult procedures involved. Otherwise, the therapy of these vascular lesions did not differ from that which would be employed under similar circumstances in civilian practice.

Table 8. Techniques of Operative Treatment in 209 Arterial Aneurysms

This total does not Include—-

aneurysm in which cure occurred spontaneously.

aneurysms In which method of management was not stated.

aneurysms in which cure occurred spontaneously.

aneurysms, In which methods of management not stated and In which spontaneous cure occurred.

aneurysms hi which cure occurred spontaneously.

Location Endoaneurysmorrhaphy Excision Proximal

ligation

End-toend anas- tomosis Total cases

Upper extremity:

Axillary 10 24 35

47

12

13

BrachiaL 16 30

Radial

Subclavian. 10

Ulnar

Lower extremity:

Femoral. ._

14 18

Gastrocnemius, muscle branch

Peroneal

Popliteal 19 21

Profunda femoris

branch

Tibial, anterior

Tibial, posterior 15

Head and neck:

Carotid. 13

Cervical, deep.

Temporal, superficial

Trunk:

Gluteal, superior __ _.

Iliac

Innominate

Thoracic, lateral

Thoracoacromial

Total 99 98 11 209
162 VASCULAR SURGERY IN WORLD WAR II

Table 9. Techniques of Operative Treatment in 585 Arteriovenous Fistulas

Location Arterial

repair

Quadruple

ligation

and

excision

Ligation

alone (mass, proximal,

distal, or proximal and distal)

Total

cases

Upper extremity;

Axillary. 32 32

Brachial 29 29

Cervical, transverse

Humeral, posterior circumflex __

Interosseous, common ...

Radial.

Scapular, transverse

Subclavian 16 18

Ulnar

Lower extremity:

Calf, to muscles of

Circumflex, lateral

Femoral 16 124 141

Geniculate _____

Gluteal, inferior

superior

Peroneal 24 25

Plantar ...

Popliteal 11 91 102

Profunda femoris 19 19

branch

Tibial.. 87 87

Head and neck;

Carotid. ______ 29 14 48

Cirsoid.

Lingual

Occipital. ____

Temporal, superficial

Vertebral. ___ 13

Trunk:

Aorta-vena cava

Hypogastric

Iliac.

Innominate

Mammary, internal. .__ __

Obturator-iliac vein

Subscapular

Thoracoacromial

Total 34 526 25 585

This total does not Include:

fistulas, In which method of managementnot stated, and In which spontaneous cure occurred.

fistula In which method of management not stated.

fistula In which spontaneous cure occurred.

fistulas, in which methods of management not stated, and in which spontaneous cure occurred.
ANEURYSMS AND FISTULAS—GENERAL CONSIDERATIONS 163

Most of the 221 arterial aneurysms were treated by endoaneurysmorrhaphy (99 cases) or excision of the aneurysm (98 cases). Most of the 593 arteriovenous

fistulas were treated by quadruple ligation and excision (526 cases). The

techniques used were almost without exception those employed for these

lesions when encountered in civilian practice.

Anesthesia. Fractional spinal analgesia was preferred for operations on

the lower extremities since all procedures in this region were likely to be long

and tedious. Thiopental sodium anesthesia administered intravenously, and

supplemented as necessary by nitrous oxide and oxygen, was preferred for

operations on other parts of the body. In operations about the neck and head

an intratracheal tube was usually introduced to ensure smooth anesthesia and

maintain an open airway.

Almost without exception there were no complications of any consequence

attributable to anesthesia at any of the vascular centers. This is notable

achievement since over half of the operations required hours or longer and

some lasted hours. The advantages of the types of anesthesia selected are

apparent for operations of such length.

PREOPERATIVE AND POSTOPERATIVE CARE

Preoperative Care

The status of patients with arterial aneurysms who are encountered in

civilian practice may or may not be good. Often it is not good because of

advancing age, the presence of organic cardiac or cardiorenal disease, hypertension, or similar complications. The great majority of aneurysms encountered

in civilian practice have been brought about by an underlying disease and the

surgical risk must be estimated with this in mind. Arteriovenous fistulas, on

the other hand, are almost without exception of traumatic origin and the

patient is quite likely to be good surgical risk.

The great majority of patients with arterial and arteriovenous fistulas

treated at the vascular centers in the Zone of Interior during World War II

were young men in excellent physical condition. They had no background of

disease, cardiac or otherwise. Some patients it is true had other injuries, but

for the most part the vascular lesion was the only disability, or the major disability, and the surgical risk had to be estimated principally on the basis of

this lesion.

Preoperative preparation, therefore, was generally limited to tests of the

circulatory status of the affected part and the institution of methods to improve the circulation. The usual routine was to keep patients with arterial

aneurysms under close observation in the hospital until the proper time for

operation arrived. If no contraindications existed they were permitted to

walk, but their activities were restricted to those which did not require strenuous effort. Patients with arteriovenous fistulas, if they showed no evidence

of cardiac enlargement, and many of them did not, were usually allowed to
164 VASCULAR SURGERY IN WORLD WAR II

leave the hospital on furlough but were required to return at regular intervals

for checkups until the appropriate time for operation arrived.

Since surgery of vascular lesions of these types had to be delayed to permit

the development of an adequate collateral circulation, any danger of infection

from the original wound had long since passed before the operation was undertaken. Preoperatively, therefore, chemotherapeutic and antibiotic agents

were not administered.

Patients whose arterial lesions had produced cardiac dilatation of any

degree or who presented evidence of actual or impending cardiac failure were

prepared for operation as they would have been under similar circumstances

in civilian practice.

When indicated, an internist was called in consultation. Physical therapy

was employed as indicated before as well as after operation. It was of the

greatest usefulness in patients in whom contractures had developed as result of disuse, or in whom concomitant lesions of nerve or bone, or nerve and

bone, complicated the vascular lesion.

Postoperative Care

Dressings covering the operative wound were always small and simple

and served only to protect the incision. However, when pressure for the obliteration of an aneurysmal sac was indicated an elastic bandage was employed.

In order to prevent swelling it was so applied as to cover the whole extremity

from toe to thigh or from fingers to axilla. Pressure was maintained until the

patient was ambulatory or until there was no longer any evidence of an accumulation of fluid in the wound.

Patients operated on for lesions of the smaller vessels, particularly vessels

of the upper extremity, were allowed to be ambulatory within 24 hours of

operation provided there were no contraindications. When their lesions involved larger blood vessels they were kept in bed for period of 10 days to

weeks until the wound was well healed.

Patients with considerable degree of cardiac dilatation or with evidence

of cardiac failure required special treatment. longer period of bed rest was

usually necessary and the return to normal activities was always graduated and

cautious. Medication depended upon the indications of the special case.

Treatment was usually carried out in cooperation with the internist.

Chemotherapy and Antibiotic Therapy

The sulfonamide drugs (antibiotics were not available in the first months

of operation of the vascular centers) were used in relatively few cases. When

such treatment was regarded as necessary, the agents were given in standard

dosages. They were never administered for purely prophylactic reasons and

sulfanilamide and similar preparations were never placed in wounds.

When penicillin became available, however, it was administered routinely

as prophylactic measure. It was given (intramuscularly, as rule) immediately after operation and continued until it was thought that all danger of
ANEURYSMS AND FISTULAS—GENERAL CONSIDERATIONS 165

infection had passed. The usual dose was 30,000 units every hours for period

of days. Reactions were minimal, and limited to urticaria and fever. They

were observed only occasionally and in every instance cleared up as soon as

therapy was discontinued.

Streptomycin did not become available until the vascular centers were in

process of deactivation. It was not regarded as indicated in any instance of

aneurysm or arteriovenous fistula then under observation.

PREOPERATIVE COMPLICATIONS

More than half (447) of the 814 vascular injuries in this series were associated with injuries of the nerves, bones, or soft tissues (Tables 10 and 11).

Frequently these injuries were of an extremely serious character and introduced

problems of repair which required patience and ingenuity for their solution.

These considerations are discussed in detail in the volumes of the history

devoted to neurosurgery and orthopedic surgery and will not be repeated here.

Other preoperative complications, with the exception of cases of major

causalgia in connection with arterial aneurysms, were confined to arteriovenous

fistulas. They consisted of major causalgia in cases; gangrene, which was seldom extensive, in 13 cases; gas gangrene in cases, in both of which it was

readily controlled; and Streptococci viridans bacteremia in case.

The single instance of Streptococcus viridans septicemia in this series is

worth recording in detail for two reasons: (1) it originated in vegetations in

femoral arteriovenous fistula, and (2) it was cured by surgical excision of the

fistula. number of instances of septicemia of this origin have been recorded

but, so far as can be determined from survey of the literature, there are on

record to date only three instances of cure of the bloodstream disease by surgical

removal of the arteriovenous fistula. The first of these cases, reported by

Hamman and Rienhoff in 1935, was an arteriovenous fistula of the external

iliac vessels which had resulted from rifle injury 17 years earlier. The second,

reported by Touroff, Lande, and Kroop in 1942, was an arteriovenous fistula

of the profunda femoris vessels combined with saccular aneurysm which

had resulted from gunshot wound years earlier. The third, reported by

Lipton and Miller in 1944, was femoral arteriovenous fistula of 15 years

duration which also had resulted from an accidental gunshot injury.

Case 2. This 26-year-old soldier was wounded (after 18 months in the Southwest

Pacific theater) on Leyte 21 December 1944. He received penetrating grenade-fragment

wounds in the right thigh, left arm, left chest, and left thigh. There was considerable bleeding

from the right thigh wound, but it was controlled by compression bandage. His wounds

were debrided at mobile surgical hospital and he was evacuated to numbered general

hospital. There, on about 18 January 1945, he called the attention of the attending medical

Hamman, L., and Rienhoff, W. F., Jr.: Subacute Streptococcus viridans septicemia cured by excision of an arteriovenous aneurysm of the external iliac artery and vein. Bull. Johns Hopkins Hosp. 57 219-234, Oct 1935.

Touroff, A. S. W.; Lande, H., and Kroop, I.: Subacute Streptococcus viridans septicemia cured by excision of an

infected traumatic arteriovenous aneurysm. Surg., Oynec. Obst. 74: 974-982, May 1942.

Lipton, S., and Miller, H.: Streptococcus viridans septicemia—subacute bacterial endarteritis of an arteriovenous

aneurysm. J. A. M. A. 126 766-769, Nov 1944.
166 VASCULAR SURGERY IN WORLD WAR II

officer to “purring” sensation in the right thigh which he had first noted on the third day

after injury. Examination disclosed the classical signs of an arteriovenous fistula and he was

evacuated by air to the Zone of Interior. The patient was admitted to the vascular center of Mayo General Hospital, 11 February

1945. His past history was noncontributory (cardiovascular history entirely normal) except

for recurring attacks of tonsillitis. Within the last 14 months he had had attacks of

malaria. His wounds had healed uneventfully and he had no symptoms other than the

“purring” sensation in the right thigh and little numbness along the medial aspect of the

knee.

Table 10. Associated Injuries in 159 Arterial Aneurysms

Location Nerve

injury Fracture Extensive

soft tissue damage Total

Upper extremity:

Axillary __ ___ ___ 32 34

Brachial 40 45

Radial 11

Subclavian 11

Ulnar

Total _______ 92 15 108

Lower extremity;

Femoral __

Peroneal

Popliteal 12

Profunda femoris

branch. __ ____

Tibial, anterior __ ___

posterior 12

Total .. 13 19 38

Head and neck:

Carotid __

Total.. __

Trunk:

Iliac. __

Total

TOTAL 114 38 159
ANEURYSMS AND FISTULAS—GENERAL CONSIDERATIONS 167

Table 11. Associated Injuries in 288 Arteriovenous Fistulas

330323 0—55 12

Location Nerve

Injury Fracture Extensive

soft tissue damage Total

Upper extremity:

Axillary 13 22 Brachial 20 23

Cervical, transverse __

Humeral, posterior circumflex.. ..

Interosseous, common

Scapular, transverse

Subclavian. 10

Ulnar __

Total 45 12 62

Lower extremity:

Calf, to muscles of.. ...

Circumflex, lateral..

Femoral.. 27 22 11 60

Gluteal, inferior

superior _.

Peroneal. ... 10 21

Plantar ..

Popliteal 24 13 41

Profunda femoris.. __

branch ...

Tibial ..

22 20 45

Total. 89 73 22 184

Head and neck:

Carotid .. 18 11 29

Occipital

Temporal, superficial ..

Vertebral

Total _. 27 14 41

Trunk:

Iliac ....

Total

TOTAL 162 99 27 288
168 VASCULAR SURGERY IN WORLD WAR II

He denied having had edema, cyanosis, coldness, pain, or weakness in the right lower

extremity.

general physical examination revealed nothing remarkable except for the generalized

yellowing of the skin commonly seen in patients who have had prolonged atabrine therapy.

The sclerae were normal in color. There was no tortuosity or thickening of the peripheral

arteries and no evidence of cardiac enlargement. The heart sounds were normal and there

were no murmurs.

Examination of the right thigh revealed an abnormal pulsation over the course of the

femoral vessels in the proximal third, associated with continuous thrill and loud, continuous bruit which could be heard down to the knee and up into the right lower quadrant of

the abdomen. Both thrill and bruit could be obliterated by direct pressure over the femoral

vessels about 15 cm. below the inguinal ligament. When this maneuver was carried out

the pulse rate slowed from 76 to 52 beats per minute and blood pressure rose from 124 mm. of mercury systolic and 64 diastolic to 138 mm. of mercury systolic and 86 diastolic. When

atropine was administered before compression of the femoral vessels, blood pressure changes

were of the same magnitude as before but the pulse decreased by only beats per minute.

The dorsalis pedis and posterior tibial pulses were normal in both feet and the venous filling

time was the same on both sides. In room at temperature of 22° C. the skin temperature

of the toes on the right foot varied from 19° to 20° C. and on the left foot from 21° to 21.5° Centigrade. After minutes of total arterial occlusion, and with the fistula completely

compressed by digital pressure, reactive hyperemia began in the toes on the right foot in

20 seconds and was complete and full in the foot in 90 seconds.

The electrocardiogram was normal except for QRS complex of 0.12 seconds duration.

Roentgenograms showed no cardiac enlargement. The frontal cardiac area was 146 sq.

cm. (Fig. 11A) as compared with predicted frontal area of 143 sq. cm. for man of the

patient’s weight and height.

diagnosis of femoral arteriovenous fistula, with collateral circulation adequate for

surgical extirpation was made. On March 1945, the 17th day of hospitalization, and before

date for operation had been set, the patient had chills and fever which recurred in 48 hours.

The clinical diagnosis of malaria was confirmed by blood smear positive for Plasmodium

vivax. The recurrence was promptly controlled by atabrine and after the blood smears

were reported as negative the patient was permitted to leave the hospital on furlough. When

he returned April 1945, he stated that shortly after he left the hospital he had had recur- rence of chills and fever, this time associated with sore throat, and that week later he had

experienced abdominal soreness and mild but persistent diarrhea. He had also suffered

moderate loss of appetite. He regarded the illnesses as recurrence of malaria and had taken

atabrine, but without results. He had been confined to bed for most of his 3-week furlough

and had lost 16 pounds in weight.

Examination on his readmittance to hospital revealed some tenderness in the region

of the transverse colon and barely palpable spleen. Stool examinations revealed infection by both hookworm and amebae. Appropriate treatment for these parasites resulted

in prompt disappearance of the intestinal symptoms.

The patient’s temperature had been 102° F. when he was readmitted to the hospital,

and though it did not rise above 99.2° F. for the next days, it was higher the following

day (Chart 18) and remained abnormal until after administration of penicillin. Atabrine

was discontinued 14 April because blood smears had been reported negative for malaria

parasites since March. On 16 April the soldier had severe chill followed by temperature rise to 102.4° F., and days later similar episode occurred though at this time

the temperature rose only to 101.3° Fahrenheit.

Following the chill and temperature elevation the patient became dyspneic and orthopneic and complained of pain and tenderness over the sternum. Within few hours the

chest pain shifted laterally and became localized in the left fourth interspace in the anterior

axillary line. There was marked tenderness in this area. Examination of the chest re-
ANEURYSMS AND FISTULAS—GENERAL CONSIDERATIONS 169

Figure 11. Roentgenograms showing change in heart size and evidence of 'pulmonary infarction. A. 13 February 1945, heart size is normal. Frontal cardiac area 146 square centimeters.

B. April, heart size has increased. Frontal cardiac area 168 square centimeters.

C. 23 April, heart size difficult to estimate because of pathologic changes in the lungs and

elevation of diaphragm. There is increased density in the left lower lung field from pulmonary infarction. D. June, weeks after operation the heart size is normal, the lung

held is clear. (The method of Ungerleider and Gubner was used in computing the size of the heart.)
170 VASCULAR SURGERY IN WORLD WAR II

Chart 18. Temperature chart of patient with Streptococus viridans septicemia preceding and

following operation.

vealed (for the first time) soft, blowing, nontransmitted systolic murmur in the third

interspace to the left of the sternum. The first heart sound was roughened and the apical

impulse was displaced cm. to the left of the midclavicular line. Over the left lower lobe

posteriorly, breath sounds were absent, crepitant rales were heard, and there was marked

dullness to percussion. The temperature was now 101.2° F., the pulse was 120 beats per

minute, and the respirations were 20 per minute. On the basis of the clinical findings

tentative diagnosis of pulmonary infarction was made.

Roentgenograms made on April revealed increased density which obliterated the

left lower lung field, finding compatible with diagnosis of pulmonary infarction. The

frontal cardiac area, which had been 146 sq. cm. on 13 February, had increased to 168 sq.

cm. by April—17 percent above normal (Fig. 11B). By 23 April, days after the development of chest symptoms and signs, it was approximately 174 square centimeters. more

exact measurement was not possible because of the pulmonary changes (Fig. 11C). On the same day an electrocardiogram showed sinus tachycardia with slight slurring of QRS in the third lead and QRS complex of from 0.10 to 0.11 seconds duration.

The persistence of intermittent chills and fever after diagnosis of malaria had been

eliminated, together with the clinical and roentgenographic signs suggestive of pulmonary

embolism, pointed to diagnosis of septicemia, the most likely source of which was thought

to be vegetations within the femoral arteriovenous fistula. Blood taken for culture on

20 April was reported 24 hours later as positive for Streptococcus viridans. At this time

leukocytes numbered 12,400 per cubic millimeter of blood, with differential count showing

28 percent lymphocytes. The concentration of hemoglobin was 11.9 gm. per 100 cc. of

the prothrombin time 30 seconds, and the hematocrit reading 36 percent. There

wa no increase in tenderness to pressure over the arteriovenous fistula. No petechiae WP,re observed.
Figure 12. Kodachrome of specimen removed at operation viewed from venous side of arteriovenous fistula. Note numerous vegetations along margins of fistula.

ANEURYSMS AND FISTULAS—GENERAL CONSIDERATIONS 171

The patient, whose expression was one of grave apprehension, was obviously acutely

ill. Dilaudid (dihydromorphinone hydrochloride) was given for the relief of chest pain.

Penicillin, begun on 19 April, was administered intramuscularly in doses of 25,000 units

every hours for days and then in doses of 12,500 units every hours for the next days.

Blood taken for culture on 21 April was again reported positive for Streptococcus viridans

but repeated cultures for the next days showed no growth of organisms. The patient

became afebrile 48 hours after penicillin was begun and there were no further chills (Chart

18). On 24 April, immediately after an intravenous injection of 100,000 units of penicillin,

the patient was operated upon.

With the patient under spinal analgesia longitudinal incision about 12 cm. long was

made over the course of the femoral vessels beginning about cm. below the inguinal fold.

The fascia was divided and the sartorious muscle retracted. great deal of scarring was

observed in the region of the vessels. The femoral artery, which was about normal in size,

and the femoral vein, which was dilated to diameter of about cm., were isolated above

and below the fistula. continuous thrill was present. The saphenous and the femoral

nerves which were adherent to the vessels were dissected free without injury. The artery

and vein were divided above and below the fistula and the stumps transfixed with silk.

large fistula almost 1.5 cm. in diameter communicating between the artery and vein was

excised. The wound was closed in layers with interrupted silk sutures. The operative

procedure was carried out without difficulty and the patient’s condition was good throughout.

Examination of the excised specimen (Fig. 12) revealed large arteriovenous fistula

almost 1.5 cm. in diameter. The margins of the fistula were studded with minute small

vegetations. Cultures made directly from these vegetations revealed heavy growth of

Streptococcus viridans, although at the time of operation blood cultures had been reported

as negative for these organisms. Histologic examination revealed that these vegetations

were literally studded with cocci (Fig. 13).

The patient’s postoperative course was uneventful. He remained afebrile, and his

pulse and blood pressure were within normal range. The bruit and thrill were no longer

present in the area of the fistula and the temperature and color of the right leg were normal.

The patient was allowed out of bed on the fourth day. For few days thereafter he complained of pulling sensation in the left chest on deep inspiration but he had no dyspnea

and orthopnea and this minor discomfort rapidly disappeared. The signs of infarction in

the left lower lobe gradually disappeared and weeks after operation clinical and roentgenologic examination revealed no abnormalities in this area. The size of the heart returned

to normal (Fig. 11D).

When the patient was first discharged from hospital he experienced slight edema of

the right leg after it had been in dependent position for long period. When examined

July 1945, no edema was present and he stated that there had been no evidence of it for

week; at this time he was wearing an elastic stocking. His only complaint was sense

of fatigue in the calf after he had walked for half mile. The feet showed no abnormal

color changes. The posterior tibial and the dorsalis pedis pulses were present on both sides

but were reduced in volume on the right. In room in which the temperature was 25.5° C.

the temperature of the toes on both feet varied between 29° and 30° Centrigrade. The

oscillometric reading in the distal thigh was 2.5 at 70 mm. of mercury on the right and

at 120 on the left. In the calf the oscillometric value was at 60 mm. of mercury on the

right side and 7.5 at 90 on the left. In the ankle it was at 70 mm. of mercury on the right

and at 80 on the left. The pulse was 56 beats per minute and the blood pressure 128

mm. of mercury systolic and 70 diastolic.

The patient was reexamined about weeks later. The elastic support had not been

worn in the interim and he had experienced no edema. After walk of about l}i miles he

stated he had sense of tightness in the right calf, but the discomfort was not great enough

to make him cease walking. There had been no recurrence of fever, chills, or pulmonary

and cardiac symptoms. He looked well and was apparently in excellent general condition.
172 VASCULAR SURGERY IN WORLD WAR II

Figure IS. Photomicrograph of portion of excised arteriovenous fistula showing two bacteriastudded vegetations (//. and E. stain, high power magnification). The dark-staining areas

are masses of cocci. Cultures of these vegetations yielded pure growth of Streptococcus

viridans.

Comment. Transient Streptococcus viridans bacteremia is not infrequent

in the course of upper respiratory or sinus infections, or following the extraction

of infected teeth. Presumably such transient bacteremia is the original source

of infection in cases of subacute bacterial endocarditis. It is therefore significant that the patient had had recurrent attacks of tonsillitis since childhood

and had had severe attack associated with pharyngitis and accompanied by

chills and fever about month before the diagnosis of septicemia was made.

It is quite conceivable that this attack resulted in infected vegetations within

the arteriovenous fistula.

Although this patient had multiplicity of other diseases (tonsillitis and

pharyngitis, malaria, hookworm, and amebic infection) the recognition of

Streptococcus viridans infection was not long delayed. The diagnosis was

relatively easy despite the coincident malaria because of the severe chills and

fever, the signs and symptoms of pulmonary infarction, and the presence of

an arteriovenous fistula. The findings on blood culture merely confirmed the

clinical suspicion.

The rapid increase in cardiac size which occurred in this case (Fig. IIA-C)

was probably the direct result of the altered circulatory dynamics produced

by the presence of the large femoral arteriovenous fistula. Similar increases
ANEURYSMS AND FISTULAS—GENERAL CONSIDERATIONS 173

were observed in other patients with similar lesions during the period of observation prior to excision of the fistula.

This case illustrates the necessity of bearing in mind the presence of arteriovenous fistula when looking for source of infection in instances of Streptococcus viridans septicemia. It also exemplifies the dramatic cure which can

be achieved in such instances by surgical removal of the defect. The patient

was treated with penicillin over 6-day period and the blood stream was thus

rendered sterile prior to operation, but the heavy growth of Streptococcus

viridans obtained from within the fistula after it had been removed is evidence

that the apparent cure would not have been permanent.

POSTOPERATIVE RESULTS

The criteria for successful operation were considered fulfilled if the objective evidences of the lesion which had been present before operation had disappeared after operation and there was no evidence of recurrence during the

postoperative period of hospitalization. These standards were deemed adequate since the period of hospitalization is much longer in military than in

civilian practice and since any recurrence of aneurysmal lesions becomes

evident rather promptly.

Of the 801 operations performed at the vascular centers during World War

II (in 13 instances in this series of 814 cases, surgery was unnecessary because

spontaneous cures occurred) there were only fatalities, 10 failures, and 36

instances of complications following operation. Much of the success can be

attributed to the youth and generally good circulatory status of the patients

in whom these lesions occurred, but other factors contributed and are worthy

of note. The thorough preoperative examination to which each patient was

submitted and the detailed evaluation of his vascular status established the

fact that the operation was being performed at the optimum time on patient

whose vascular status was as good as it could be made. Furthermore, the

surgeons who performed the operations in these centers were men preeminent

in the field of vascular surgery and had at their disposal the appropriate precision instruments and other necessary equipment.

It is possible, too, that the adjunct use of certain measures, particularly

anticoagulant therapy (see Chapter X) and sympathectomy (see Chapter XI)

played some part in the results. On the other hand, neither of these methods

was employed at one center (Ashford) where the results were quite as good

as those obtained at the other centers. The conclusion seems warranted,

therefore, that while these methods may be useful in selected cases, they are

certainly not indispensable.

Complications

The number ofpostoperative complications in this series (36) isremarkably

small when weighed against the number of operations (801) performed for

aneurysms and arteriovenous fistulas. These complications included;
174 VASCULAR SURGERY IN WORLD WAR II

1. Nineteen instances of wound infection: 12 in arteriovenous fistulas and

in aneurysms. In arterial aneurysm the infection progressed to necrosis.

2. Four instances of hemorrhage: in arteriovenous fistulas and in an

aneurysm.

3. Five instances of hematomas in the wound: in arteriovenous fistulas

and in an aneurysm.

4. One instance of mediastinal abscess in an arteriovenous fistula.

5. Three instances of major causalgia: in aneurysms and in an arteriovenous fistula.

6. Two instances of hemiplegia: in an aneurysm and in fistula.

7. Two instances of gangrene, both in arteriovenous fistulas.

Failures

There was immediate evidence of failure following 10 operations performed

at the vascular centers. The failures occurred in—

1. Two arterial aneurysms, both in the subclavian artery.

2. Eight arteriovenous fistulas: in the aorta and vena cava, in the

carotid, in the superficial temporal artery, and cirsoid aneurysms.

Fatalities

Four deaths occurred in the 801 cases treated surgically at the vascular

centers. The distribution of the lesiops was as follows:

1. Aneurysm of the deep cervical artery.

2. Aneurysm of the subclavian artery.

3. Arteriovenous fistula between subclavian artery and vein.

4. Arteriovenous communication between the internal carotid artery and

the cavernous sinus.

The details of these cases are as follows:

Case 3. 22-year-old soldier was operated on months after injury for large

aneurysm on the left side of the neck which was causing good deal of pain. Intratracheal

anesthesia was used. After the carotid artery had been isolated and tape had been placed

about it, temporary occlusion of the vessel did not end the pulsation in the area. Compression of the vertebral and subclavian vessels was equally ineffective. It was apparent from

these phenomena that some one of the small branches of the carotid artery was the site of

the aneurysm, but the sac was so large that the vessel could not be isolated.

cautious attempt was therefore made to free the sac with the idea of isolating the

vessel when it was elevated. During this attempt, however, the sac was accidentally entered.

The opening into the artery could easily be occluded by introduction of the finger, but each

time that suture transfixion of the opening was attempted considerable amount of blood

was lost. Although the patient had been receiving plasma and blood throughout the

procedure, he was now discovered to be in shock and in matter of moments, pulseless.

His blood pressure could not be determined and for several minutes breathing had to be

maintained by artificial respiration.

It was finally possible to suture the artery within the aneurysm and there was some

improvement in his condition following the introduction of more blood, but he never regained
ANEURYSMS AND FISTULAS—GENERAL CONSIDERATIONS 175

consciousness. Convulsions ensued and death occurred 24 hours after operation. Necropsy

revealed diffuse acute and anoxic edema and necrosis of the middle layer of the right cerebral

cortex. The vessel involved proved to be the deep cervical artery.

Comment. This death should not have occurred. An inexperienced

anesthetist gave the anesthetic and the surgeon had no warning of the patient’s

condition until it had become irreversible. Had the proper warning been

given, the operation could probably have been terminated quickly and without

further loss of blood by packing the sac and suturing the aneurysm, or bleeding

could have been controlled by pressure until the patient’s status permitted

the loss of more blood while another attempt was made to suture the vessel.

Case 4- 24-year-old soldier was operated on 11 months after injury for large

subclavian arterial aneurysm which was partly in the neck and partly in the mediastinum.

Intratracheal anesthesia was used. Excellent exposure was obtained by resecting the

inner portion of the clavicle and splitting the sternum. The subclavian artery was ligated

proximal and distal to the opening in the sac.

Although there was no further bleeding, the sac continued to pulsate feebly and the

introduction of needle revealed arterial blood under pressure. This blood was obviously

coming from the vertebral artery which was the only vessel trapped between the two ligatures. The aneurysm was so large that access to the vertebral artery in its free portion was

completely prevented. The sac was therefore gradually freed without special difficulty.

When the posterior aspect had been dissected free almost to the point of the opening, the

sac was quickly opened and back bleeding from the vertebral artery readily controlled.

At this time the wound was dry and the major portion of the sac could be excised.

The patient had received blood throughout the operationand his systolic blood pressure

had never fallen below 90 mm. of mercury. Except that he was notably drowsy after

operation, his condition seemed good. The blood pressure was constantly in the neighborhood of 130 mm. of mercury systolic and 80 diastolic and the pulse, which was of good

volume, in the neighborhood of 100 beats per minute.

The night after the operation the patient woke suddenly and complained of severe

occipital headache. Shortly afterward he became stuporous and then comatose, and death

occurred about noon the following day. There was rapid rise of both temperature and

pulse rate during the night and just prior to death they were greatly elevated.

Necropsy revealed encephalomalacia of the left cerebellum with some diffuse old subarachnoid hemorrhage and scarring. No thrombus could be demonstrated in the vertebral

artery or in the circle of Willis. The right vertebral artery and both carotid arteries were

intact.

Comment. The course of events in this case was unexpected and cannot be

explained. In retrospect, it seems that the management of the case was correct

and that the operative procedure was properly performed.

Case 5. 20-year-old paratrooper was stabbed with knife in the left infraclavicular

region. Bleeding, which was profuse, was controlled by pressure but neither formal debridement nor exploration was carried out; the wound was merely closed with sutures. Slight

drainage from the wound had continued for approximately weeks after the injury. Then

complete healing occurred. Within short time after the injury the patient became conscious of buzzing sensation in the left upper chest and in the region of the shoulder.

Two and one-half months after injury he was admitted to vascular center in the

Zone of Interior. Examination given at the time of admittance revealed the typical symptoms and signs of an arteriovenous communication in the first part of the subclavian vessels.

There were no trophic changes in the left upper extremity, also no evidence of cardiac

decompensation.
176 VASCULAR SURGERY IN WORLD WAR II

At operation, which lasted hours, the left clavicle was resected, and the median

half of the bone removed, the first portion of the subclavian artery was then identified

and the fistula located between the subclavian artery and vein. It lay so near the aortic

arch that its isolation was extremely difficult and on several occasions brisk bleeding was

encountered, though it could always be satisfactorily controlled by means of sutures or

ligatures.

Convalescence was satisfactory until the fourth postoperative day when it became

apparent that the wound was infected. Six days later secondary hemorrhage occurred

from the wound; it was finally controlled in the operating room by suture and ligature.

For the next days recovery was uneventful. Then bleeding from the wound recurred.

This time the attempt to control the hemorrhage by surgery was ineffective for all the

structures were so friable that isolation of the bleeding vessel was not possible and the

patient died on the operating table. continuous transfusion of whole blood was given

from the time he was placed on the operating table until death occurred.

Comment. The wound infection which caused the hemorrhage must be

considered responsible for this death. Penicillin had been administered immediately after the first operation but despite this precaution infection

developed.

Case 6. 35-year-old soldier sustained wound of the head and neck. The injury

was followed by typical symptoms and signs of an arteriovenous communication between

the internal carotid artery and the cavernous sinus. bruit was audible to the patient

and was particularly prominent when he was in bed at night. The left eye became prominent

and its conjunctiva edematous and engorged. Six months after injury he was admitted to

vascular center in the Zone of Interior.

The left common carotid artery was ligated and as result there was diminution of the

bruit and decreased prominence of the left eye. Vascularity of the conjunctiva also became

less. Since this operation did not eliminate the bruit completely, second operation was

performed at which the internal carotid artery was isolated and divided. The bruit was

absent for about weeks after this operation, then recurred at occasional intervals.

When the patient was on furlough he had an episode of unconsciousness which was

believed to be the result of cerebral accident. When he returned to the hospital, the

left eye had again become prominent, though not as prominent as when he was first seen,

and the bruit was again audible. It was then decided that intracranial ligation of the

affected artery must be attempted.

The internal carotid artery was excellently exposed by retraction of the left frontal

lobe and was isolated at its point of exit from the cavernous sinus. Two tantalum clips

were applied to it. Operation was carried out without incident and without undue loss of

blood but the patient did not respond and died on the third postoperative day. At necropsy

one of the tantalum clips was found on the carotid artery and the other on the posterior

communicating branch.

Comment. Death in this case can be attributed to an insufficient arterial

blood supply to the cerebral tissues.

MULTIPLE ANEURYSMS AND ARTERIOVENOUS FISTULAS

Since multiple vascular injuries were so frequent in World War II it was

to be expected that certain casualties in whom sequelae from these injuries

developed would sometimes present multiple lesions. Of the 814 aneurysms

and arteriovenous fistulas observed at the vascular centers in the Zone of

Interior, 46 occurred in 20 patients (Table 12).
ANEURYSMS AND FISTULAS—GENERAL CONSIDERATIONS 177

Table 12. Distribution of Multiple Aneurysms and Arteriovenous Fistulas

Among 20 Patients with 46 Lesions

Fifteen patients had lesions each, had lesions, and patient had

lesions. The 20 patients thus presented total of 46 separate vascular sequelae

of their combat-incurred injuries.

In 15 patients the multiple lesions were arteriovenous fistulas; in the remaining the distribution was as follows: had aneurysms, had an aneurysm

and an arteriovenous fistula, and patient had an aneurysm and arteriovenous

fistulas.

Because of its unusual character the case report of the patient with

arteriovenous fistulas is reported in detail.

Case 7. 22-year-old sergeant was wounded on 16 August 1944 in Southern France

by an exploding land mine. He received compound comminuted fracture of the right

fifth metatarsal bone in addition to multiple soft-tissue injuries of the back, thighs, legs, and

feet. Bleeding was minimal. The wounds were dressed and casts applied to both legs.

The patient was transferred by ship to station hospital in Italy. The cast was

removed from the left leg on September and from the right leg on November. The

patient was found to have some weakness of extension of the right foot, paralysis of the right

toe extensors, hyperesthesia of the dorsal surface of the right toes, and hypesthesia in the

distribution of the left saphenous nerve. He was evacuated to the Zone of Interior and on

31 October admitted to general hospital.

Examination at the general hospital confirmed the neurologic findings in the right foot.

The fracture was found to be healed. This examination also disclosed signs of the presence

Arterial aneurysms Arteriovenous fistulas Number of lesions

Anterior tibial, posterior tibial (2, ineluding branch), peroneal (branch).

Ulnar ...

Posterior tibial, carotid, femoral

Posterior tibial

Posterior tibial Posterior tibial, geniculate

Profunda femoris

Peroneal, anterior tibial

Gastrocnemius, posterior tibial

Femoral

Femoral, brachial

Femoral, carotid ...

Profunda femoris, superior femoral

Popliteal, posterior tibial

Popliteal, posterior tibial

Brachial Anterior tibial

Axillary.. Posterior tibial ...

External iliac, hypogastric

Brachial, vertebral

Profunda femoris, femoral

Ulnar, radial

Total 46
178 VASCULAR SURGERY IN WORLD WAR II

of an arteriovenous fistula located anteriorly in the distal portion of the right leg. The

patient was therefore transferred to vascular center.

On November 1944 when admitted to the vascular center at Mayo General Hospital

he had few complaints. He stated that he had some weakness of extension off the right foot

and toes, and occasionally slight burning pain on the dorsal surface of this foot, but the

hyperesthesia had disappeared. Along the left internal malleolus he still had some residual

hypesthesia. He said the right foot was somewhat warmer than the left and that sweating

was excessive in both feet. He denied having had color changes, venous difficulties, trophic

changes, precordial distress, dyspnea, or cyanosis.

Physical examination revealed 150 wounds. All of them were well healed and most

were very small. The majority were scattered over the legs, feet, and thighs. Roentgenologic examination of the extremities revealed numerous small metallic fragments scattered

throughout the soft parts in these areas.

Neurologic findings were limited to small area off hypesthesia along the left internal

malleolus, loss of extensor power in the right toes, and some weakness of extension and

eversion of the right foot.

All the toes of both feet became slightly cyanotic when in dependent position. The peripheral arteries were neither tortuous nor thickened, the veins neither dilated nor

thrombosed. Those in the right foot filled in seconds, in the left after 15 seconds. The

veins on the right side were somewhat better filled. Sweating off both feet was moderate.

Slight pitting edema was present in the right foot and leg. There were no trophic changes.

About 10 cm, above the right internal malleolus, between the tibia and fibula anteriorly,

an abnormal pulsation was present associated with continuous thrill and bruit audible down into the foot and up to the knee. Direct pressure over the anterior tibial vessels in

this area obliterated the thrill, pulsation, and bruit, and produced drop in the pulse rate

from 72 to 67 beats per minute. When the arteriovenous fistula in the region off the right

anterior tibial vessels was obliterated by direct pressure, loud, continuous bruit was audible

posteriorly in the calf about 20 cm. above the malleolar area. There was no thrill in this

area and the bruit could be obliterated by rather broad pressure against the calf muscles

proximal to the point of maximum bruit. About 2*0 cm, above the malleoli on the posterior

medial aspect off the left leg continuous thrillcould be felt and continuous bruit was heard.

The bruit could not be obliterated by pressure in this area but ceased when the popliteal

artery was compressed.

Blood pressure varied from 126 mm. off mercury systolic and 72 (diastolic to 116 mm, off

mercury systolic and 76 (jiastolic. It did not change when all the pulses in both legs were

occluded, but the pulse rate dropped at this time from 84 to 68 beats per minute.

Skin temperatures off the toes on both feet were about equal. On one occasion, in

room at 22° C., the temperature of the toes on each foot varied from 22° to 23° C, and on

another occasion from 32.5° to 35.5° Centigrade. When the reactive hyperemia test was

carried out with the anterior tibial artery occluded, good flush began in 25 seconds and

was complete in 50 seconds. It was concluded that the patient had arteriovenous fistulas, involving the right

anterior tibial vessels and probably involving the right and left posterior tibial vessels.

The patient was given brief furlough at the conclusion off the examinations described.

On his return he complained of some discomfort in both calves on walking and some swelling

of both ankles. Examination at this time revealed moderate edema off both ankles. The

circumference at this level was 2.5 cm. greater on the right than on the left side.

On 29 December 1944 the anterior tibial vessels off the right were explored and double

fistula found between the anterior tibial artery and two anterior tibial veins. The veins

lay on either side of the artery Each off these communications was about mm. in diameter.

The involved vessels were ligated proximally and distally, and the fistula excised. The postoperative course was smooth and the patient showed no evidence off vascular insufficiency

at any time.
ANEURYSMS AND FISTULAS—GENERAL CONSIDERATIONS 179

second operation, this time on the left leg, was done January 1945 through posterolateral incision. The posterior tibial and the peroneal veins were found to be considerably dilated and to communicate through two channels. The posterior tibial vein itself

communicated through fistula about mm. in diameter with the posterior tibial artery

which also exhibited saccular aneurysm on its wall opposite to the communication. This

aneurysm was well organized and approximately cm. in diameter. The lesions were

excised and recovery was uneventful.

third operation was carried out 12 February 1945, this time to locate the second

aneurysm in the right leg. The posterior tibial artery and vein were exposed through

posteromedial incision in the calf. Both were found to be of normal size and appearance and

no thrill could be palpated in this area. Palpation beneath the gastrocnemius, however,

revealed continuous thrill on the posterior aspect of the soleus muscle somewhat medial

to the operative wound. The patient’s muscles were so large and well developed that access

to the involved area was not possible through the original incision and second longitudinal

incision was made posteriorly and directly over it. The gastrocnemius was divided in

the direction of its fibers and the soleus exposed. Within the body of the latter muscle

was found small artery, about the diameter of matchstick, which communicated with

vein about twice its size through small saccular aneurysm cm. in diameter. These vessels appeared to be muscular branches from the posterior tibial vessels. Artery and vr'n

were ligated proximally and distally and the aneurysm and communicating vessels exised.

When these procedures had been completed the thrill and bruit originally present in

this area were no longer present but fairly loud and continuous bruit could be heard somewhat lateral and cephalad to the incision. Again the bulk of the muscles prevented access

to the affected area through the original incision and third longitudinal incision was made

somewhat higher along the posterolateral aspect of the calf. When the fibers of the gastrocnemius muscle were separated and the soleus exposed, small artery was found in the body

of that muscle which communicated through fistula with vein dilated to the diameter of

almost centimeter. These vessels were thought to be muscular branches of the peroneal

vessel. The vessels communicating with it were quadruply ligated and the fistula excised.

Recovery was uneventful. diagrammatic sketch of the fistulas found is shown in Figure 14.

When his convalescence from the third operation was completed, the patient was able

to walk at reasonably brisk pace for more than mile with no resultant discomfort in the

calves of his legs. He regained fairly complete power of extension of the right foot; likewise, function of all the extensors of the toes except that of the great toe.

The extremities no longer presented any edema and there was no substantial difference

in their circumferences. Both feet were warm. Clinically the temperature appeared to be

the same on both sides, but when thermocouple was used it was found that the toes on the

right foot tended to be somewhat warmer than those on the left. In room in which the

environmental temperature was 23° C., the temperature of the toes on the right foot varied

from 32° to 33° C., and that of the toes on the left foot from 28° to 30° Centigrade. The

pulsations of the posterior tibial artery were normal on the right side but absent on the left

side. Both dorsalis pedis pulses were normal. Oscillometric readings at the ankles were 4.5

units on the right side and 3.5 units on the left at 90 mm. of mercury.

After operation the pulse was 72 beats per minute and the blood pressure 108 mm. of

mercury systolic and 72 diastolic. The cardiac size was unchanged. The predicted frontal

cardiac area for man of this patient’s height and weight was 124 square centimeters. The

actual measurements on admittance and after each of the operations were 112 square centimeters. Electrocardiograms taken before each of the operations showed no diagnostic

deformity.

The patient was returned to duty after neurosurgical consultant had agreed that the

peroneal paralysis had so nearly disappeared that no operative procedure was indicated.
180 VASCULAR SURGERY IN WORLD WAR II

Figure 4. Diagrammatic showing of location and general appearance of the four arteriovenous

fistulas present following injury by land mine. No effort has been made to draw the lesions

to scale.

Comment. Careful palpation for thrill and auscultation for bruit should

be an essential step of the final stages of operative procedures for the cure of

arteriovenous fistulas. This case illustrates the wisdom of this precaution

particularly in the battle casualty whose wounds are multiple and relatively small.
CHAPTER

Arterial Aneurysms and Arteriovenous Fistulas

Circulatory Effects of Arteriovenous Fistulas

Daniel C. Elkin, M. D.

LOCAL CIRCULATORY MANIFESTATIONS OF

ARTERIOVENOUS FISTULAS

As in lesions observed in civilian practice, the local evidences of an arteriovenous fistula were similar regardless of the site of the lesion. The most

common sign was the bruit, or murmur, which could be heard with stethoscope in the region of the fistula. In contrast to the purely systolic sound of

an arterial aneurysm, that produced by an arteriovenous fistula was continuous murmur extending through both systole and diastole. Although in

general the larger the fistula the louder the murmur, this was not always the

case. At times small fistulas produced loud murmurs. These murmurs, like

those arising from the heart, were transmitted considerable distance from

the site of origin. The chief cause of failure to hear the murmur was simply

failure to listen for it.

When the murmur was of sufficient intensity, thrill was generally felt.

Again, although somewhat indicative of the size of the fistula, the intensity

of the thrill did not offer completely reliable evidence of the size since it could

be modified by the position of the fistula and the structures overlying it.

The thrill was less well transmitted than the murmur, and was localized to an

area near the lesion.

Some arteriovenous fistulas were associated with no external evidence of

either arterial or venous dilatation. Occasionally, however, there was pulsating mass of variable size in the affected area caused by aneurysmal dilatation

of either the involved artery or vein, or by false sac in the region of the

fistula. Superficial veins near the fistula or distal to it were usually dilated

and tortuous (Fig. 15). This dilatation disappeared soon after the artery was

repaired. The pressure in the veins in the vicinity of the fistula was elevated

but the systemic venous pressure was normal. Blood withdrawn from veins

near the fistula always showed an abnormally high oxygen content.

In the region of the fistula itself the skin was warmer than normal but

in the area distal to it there were sometimes signs of circulatory insufficiency

ranging from local coolness and pallor to such severe manifestations as anemia

or gangrene. Edema sometimes developed in the area distal to the lesion.

The special studies reported in this chapter were made by James V. Warren, M. D., Emory University Hospital,

Atlanta, Qa.
182 VASCULAR SURGERY IN WORLD WAR II

Figure 16. A. Plantar arteriovenous fistula. Note dilatation and tortuosity of superficial

veins before operation. B. Same foot weeks after excision of the fistula.

Skin temperature studies and oscillometric records confirmed these clinical

observations (Chart 19). Oscillometric studies revealed increased pulsations

at the site of the fistula which diminished gradually as they were measured

proximally and distally.

When the vessels were exposed at operation the proximal artery and vein

were usually dilated. The artery distal to the fistula was likely to be small,

its size depending upon the amount of blood shunted away from it through

the fistulous communication. The vein distal to the fistula was usually dilated

because of the arterial blood shunted into it, though the enlargement was

greater on the proximal side. All collateral branches in the region of the

fistula, whether arterial or venous, were increased in size. Serial sections of

the vessel walls did not usually reveal significant changes.

CARDIAC MANIFESTATIONS OF ARTERIOVENOUS FISTULAS

Patients with arteriovenous fistulas resulting from battle injuries usually

presented no cardiac abnormalities upon physical examination. Alterations in

size were sometimes observed, but only occasionally was the increase greatly

in excess of normal standards. Whatever increase might be present could be

detected only by the subsequent decrease in the transverse diameter of the

heart as measured in teleoroentgenograms taken after operative eradication

of the fistula (Fig. 16A and B). Only on relatively infrequent occasions was

this increased size in excess of the normal standards; therefore it was noted

only by the comparison of films made before and after the removal of the

fistula. Occasionally, however, the heart became considerably enlarged.

Since the alteration was reversible and disappeared promptly after removal of

the fistula this enlargement was assumed to represent dilatation rather than

true hypertrophy. The irreversible hypertrophy occasionally seen in patients
CIRCULATORY EFFECTS OF FISTULAS 183

Chart 19. Oscillometric and skin temperature determinations in left plantar arteriovenous fistula Note that oscillations and skin temperatures are reduced distal to the lesion.

with longstanding lesions was practically never observed in patients in military

service since men were not inducted into the Army with such lesions.

It is generally recognized that in patients with arteriovenous fistulas congestive heart failure may develop, though the mechanism producing the

cardiac decompensation is in dispute. It has been variously ascribed to the

greatly increased demands on the heart and to the diminution of coronary

blood flow secondary to the lowered mean arterial pressure.

Prior to World War II studies on the cardiac output in arteriovenous

fistulas (a knowledge of which is essential in the elucidation of the altered

circulatory dynamics in these patients) had been few in number and not

330323 0—55 -13
184 VASCULAR SURGERY IN WORLD WAR II

Figure 16. Serial teleoroentgenograms in femoral arteriovenous fistula. A. Preoperative view

shows heart of increased size. B. Postoperative view shows decrease in cardiac size.

entirely consistent in results. Lewis and Drury, whose studies were made with

glass cardiometer inclosing the heart, reported in 1923 that an increase in

cardiac output was sometimes observed when an arteriovenous fistula was

open and that an increased central venous pressure was observed in association

with the elevated cardiac output. They therefore assumed that in human

subjects the cardiac output was normal when the venous pressure was normal; no actual measurements were made. In 1924, Harrison, Dock, and Holman,

who used the direct Fick technique, reported the elevation of cardiac output

in animals with experimental arteriovenous fistulas; their observations were

confirmed by number of other observers. The few studies made on clinical

subjects were much less conclusive, although in most instances the cardiac

output was found to be increased. The possibility exists that the foreign gas

methods often used in clinical studies were invalidated by the abnormal circulatory dynamics present in patients with arteriovenous fistulas.

Investigations conducted in peacetime were necessarily limited to experimental animals with artifically created fistulas and to clinical cases as they were

encountered in individual experiences. During World War II the concentration of patients with these lesions at vascular centers in the Zone of Interior

permitted studies which would be impossible except in time of war, and the

investigations carried out throw some light, both positively and negatively,

upon the alteration in circulatory dynamics caused by the presence of arteriovenous fistulas.

Lewis, T., and Drury, A. N.: Observations relating to arteriovenous aneurism. Heart 10; 301-389, Oct 1923.

Harrison, T.R.: Dock, W., and Holman, E.; Experimentalstudies inarterio-venous flstulae; cardiac output. Heart

11: 337-341, Dec 1924.
CIRCULATORY EFFECTS OF FISTULAS 185

Materials and Methods

At Ashford General Hospital the cardiac output was studied in 47 patients

with arteriovenous fistulas by means of the low frequency, critically damped ballistocardiograph (Table 13). All but of the 47 were males. The patients

were presumably normal prior to their injuries and none had evidence of frank congestive heart failure. The interval between the injury which resulted in

the arteriovenous fistula and the operative repair varied from months to

slightly over years. Definite local signs of the fistula, including thrill or

murmur near its site, were present in all patients, and in all the fistula was

demonstrated and eradicated successfully by surgical intervention. The postoperative course was without serious complications in all instances, and no

patient presented evidence of recurrence of the lesion during the period of observation.

The ballistocardiograph, which was utilized to determine the cardiac output from the ballistic recoil of the body with each heart beat, is table or bed

so suspended on four steel strips or springs that movement only in the longitudiTable 13. Preoperative and Postoperative Ballistocardiographic Observations in 47 Patients With Arteriovenous Fistulas*

’Figures In columns through are averages.

Location Number

of cases

Duration of fistula

Time in relation to operation Heart

rate Stroke

volume Cardiacindex

Change in cardiac

size

Change in blood

volume

Carotid

Months Days Cc.

Liters per minute

per sq. meter Cm. Cc. per sq. meter

70.0

73.0 116.380.3 4.5

3.7

-0.5 -440

14 after ..

Vertebral.-. 81.0

78.0

114.0

93.8

4.5

3.7

-0.2 Unknown

Subclavian 71.0

71.0

114.0

80.5 4.02.8

+1.2 -155

Axillary. 11 65.2

78.0

145.1

104.8

4.9

4.5

Unknown -200

14 after

Brachial 74.0

66.0

122.0

94.5

4.3

3.9

-0.2 +40

14 after ...

Iliac 84.0

72.0

115.8

80.0

7.1

3.2

-0.6 -453

20 after

Femoral 12 82.0

73.0

115.7

94.9

6.0

3.9

-1.2 -304

Popliteal 10 66.5

65.6

134.6

103.9

4.8

3.6

-0.3 -210

21 after

Tiblal 11 67.0

70.0

107.4

94.0

4.0

3.5

-0.2 -123
186 VASCULAR SURGERY IN WORLD WAR II

nal direction is possible. Tbe length of the springs is adjustable and the

inherent frequency of the bed can therefore be kept -constant in spite of variations in the weights of patients. When the bed is displaced it returns to its

original resting position without overshoot because it is critically damped.

Movements of the bed are recorded photographically, by means off light beam

and mirror, with -camera similar to that used in an electro-cardiograph. The

output of the heart was -calculated in the studies at Ashford General Hospital

from the measurement off several features of the baHistocardiographic tracing

and the determination off the patient’s blood pressure (Chart 20), The ballistocardiographic measurements were checked against -comparative studies by

the direct Fick technique. The observations were recorded in terms of the

cardiac index, that is, the output off the heart in liters per minute per square

meter off body surface, in order to facilitate -comparisons between individuals

of various sizes.

All determinations were made hours or more after the previous meal

and after the patient had relaxed on the ballistocardiographic table for 15

minutes or more. Arterial pressure was obtained by the auscultatory method

with an ordinary mercury manometer. The transverse cardiac diameter as

measured from teleoroentgenograms was used as an index of changes in the

size of the heart.

Although several studies had previously been made to determine the correlation between the ballistocardiograph ic method and the Fick catheter

TEMPORARY OCCLUSION OF ARTERIOVENOUS FISTULA

ARTERIAL PRESSURE

BALLISTOCARDIOGRAM

STROKE VOLUME 130 102

HEART RATE 70 59

CARDIAC OUTPUT

ATRIAL PRESSURE 30 30

'Chart 20. Effects of temporary occlusion of arteriovenous fistula on arterial pressure, strohe

volume, heart rate, oardriac (output., (and atrial pressure.
CIRCULATORY EFFECTS OF FISTULAS 187

method of measuring the cardiac output, additional studies were made as

part of this investigation to establish the validity of the ballistocardiographic

method under the conditions of the investigation. The control studies were

made on patients with arteriovenous fistulas and on others with large areas

of reactive hyperemia. Reactive hyperemia was produced by applying blood pressure cuffs around the upper parts of both legs and then inflating them

above arterial pressure for 20 minutes. The state ofreactive hyperemia which

ensued when the cuffs were released was for all practical purposes temporary

arteriovenous fistula. With the release of the cuffs the cardiac output in each

case rapidly rose to about twice the normal level.

Results

The control studies described established the validity of the ballistocardiograph as means of measuring the output of the heart. Excellent correlation

was obtained.

The blood pressure showed little variation from the preoperative to the

postoperative period. In the cases in which change occurred, the tendency

was toward diminution of the pulse pressure after operation chiefly because of

an elevation of the diastolic pressure.

When the normal resting cardiac output, that is the postoperative value, was compared with the preoperative cardiac output, the latter was found to

range from 21 percent below, to 127 percent above the former (Chart 21).

(For correct interpretation of these results it is necessary to bear in mind that

variations of as much as 25 percent above or below the value selected as the

resting cardiac output can be expected in normal subjects when repeated

measurements are made at different times.)

The postoperative alteration in cardiac output was obviously the result of

change in stroke volume rather than of change in pulse rate. When the

fistula was intact the basal pulse rate was above 85 in only of the 47 patients,

the vessels involved in these patients were the femoral vessels in patients,

the iliacs in 2, and the subclavian in 1. The cardiac output in this group of

patients before operation ranged from 32 to 127 percent (average 82 percent)

above the postoperative level (Chart 22).

Comment

It is fortunate that the ballistocardiographic method of studying the

cardiac output is apparently accurate since it possesses several important advantages over other methods now available: (1) From the patient’s standpoint

this is the simplest of all methods since he merely lies on the table completely

relaxed and does not have to endure the psychologically disturbing effects of

the introduction of needles or the use of rebreathing apparatus. (2) Repeated

determinations can easily be made on the same subject. (3) Extremely rapid

changes in cardiac output, which cannot be observed by other methods, can

be studied by this method.
188 VASCULAR SURGERY IN WORLD WAR II

EFFECT OF A-V FISTULA ON CARDIAC OUTPUT

Chart 21. Effects (in percentages of normal values) of arteriovenous fistula on cardiac output.

The shaded bars represent the variation of increase and the black bars the variation of

decrease. change of less than 25 percent in cardiac output is considered within the range

of normal variation. Note that only J)0 of the 47 patients studied are depicted in the chart

inasmuch as readings were not obtained on 7.

FEMORAL ARTERIOVENOUS FISTULA

PULSE

RATE STROKE

VOLUME

CARDIAC

INDEX

BEFORE OPERATION

81 204 9.0

AFTER OPERATION

73 14 4.5

Chart 22. Ballistocardiographic observations before and after excision of femoral arteriovenous

fistula.
CIRCULATORY EFFECTS OF FISTULAS 189

The person-to-person variability in cardiac output is large and in this

series the postoperative cardiac index varied considerably from patient to

patient but the range was similar to that found in comparable normal subjects

studied by the catheter method by Stead, Warren, Merrill, and Brannon. If

necessary, the investigation at Ashford General Hospital could have been

carried out by using the average normal value obtained by this study, but all

the patients in the series returned to normal state after operation without

evidence of residual abnormality in the circulation, and there seemed full justification for utilizing individual postoperative values as the basis for estimating

the load placed on the heart by the fistula before operation.

Since variation of 25 percent above and below the postoperative cardiac

index could be expected in any group of subjects, change after operation

within this range could not be attributed to the effect of the fistula on the circulation. In 22 of the 47 patients, approximately 47 percent, the postoperative

alteration was within this range. In the other 25 patients the cardiac output

when the fistula was open was more than 25 percent greater than the output

after it had been closed at operation, the altered values ranging from 25 to 127

percent. In other words, slightly more than half of the 47 patients with arteriovenous fistulas studied by the ballistocardiographic method had significantly

elevated cardiac output before operation as measured under basal conditions.

It was difficult to estimate the functional size of the fistula from either

clinical or pathologic evidence. The size of the vessel involved and the intensity

of the thrill or the murmur were not entirelyreliable in predicting the increase in

the cardiac output, though in general, clinical evidence of large fistula or of the

presence of fistula located in large vessel was associated with the greatest

increase in cardiac output. An analysis of the 47 cases showed that while all

of the patients with the most appreciable increase in cardiac output had fistulas

involving relatively large vessels, the relationship appeared to be no more specific. fistula involving the femoral vessels might be associated with large

increase in the cardiac output, but did not necessarily cause it. On the other

hand fistula fed by small vessel, because of the limited arterial inflow, produced at the most small increase in the cardiac output. The increase in the

cardiac output is perhaps, as Starr’s studies indicate, the best index of the

load placed on the circulation by an arteriovenous fistula.

When an attempt was made to correlate the duration of the fistula with the

increase in cardiac output it was found that in general the greatest increases in

cardiac output occurred in association with fistulas ofrelatively short duration,

and vice versa. reasonable explanation of this observation is that larger fistulas were promptly diagnosed (and the patients sent immediately to the vascular

centers), while small fistulas were frequently overlooked for long periods of time.

Stead, E. A., Jr.; Warren, J. V.; Merrill, A. J., and Brannon, E. S.: Cardiac output in male subjects as measured by

the technique of right atrial catheterization; normal valueswith observations on the effect of anxiety and tilting. J. Clin.

Investigation 24: 326-331, May 1945.

Starr, I.: Clinical studies; with the balllstocardiograph in congestive failure, on digitalis action, on changes in

ballistic form, and certain acute experiments. Am. J. M. Sc. 202: 469-485, Oct 1941.
190 VASCULAR SURGERY IN WORLD WAR II

Cardiac enlargement, as demonstrated by an increased transverse cardiac

diameter in teleoroentgenograms, is recognized as frequent accompaniment of

arteriovenous fistula. The increase is reversible and the heart returns to its

normal size after the fistula is corrected. An attempt to correlate the change

in the transverse diameter of the heart following operation on the patients in

this series with the degree of increase in cardiac output resulted in correlation

coefficient of 0.12, which is not significant. This lack of correlation suggests

comparison with the observations made in arterial hypertension in which the

amount of cardiac enlargement cannot be directly correlated with either the

degree or the duration of the increased arterial pressure. Given patients with

the same degree of hypertension, may have marked cardiac enlargement and

the other no enlargement at all. Such was the case in instances of cardiac

enlargement associated with arteriovenous fistula in this series.

From these studies it may therefore by concluded that many, though by no

means all, patients with arteriovenous fistulas have distinct elevations of the

cardiac output as result of the lesion, with return to values apparently normal

after correction of the fistula. These observations are in accord with previous

observations.

Why the increased cardiac output occurs is question of considerable

interest. Most textbooks stress the importance of the filling pressure of the

ventricles, that is, the pressure in the atria and the great veins, but this is not

an adequate explanation; The studies by Starr and his associates, corroborated

in this series, show that in patients with large areas of reactive hyperemia there

may be decided change in cardiac output without any change at all in right

atrial pressure.

With this change eliminated as the explanation of the increased cardiac

output in association with arteriovenous fistulas, changes in the arterial tree

offer possible explanation. When the fistula is open there is definite reduction in peripheral resistance. Ballistocardiographic studies show that when

the fistula is compressed and then released, changes in stroke volume and heart

rate are almost instantaneous. The evidence indicated that the alteration in

cardiac output is predominantly the result of change in stroke volume rather

than pulse rate and is related to change in the arterial tree rather than to an

increase in filling pressure presented to the right side of the heart. An increase in cardiac output also occurs in clinical conditions in which the

circulatory dynamics are altered as they are altered in arteriovenous fistulas.

In patent ductus arteriosus, for instance, which is actually an arteriovenous

fistula between the aorta and the pulmonary artery, such an increase was reported by Eppinger, Burwell, and Gross. During the later months of pregStarr, I.; Rawson, A. J.; Schroeder, H. A., and Joseph, N. R.: Studies on the estimation of the cardiac output in

man, and of abnormalities in cardiac function, from the heart’s recoil and the blood’s impacts; the ballistocardiogram.

Am. J. Physiol. 127: 1-28, Aug 1939. Eppinger, E. C.; Burwell, C. S., and Gross, R. E.: Effects of the patent ductus arteriosus on circulation. J. Clin.

Investigation 20: 127-143, Mar 1941.
CIRCULATORY EFFECTS OF FISTULAS 191

nancy the cardiac output is almost always elevated, and Burwell has pointed

out that in many ways the placenta behaves like modified arteriovenous fistula.

The studies carried out at Ashford General Hospital furnish no direct

evidence concerning cardiac failure in patients with arteriovenous fistulas. It

seems possible, however, that in this condition just as in patent ductus arteriosus, severe anemia, and thyrotoxicosis, failure occurs when the cardiac output is far above normal. In arteriovenous fistula one would not necessarily

expect low cardiac output to indicate circulatory inadequacy, though cardiac

failure would not necessarily develop in patients with the highest cardiac outputs. The resistance of the cardiovascular system to stress varies widely from

person to person and the amount of overwork which causes failure in one subject

would not necessarily cause it in another.

The explanation is probably along the lines suggested by Starr and Jonas

for cardiac failure in thyrotoxicosis: It occurs in patients in whom the heart is

not able to increase its output to meet increased demands, which means that

normal cardiac output in patient with extreme hyperthyroidism may be taken

to indicate the possibility of cardiac failure. Similarly, cardiac failure might

be expected to develop in patients with arteriovenous fistulas in whom the cardiac

output does not increase to compensate for the loss of effective output by way

of the fistula.

The combination of normal cardiac output and large fistula might

therefore be more indicative of cardiac insufficiency than large cardiac output

per se. If this reasoning is correct, it furnishes an additional explanation of the

inability in this investigation to correlate cardiac enlargement or elevated blood

volume directly with the increase in cardiac output.

THE BLOOD VOLUME IN ARTERIOVENOUS FISTULAS

Holman, 10 in 1924, seems to have been the first to report an increase in

blood volume in animals in which arteriovenous fistulas had been produced,

with return to normal level following the removal of these lesions. In his

method the dye brilliant vital red was used to determine the blood volume.

Four minutes after the dye was injected sample of blood was drawn. The

five animals in which he had produced particularly large arteriovenous communications all showed an increased blood volume, and in general the increase

appeared to be related to the size of the fistula. Similar blood volume studies

were reported later in clinical cases of arteriovenous fistulas, the increased blood

volume in most instances returning to normal after correction of the lesions. 11

Burwell,C. S.: Placenta as modified arteriovenous fistula considered inrelation to the circulatory adjustments to

pregnancy. Am. J. M. Sc. 195; 1-7, Jan 1938.

Starr, I., and Jonas, L.: Supernormal circulation in resting subjects (hyperkinemia), with study of the relation of

kinemicabnormalities to the basal metabolic rate. Arch. Int. Med. 71: 1-22, Jan 1943. 10 Holman, E.: Experimental studies in arteriovenous fistulas; blood volume variation (pt 1). Arch. Surg. 9: 822-836,

Nov 1924.

11 (1) Holman, Emile: Arteriovenous Aneurysm. Abnormal Communication Between Arterial and Venous Circulations. New York, The Macmillan Company, 1937. (2) Holman, E.: Clinical and experimental observations on arteriovenous fistulae. Ann. Surg. 112: 840-875, Nov 1940.
192 VASCULAR SURGERY IN WORLD WAR II

In Rowntree and Brown’s blood volume studies 12 on patients with

arteriovenous fistulas, of which were congenital, the average value for the

group was slightly above normal but only patient showed distinct elevation.

Pemberton and Saint 13 reported finding somewhat elevated value in single

patient with congenital arteriovenous communication. In view of their own

observation on patients, studied before and after operation, Reid and

McGuire 14 expressed some doubt concerning changes in the blood volume in

arteriovenous fistulas. In the first case there was no essential change. In the

second there was decrease of 1,000 cc. after operation, but months later the

value was the same as before operation. The same authors reported slight

increase in the blood volume in experimental animals with arteriovenous

fistulas. Ellis and Weiss, 16 who used Evans blue dye T-1824 to study single

patient before operation, found the blood volume within normal limits.

Kennedy and Burwell 16 found greatly elevated blood volume before operation in patient with multiple arteriovenous communications; the fistulas

recurred in this case and there was considerable fluctuation in the postoperative

results.

The methods used in the early studies of the blood volume in arteriovenous

fistulas are open to many theoretical and practical objections. The later observations mentioned, which are not open to these objections, are limited in

number. For these reasons, advantage was taken of the concentration of

patients with arteriovenous fistulas in the vascular centers of the Zone of

Interior to attempt more conclusive studies on the blood volume in the presence

of these lesions.

Materials and Methods

The blood volume was studied at Ashford General Hospital in 41 patients

with arteriovenous fistulas by means of the blue dye T-1824 (Table 14). All

the lesions followed trauma. The patients, of whom was woman, were all

young adults and all apparently healthy prior to injury. At the time of the

investigation none had complicating injuries or illnesses which might have

altered the blood volume.

Blood vessels in all parts of the body were involved. Every patient presented the physical signs characteristic of arteriovenous fistulas and in no instance was there any evidence of frank cardiac decompensation. The interval

between wounding and operation varied from months to little over years.

Rowntree, Leonard Q., and Brown, George E.: The Volume of the Blood and Plasma In Health and Disease. Philadelphia, W. B. Saunders Company, 1929. 13 Pemberton, J. de J., and Saint, J. H.: Congenitalarteriovenouscommunications. Surg., Qynec. Obst. 46:470-483,

Apr 1928.

14 Reid, M. R., and McGuire, J.: Arteriovenousaneurysms. Ann. Surg. 108: 643-693, Oct 1938. 13 Ellis, L. B., and Weiss, S.: Local and systemiceffects ofarteriovenous fistula on the circulationin man. Am. Heart

J. 5: 63S-647, Jun 1930. 16 Kennedy, J. A., and Burwell, C. S.: Measurements of the circulation in patient with multiple arteriovenous connections. Am. Heart J. 28: 133-148, Aug 1944.
CIRCULATORY EFFECTS OF FISTULAS 193

Table 14. Preoperative and Postoperative Blood Volume Studies in 41 Patients

With Arteriovenous Fistulas*

Figures In columns through 10 are averages.

In every case the fistula was successfully excised, with no complications postoperatively. Thiopental sodium anesthesia or continuous spinal analgesia was

used.

Determinations of the blood volume were made under basal conditions, at

least 12 hours after the last meal and before patients had risen in the morning.

With the exception of the determinations made on the third postoperative day,

all preoperative and postoperative studies were made on patients who were

ambulatory.

The plasma volume was measured with blue dye T-1824, as recommended

by Gregersen, Gibson, and Stead. 17 Blood samples were drawn from the antecubital veins. The syringes used were dry and in order to avoid hemoconcentration, tourniquets were not used. Following withdrawal of the dye-free

sample, cc. of the dye (0.1-percent solution) were injected from calibrated

17 Gregersen, M. I.; Gibson, J. J., and Stead, E. A.: Plasma volume determination with dyes; errors in colorimetry;

use of the blue dye T-1824. Am. J. Physiol. 113 54-55, Sep 1935.

Location

Number of

cases

Duration of fistula

Time in relation to operation Plasma

volume Hematocrit

Total

blood

volume

Deviation

from normal blood vol- ume

Total

plasma

protein

Cardiac size

Months Days Cc. Cc. cells inlOOcc. Cc. Cc. per sq. meter Om.% Cm.

Carotid 3. before

21 after

2650.

2420.

48.

44.

5100.

4385.

-440 6.

6.

-1.

Subclavian 3. before

12 after

2848.

2932.

49.

46.

5540.

5387.

-168 6.

6.

0.

Axillary 8. 12 before

20 after

2990.

2806.

47.

46.

5700.

4947.

-123 6.

6.

-5.

Brachial 3. before

10 after

2620.

2970.

47.

49.

5053.

5220.

90 6.

6.

-0.

Iliac 6. 14 before

14 after

3146.

2667.

44.

46.

5616.

4957.

-365 6.

6.

-0.

Femoral 13 6. before

14 after

2972.

2618.

47.

49.

5645.

5169.

-284 6.

6.

-1.

Popliteal 6. before

15 after

2827.

2856.

49.

47.

5584.

5476.

-76 6.

6.

-0.

Tibial 8. before

20 after

2735.

2661.

45.

45.

5068.

4865.

-117 6.

6.

-0.
194 VASCULAR SURGERY IN WORLD WAR II

syringe which was then rinsed three times with blood. Care was taken to

prevent extravascular loss of the dye. If any loss occurred, note was made

of it. Exactly 10 minutes after the dye had been injected, sample of blood

was obtained with the proper precautions against hemolysis and hemoconcentration. In some cases an indwelling needle was left in place and serial samples

were obtained to determine the rate of disappearance of the dye.

The blood samples were placed in small tubes where they were covered

with mineral oil and allowed to clot and retract before they were gently centrifuged. Any sample which showed evidence of lipemia or hemolysis was discarded.

The concentration of the dye T-1824 was determined by measuring the

light absorption of the dye-containing serum sample in relation to the dye-free

sample at wave length of 620 millimicrons with Coleman Junior spectrophotometer or with Nickerson decade photometer. 18 The apparatus had

previously been calibrated with known amounts of dye in serum.

The plasma volume was calculated from the single 10-minute point as

suggested by Gregersen and Rawson, 16 or from the dye concentration value

obtained from extrapolation of the disappearance curve plotted on semilogarithmic scale. The total blood volume was determined from the plasma

volume and the hematocrit reading. To facilitate comparisons between patients of different sizes, the blood volume per square meter of body surface was

also calculated.

When the dye-free blood specimen was withdrawn, sufficient blood was also

obtained for hematocrit readings, and determinations of hemoglobin and total

protein. Heparin was used as the anticoagulant in the hematocrit tubes. The

hemoglobin concentration was determined by measuring the optical density of

dilute alkaline solution of blood. The total protein value was determined by

the density method of Barbour and Hamilton. 20

Many of the patients in whom blood volume studies were made underwent

additional studies including determination of the cardiac output by means of

the ballistocardiograph and estimations of the size of the heart by measurement

of the transverse cardiac diameter on teleoroentgenogram.

Results

In the 41 patients studied, the blood volume per square meter of body surface ranged before operation from 2,400 cc. to 4,030 cubic centimeters. Ten

days or more after operation the values ranged from 2,330 cc. to 3,380 cc., the

alterations varying from decrease of 1,060 cc. to an increase of 190 cubic

centimeters. In 23 cases, approximately 56 percent of the series, the change

was less than 200 cubic centimeters. In 18 patients, 44 percent of the series,

18 Nickerson, J. L.: Portable decade photometer for determination of blood volume with the dye T-1824. Rev.

Scient. Instruments 15: 69-72, Mar 1944. 19 Gregersen, M. I., and Rawson, R. A.: Disappearanceof T-1824and structurally related dyes from the blood stream.

Am. J. Physiol. 138; 698-707, Apr 1943. 20 Barbour, H. G., and Hamilton, W. F.: Blood specificgravity; its significance and new method forits determination. Am. J. Physiol. 69: 654-661, Aug 1924.
CIRCULATORY EFFECTS OF FISTULAS 195

there was postoperative decrease in the blood volume which ranged from 200

to 1,060 cc. per square meter. In no patient was the rise following operation

greater than 200 cc. (Chart 23). These data were confirmed in most instances

by serial observations.

Plasma volume fluctuated as did the total blood volume. Hematocrit

readings varied only slightly but more often than not showed tendency to

fall slightly after operation. Calculated red blood cell volume underwent

similar changes. Changes in hemoglobin values and total protein concentration were not significant.

Comment

Technical Methods. The blue dye T-1824 had been widely used for the

determination of the plasma volume. In this series two methods were originally employed, the semilogarithmic plotting of disappearance of the dye, as

recommended by Gregersen and Rawson, 21 and the examination of the single

dyed specimen obtained 10 minutes after injection of the dye as recommended

by Gregersen 22 for certain situations. The latter method, simpler to perform,

proved as reliable as an extrapolated value for dye concentration obtained from

the disappearance curve of the dye. Gregersen’s results with the two methods

were obtained in normal subjects and in subjects in shock. In the cases in this

series in which both methods were used there was no evidence that the disappearance rate of the dye was affected by the presence of the arteriovenous fistula, and the plasma volume obtained by both methods was substantially the

same. After the reliability of both methods had been established by comparative studies, Gregersen’s 10-minute method was used almost exclusively because

its simplicity permitted serial determinations of the plasma volume of large

number of patients who were available for study for limited time only. No

patient in this series had frank congestive heart failure; however, there is

possibility that the prolonged mixing time of the dye in this type of case might

invalidate the 10-minute method.

The calculation of total blood volume from the hematocrit reading and

plasma volume has been criticized adversely by some observers on two counts:

(1) the imperfection of the peripheral venous hematocrit reading as evidence of

the proportion of cells in the blood throughout the body, and (2) the failure of

the hematocrit reading to indicate the true cell-plasma ratio because of plasma

trapped among the cells. These determinations proved useful in this series,

however, because comparative observations were made in the same persons

with minimal hematocrit changes.

In this study total blood volume was determined instead of plasma volume

because the body appears to maintain it at constant level at the expense of

the cell-plasma ratio and hence it is more stable value. Plasma volume ap21 See footnote 19, p. 194. 22 Gregersen, M.I.: Practical method for determination ofblood volume with the dye T-1824. J. Lab Clin. Med.

29: 1266-1286, Dec 1944.
196 VASCULAR SURGERY IN WORLD WAR II

EFFECT OF A-V FISTULA

ON BLOOD VOLUME

EXPRESSED AS CHANGE IN BLOOD VOLUME

PER SQUARE METER OF BODY SURFACE

FOLLOWING OPERATIVE REMOVAL

Chart 23. Effects on blood volume (expressed as changes per square meter of body surface of excision of arteriovenous fistula. The shaded bars represent the variation of increase and

the black bars the variation of decrease. change of 200 cc. in blood volume is considered

within the range of normal variations. Note that only 35 of the 41 patients are depicted in

the chart inasmuch as readings were not obtained for 6.

parently varies rapidly to compensate for changes in red cell volume because

the body can mobilize fluid and protein withrelative rapidity. Studies on the

effect of simple hemorrhage by Ebert, Stead, and Gibson 23 indicate that changes

in plasma volume occur with slow readjustment of the red cell volume and

hematocrit reading to the normal value. Similar changes might be seen soon

after an operation in which blood loss and dehydration have occurred. For

these reasons plasma volume is subject to much more fluctuation than is total

blood volume, and information concerning it was of less value for the purposes

of this study than evidence of changes in total blood volume.

23 Ebert, R. V.; Stead, E. A., Jr., and Gibson, J. G., Jr.: Response ofnormal subjects to acute bloodloss, with special

reference to the mechanism ofrestoration ofblood volume. Arch. Int. Med. 68: 578-590, Sep 1941.
CIRCULATORY EFFECTS OF FISTULAS 197

Although some of the postoperative measurements calculated on these patients were made relatively soon after operation, they were delayed long

enough to escape any immediate effects of the procedure, for example, blood

loss and dehydration. Only observations made 10 days or more after operation

were used in the calculation of normal values; by this time almost all the patients

were ambulatory. The average blood volume per square meter of body surface was approximately 2,800 cc., which is within the same range as the values

reported for normal male subjects by Gibson and Evans. 24

Results. The majority (23) of the 41 patients in this series showed

difference of less than 200 cc. between the preoperative and postoperative blood

volumes per square meter of body surface. Such change, which amounted to

only about percent of the normal value, might have been expected as result

of technical errors in the determinations, i. e., factors introduced by the operation and bed rest without regard to the presence of the arteriovenous fistula and

its eradication. On the other hand, although in no instance was the postoperative increase in blood volume greater than 200 cc., 18 patients, almost 44 percent, showed postoperative decrease greater than 200 cubic centimeters. In

several instances serial observations showed the decline to be in progress by the

third day after operation and to be apparently complete by the 10th day.

Observations made on these patients were in agreement with previous

observations to the effect that blood volume may be significantly elevated in

patients with arteriovenous fistulas. This is not, however, an inevitable reaction, since elevations were observed in only 18 of the 41 patients studied. Previous studies had supplied no satisfactory explanation of the alteration, and an

attempt was therefore made to relate it to other alterations in the circulation

observed in patients with arteriovenous fistulas at the vascular center of

Ashford General Hospital.

The possibility that the increase in blood volume might be related to the

size of the fistula was investigated. In this series or patients with the

most extreme elevations in blood volume had fistulas which involved the iliac

vessels. It was difficult, however, to establish this explanation because the

exact size of the fistula could rarely be determined. Clinical evidence, such

as the size of the vessels involved and the intensity of associated thrills and

murmurs, supplied some data concerning the magnitude of the shunt of blood,

but was obviously not accurate. Actual measurement of the fistulous opening

at time of operation did not prove successful because of vascular spasm, and

measurement of the specimen after removal was unsatisfactory for the same

reason and because tissue fixation resulted in shrinkage.

As was pointed out previously in this chapter, the resting level of cardiac

output is above normal in many patients with arteriovenous fistulas. Since

it is possible that the elevation of the cardiac output above normal may be

21 Gibson, J. O., and Evans, W. A., Jr.: Clinical studiesof the blood volume; relation of plasma and totalblood volume

to venous pressure, blood velocity rate, physical measurements, age and sex In 90 normal humans. J. Clin. Investigation

16; 317-328, May 1937.
198 VASCULAR SURGERY IN WORLD WAR II

proportional to the size of the fistula, an attempt was made to correlate this

increase with the increase in the blood volume. In order to avoid the difficulties

inherent in the range in basal cardiac output in the series, blood volume change

was plotted against percentage deviation from normal in cardiac output. In

other words, if cardiac output before operation was twice the basal value determined after operation, an increase in cardiac output of 100 percent was plotted.

The coefficient thus obtained, 0.26, did not indicate any significant correlation.

In spite of the negative results just reported, it was still thought possible

that the size of the fistula might be at least one of several factors responsible

for the increased blood volume observed in some patients with arteriovenous

fistulas. It has been well established by roentgenologic methods that in this

lesion the heart may increase in size with the development of the fistula but

return to normal size after the fistula is removed. In view of the evidence

already existing that the size of the heart is related to the magnitude of the

blood volume, an attempt was made to correlate these measurements in the

29 patients in the series who had preoperative and postoperative teleoroentgenograms, which in some instances were serial. Changes in the blood volume

were plotted against changes in the transverse diameter of the heart as measured

on the teleoroentgenogram. The correlation coefficient thus obtained, 0.36,

indicated that the degree of correlation between these values was not significant.

It cannot be said that these results were surprising. Earlier studies by

Weens, Brannon, and Warren 25 had shown that in normal subjects rapid

increase in blood volume of about 1,000 cc. fails to produce any distinct change

in the heart size. It is true that Holman 26 was able to produce changes in the

size of the heart in dogs when he increased or decreased the blood volume,

but these experimental changes were of much greater magnitude than those

observed clinically in arteriovenous fistulas. change of 500 cc. in dogs

would be, roughly equivalent to change of 4,000 cc. in human subject. In

neither of the studies just mentioned was the increase in blood volume accompanied by an increase in extracellular fluid volume, which might alter the

situation considerably. It seems likely that other factors than cardiac size,

such as the increased demand placed on the heart, may play major role in

the increase in blood volume in arteriovenous fistulas.

An attempt to relate the increase in the blood volume to the duration of

the arteriovenous fistula proved unsuccessful because few patients in this

series had large fistulas of long duration. The lesions of longest duration, as

already mentioned, were usually of small size, for which reason many of them

had been overlooked originally by both patients and medical attendants.

The results of the study of arteriovenous fistulas at Ashford General

Hospital thus produced no explanation for the elevation sometimes observed

in blood volumes with the onset of the lesion or for the return to normal levels

after its eradication. This is scarcely surprising, since the basic factors con25 Weens, H. S.; Brannon, E. S., and Warren, J. V.: Unpublished data. 26 See footnote 10, p. 191.
CIRCULATORY EFFECTS OF FISTULAS 199

trolling the size of the blood volume in normal subjects are still imperfectly

understood.

Holman 27 advanced the opinion that the increase in blood volume merely

compensates for the loss of blood through the fistula. His apparently interchangeable use of the terms blood volume and volume of blood flow somewhat

confuses the explanation.

Reid and McGuire’s suggestion 28 was that the increase in blood volume

seen in patients with arteriovenous fistulas represents merely the nonspecific

increase in blood volume seen in patients with congestive heart failure of any

type and is not the specific result of the presence of the arteriovenous fistula.

Although none of the patients studied at Ashford General Hospital developed

the complete clinical picture of cardiac failure, it seems possible that there

might have been similar mechanism at work in the cases in which an increase

in blood volume was observed. Warren and Stead 29 pointed out that in

patients with chronic congestive heart failure the increase in blood volume,

as well as certain other abnormalities in fluid dynamics, could be explained

by deficient output of the heart rather than, as it is usually explained, by

increased venous pressure. If this explanation is correct, it may be that the

mechanism of the increase in blood volume in patients with arteriovenous

fistulas is similar: In cardiac failure the circulation would be inadequate because

of the inability of the heart to pump blood. In arteriovenous fistula the blood

flow would be inadequate because much of the cardiac output is shunted

through the fistula.

Previously in this chapter attention was called to the similarity between

cardiac output in arteriovenous fistulas and conditions such as patent ductus

arteriosus and pregnancy, i. e., increase of cardiac output through alteration

of circulatory dynamics. Although the mechanism by which the increase in

blood volume observed in arteriovenous fistulas is attained is not fully understood, the basic explanation may be an increase in the production of blood.

When some large venous channels are engorged with blood, as they are when

this lesion is present, the amount of blood remaining in the rest of the vascular

bed would be less than normal unless increased production of blood were

stimulated.

THE EFFECT ON HEART RATE, STROKE VOLUME, AND CARDIAC OUTPUT OF TEMPORARY OCCLUSION OF ARTERIOVENOUS FISTULAS

Slowing of the heart rate, the most commonly recognized result of temporary occlusion of an arteriovenous fistula, was first described by Nicoladoni 30

27 See footnote 11 (1), p. 191. 28 See footnote 14, p. 192. 29 Warren, J. V., and Stead, E. A.: Fluid dynamics In chronic congestive heart failure; interpretationof the mechanisms producing the edema, increased plasma volume and elevated venous pressure in certain patients with prolonged

congestive failure. Arch. Int. Med. 73: 138-147, Feb 1944. 30 Nicoladoni, C.: Phlebarteriectasle derrechten oberen Extremist. Arch. f. klin. Chir. 18: 252-274, 1875.

330323 0—55 14
200 VASCULAR SURGERY IN WORLD WAR II

in 1875. In 1890 Branham 31 also described it without knowledge of the

previous description, and it is now usually referred to as Branham’s sign.

Further observations on this sign, and on the effect on the stroke volume and

cardiac output of temporary occlusion of arteriovenous fistulas, were made on

group of patients with these lesions at the vascular center of Ashford General

Hospital (Table 15).

Table 15. Preoperative and Postoperative Studies of Effects of Temporary

Occlusion in 25 Patients with Arteriovenous Fistulas*

Figures in columns through are averages

Materials and Methods

The investigation was carried out on 25 patients with arteriovenous

fistulas of traumatic origin, none of whom presented clinical evidence of cardiac

decompensation or of any complicating disease which might be expected to

alter the response of the vascular system. They formed part of the group

upon whom studies of the cardiac output had been made but were limited to

those with lesions of the extremities.

The patient under investigation was placed in the critically damped

ballistocardiograph described earlier in this chapter and blood pressure cuff

bound about the affected extremity in such way that when it was deflated

there was no interference with the venous blood flow. The fistula was occluded

by rapidly raising the pressure in the cuff to 200 mm. of mercury from pressure

bottle system. To familiarize the patient with the method and to be certain

that no discomfort was connected with it, the procedure was carried out

31 Branham, H. H.; Aneurismal varix of the femoral artery and vein following gunshot wound. Internat. J. Surg.

250-251, Nov 1890.

Location Number

of cases

Duration of fistula

Time in relation

to operation

Fistula

occluded

Heart

rate Strokevolume

Arterial

pressure

Cardiac

index

Months Days Cc. Mm. Hg.

Liters per minute per

sq. meter

Brachial before. No.. 70. 126. 128/80

125/80

4.

before Yes.. 54. 115. 3.

after 68. 105. 122/67 4.

Femoral before No.. 77. 132. 119/91

118/74

5.

before Yes.. 61. 104. 3.

15 after __

69. 93. 115/74 3.

Popliteal 10 before No.. 65. 135. 118/58

117/82

4.

11 before Yes.. 55. 102. 3.

17 after 65. 103. 115/49 4.

Tibial... 11 before No.. 67. 107. 122/10 4.

before Yes.. 63. 91. 124/79 3.

23 after 68. 95. 114/66 3.
CIRCULATORY EFFECTS OF FISTULAS 201

several times before the ballistic records were begun. Ballistic tracings and

arterial blood pressure determinations by the auscultatory method were obtained with the fistula open and with it occluded. At least sets of observations were made on each patient. In patients the observations were repeated after mg. of atropine sulfate had been injected intravenously and

enough time had elapsed for it to exert its maximum effect (Table 16). In all

patients after operative removal of the fistula another ballistocardiographic

record was made.

Results

Ballistocardiographic tracings showed that when the arteriovenous fistula

was suddenly occluded, 17 of the 25 patients showed decrease in the heart

rate ranging from to 32 beats per minute. In the other patients decrease

also occurred but it was less than beats.

In 19 patients the stroke volume of the heart decreased more than 10 cc.

when the fistula was suddenly occluded. The effect of occlusion on the cardiac

index (the cardiac output in liters per minute per square meter of body surface)

varied from no change at all to decrease of 3.6 liters. In 22 of the 25 patients

the decrease was 0.5 liter or more. Under the conditions of the study, 0.5

liter probably represented the minimal detectable change.

Changes in arterial pressure following occlusion of the fistula were seldom

marked. The diastolic pressure increased almost constantly; the increase in

the systolic pressure was less frequent.

In all patients in whom additional studies were made after injections of

atropine, an increased pulse rate was observed. In some instances this was

accompanied by an increase in the cardiac index over the basal level. When

the fistula was occluded, although the change in the pulse rate did not exceed

beats per minute in any case, stroke volume was altered in every instance.

Decline in the cardiac index was from 1.0 to 2.2 liters per minute per square

meter; that in cardiac output was from 1.8 to 4.2 liters (Table 16).

Comment

The ballistocardiograph was not altogether ideal for the purposes of this

study because it prevented the use of manual compression for the occlusion of

the arteriovenous fistula. Since this compression would have interfered with

the movements of the ballistic bed, blood pressure cuff was used which meant

that not only the fistula itself was occluded but all the circulation of the extremity distal to the cuff as well. Observations on normal subjects, however,

and on the normal extremities of patients with arteriovenous fistulas elsewhere

in the body, showed practically no change in the cardiac output or pulse rate

when it was employed. For comparative purposes, the Matas compressor,

which occludes only the major vessel entering the fistula, was tested in

patient. Response of heart rate and cardiac output was the same by both

methods.
202 VASCULAR SURGERY IN WORLD WAR II

Table 16. Preoperative Studies of Effects of Temporary Occlusion With and

Without Atropinization in Patients with Arteriovenous Fistulas

'In each case the dose of atropine was mg. Intravenously,

After atropinization.

The results of this investigation further confirmed the well-accepted fact

that closure of an arteriovenous fistula is usually accompanied by slowing of

the heart rate, though the specific stimulus which results in the bradycardic

response is not clearly understood, just as the mechanism producing the change

is still to be elucidated. The speed of the reaction suggests that nervous

reflex may be involved. It has been suggested that the vascular bed in and

around the fistula may take on function similar to that assumed in carotid

sinus or aortic depressor areas in that local pressure changes are reflected by

reflex changes in cardiac function. This does not seem likely. Observations

by Gerlach and Harke,32 which were confirmed by observations at the vascular

center ofAshford General Hospital, show that Branham’s sign can be produced

when patient is under high spinal analgesia and when the area of the fistula

82 Gerlach, F., and Harke, W.: Compressionofarteriovenous aneurysms. Klin. Wchnschr. 3: 980-981, May 1924.

Location Fistula

occluded Heartrate Strokevolume Arterial

pressure Cardiacoutput Cardiac

Index

Cc. Mm. Hg Liters per minute

Liters per minute per sq. meter

FemoraL. No 83 124 110/60 10. 5.

Yes 61 107 115/70 6. 3.

No 100 123 125/85 12. 7.

Yes 104 83 145/95 8. 4.

Femoral No 76 158 120/55 12. 6.

Yes 44 139 125/70 6. 3.

No 93 105 130/85 9. 5.

Yes 94 84 150/90 7. 4.

Popliteal No 83 140 115/60 11. 6.

Yes 62 110 115/70 6. 3.

No 123 127 135/90 15. 8.

Yes 119 102 140/100 12. 6.

Popliteal No 62 93 110/60 5. 3.

Yes 59 70 115/75 4. 2.

No 102 86 120/65 8. 5.

Yes 102 62 130/85 6. 4.

TibiaL No 71 132 120/60 9. 5.

Yes 57 120 120/80 6. 3.

No 98 100 140/90 9. 5.

Yes 96 59 160/100 5. 3.
CIRCULATORY EFFECTS OF FISTULAS 203

is presumably devoid of functional nervous connections, though it is not certain

that functional denervation is complete.

Lewis and Drury 33 found it possible to block the slowing of the heart

rate produced by occlusion of the fistula by preliminary administration of

atropine and the same result was observed in the patients in this series in

which this method was used. Ellis and Weiss, 34 and Kramer and Kahn, 35

made the same observations. Rieder’s negative results 36 can probably be explained by the use of inadequate dosages. The effect of atropine has been interpreted as evidence that the pulse-slowing response is mediated not only

by nervous mechanism in general but by the vagus nerve in particular.

According to the results of this investigation, occlusion of the fistula also

produces striking decrease in the stroke output of the heart. This decrease,

together with the decrease in the heart rate, results in reduction of the cardiac

output. The stroke volume reduction, however, is independent of the change

in the heart rate, and atropine which can abolish the change in the heart rate

does not affect the reduction in the stroke volume (Chart 24).

BALLISTOCARDIOGRAM PULSE STROKE CARDIAC

RATE VOLUME INDEX

86 140 6.2

62 NO 3.5

120 151 9.3

120 94 5.8

FISTULA

OPEN

FISTULA

OCCLUDED

AFTER ATROPINE

FISTULA OPEN

AFTER ATROPINE

FISTULA OCCLUDED

Chart 24. Ballistocardiographic studies in popliteal arteriovenous fistula before and after intravenous administration of mg. of atropine sulfate. Note that after administration of

the drug the pulse rate rises but is not slowed when the fistula is occluded, although the stroke

volume and cardiac index both decrease.

Changes in the stroke volume occur very promptly, significant alterations

appearing within the first three heart beats after the fistula is occluded. On

theoretical grounds three possible mechanisms might be responsible: (1) change

in the emptying of the heart, (2) variation in the degree of diastolicrelaxation

of the ventricles, and (3) change in the pressure gradient producing filling

33 See footnote 2, p. 184. 34 See footnote 15, p. 192. 33 Kramer, M., and Kahn, J. H.: Unpublished data. 33 Rleder, W.: Heart impairment due to arteriovenous aneurysm. Arch. f. kiln. Chir. 139 597-606, 1926.
204 VASCULAR SURGERY IN WORLD WAR II

of the ventricles. If either of the first two processes is responsible, the mechanism must be under nervous control because of the rapidity with which changes

in the stroke volume appear. It is not likely that the vagus forms part of the

reflex pathway since atropine, which suppresses the vagal control of the heart

rate, does not affect the stroke volume. If change in the pressure gradient

causing filling of the ventricles is responsible for the change in the stroke

volume, it also occurs rapidly. Studies of catheterization of the right side of

the heart carried out by Nickerson, Warren, and Brannon 37 indicate that no

significant change occurs in the mean right atrial pressure when the fistula is

closed, though there are large changes in the stroke volume. The conclusion

that there is no change in the pressure gradient causing filling of the heart is

not necessarily correct, however, since pressure gradient cannot be determined by measuring the pressure at single point in system.

Changes in cardiac output and stroke volume similar to those described

in these 25 patients with arteriovenous fistulas occurred in normal subjects

upon the production of large areas ofreactive hyperemia. When blood pressure

cuffs were placed about the upper thigh and inflated to 200 mm. of mercury

pressure, little change in the heart rate and cardiac output was noted. When

the pressure was continued for 20 minutes and observations were made as it

was released, increases in heart rate and cardiac output were almost double

the prepressure levels. These changes, as in the patients with arteriovenous

fistulas, occurred without significant alteration in the atrial pressure.

In general, the output of the heart following temporary occlusion of an

arteriovenous fistula was almost the same as the output under similar conditions

several weeks after operative removal of the fistula. Since the cardiac output

is highly variable function changing markedly under the influence of even

the emotional content of thought, it is difficult to say whether the lack of exact

coincidence in the values represented real difference in output, dependent

upon the length of time the fistula was closed, or merely represented variation

in the conditions under which the values were obtained.

It was not possible in these studies to confirm Holman’s observation 38 that

proximity of the fistula to the heart is important in the cardiac output. The

size of the fistula and of the vessels feeding it seemed more important than its

position in determining the amount of blood flowing through it. Fistulas close

to the heart were associated with both large and small increases in cardiac

output.

SUMMARY AND CONCLUSIONS

The concentration of casualties with vascular injuries in vascular centers

in general hospitals in the Zone of Interior in World War II presented an

unparalleled opportunity for the study of certain phases of arteriovenous

3? Nickerson, J. L.; Warren, J, V., and Brannon, E. S.; Cardiac output in man; studies with the low frequency,

critically-damped ballistocardiograph and the method of right atrial catheterization. J. Clin. Investigation 26: 1-10,

Jan 1947.

38 See footnote 11 (1), p. 191.
CIRCULATORY EFFECTS OF FISTULAS 205

fistulas. This chapter is the record of the studies carried out at the vascular

center at the Ashford General Hospital.

The investigation included studies of the local and systemic effects of

arteriovenous fistulas on the circulation and of their effect on the size of the

heart, the cardiac output, and the blood volume.

In many of the subjects both the cardiac output and blood volume were

elevated above normal level and the size of the heart was somewhat increased.

After operative eradication of the fistula there was practically uniform return

of all three to normal. None of the patients under investigation developed

frank congestive heart failure.

Studies carried out after temporary occlusion of arteriovenous fistulas

included slowing of the pulse rate (Branham’s sign), which is apparently

mediated by the vagus nerve, and almost immediate lowering of the cardiac

output and stroke volume of the heart, the latter reaction apparently being

nervous reflex related to the sudden change in resistance against which the

heart must pump. The pulse pressure decreases on occlusion of the fistula

because of the rise in diastolic pressure, thus returning the character of the

pulse to normal.

In spite of the information secured by these various studies, rational

and more nearly complete explanation of the genesis of the effects of an arteriovenous fistula on the circulation must await an extension of basic knowledge

concerning the circulatory system.
CHAPTER VI

Arterial Aneurysms and Arteriovenous Fistulas

Alterations in the Cardiac Size

in Arteriovenous Fistulas

Harris B. Shumacker, Jr., M. D.

Although numerous instances of cardiac enlargement associated with the

presence of arteriovenous fistulas were recorded prior to the outbreak of

World War II, these reports, for the most part, concerned only individual

cases or small groups of cases. No series large enough to supply statistical

data were on record and such conclusions as had been arrived at concerning

this phenomenon were based, therefore, on clinical impressions. The experience in World War II altered this situation. At the vascular center of

Mayo General Hospital detailed studies of the heart size before and after

operative removal of the traumatic arteriovenous fistula were carried out on

large number of patients with this type of lesion. These studies have made possible certain conclusions based on factual data.

MATERIALS AND METHODS

The studies reported in this chapter were carried out on 185 soldiers with

traumatic arteriovenous fistulas which in all but few instances followed

combat-incurred injuries. Only patient was woman and most of the

group were young adults.

Clinical Manifestations. This series does not include any patient in

whom organic heart disease was known to exist. While number of patients

complained of dyspnea on exertion, palpitation, or distressing pounding of

the heart especially when recumbent, many others who presented roentgenologic evidence of considerable increase in cardiac frontal area complained

of no symptoms which were referrable to the heart.

Among the 185 soldiers there were only instances of frank cardiac

failure. In the episode occurred before the first roentgenologic examination

was made. This patient had traumatic fistulas, involving the external iliac

vessels and involving the hypogastric vessel. The severe dyspnea, orthopnea,

and edema originally present after his injury disappeared after resection of the

iliac fistula in hospital overseas. Although his heart was still enlarged he

was relatively asymptomatic between the first operation and the second,

when excision of the hypogastric fistula brought about further decrease in

the cardiac frontal area.
ALTERATIONS IN CARDIAC SIZE IN FISTULAS 207

The second patient with frank cardiac failure, whose cardiac frontal

area had progressively increased in size, became extremely orthopneic when he

experienced small pulmonary infarction and Streptococcus viridans septicemia as the result of infection of the fistula (see Chapter IV). After the

fistula had been excised he was relieved of all symptoms and the heart returned

to normal size.

Methods. Teleoroentgenograms were made in all 185 patients in the

series, usually both before and after operation. The predicted and actual

frontal areas of the cardiac silhouette were calculated according to the method

of Ungerleider and Gubner, calculations of the predicted values being made

according to the height and weight of the patients on their admission to the

vascular center.

Before operation, whenever the location of the fistula permitted it, several

determinations of the blood pressure and pulse, with and without occlusion

of the fistula, were made. The precise findings at operation were recorded

in each patient; in most instances these observations included actual measurements or careful estimation of the size of the fistula.

ANALYSIS OF DATA

Regional Distribution. An analysis of the 185 patients with arteriovenous

fistulas from the standpoint of location of the lesion (Table 17), showed that

in 131 these involved vessels of the pelvis and lower extremity, while in 54,

vessels of the head, neck, and upper extremity were affected. (There were 53

patients with fistulas of the femoral artery—the highest number for any

single vessel.)

Age Distribution. The age range in this series was 19 to 46 years; average

age was 24.5 years. The age range varied somewhat in the different anatomic

groups (Table 17), but average ages for patients with lesions of the pelvis and

lower extremity (24 years) and for lesions of the head, neck, and upper extremity

(25.7 years) were not widely different. The lowest average age, 22.4, occurred

in patients with lesions of the femoral artery and the highest, 27.7 years, in

those with lesions in the miscellaneous group of vessels in the upper part of

the body not segregated into special categories.

Duration of Fistula. The time interval between injury and operation in

these 185 patients varied from 1.0 to 30.0 months and averaged 5.4 months

(Table 18). However, there was little difference in the average duration of the

fistula in most of the regional categories. The highest average duration, 9.2

months, was in the category which included the profunda femoris, hypogastric,

obturator, and superior gluteal arteries and can probably be explained by the

small number of cases (9) in this group. The data on the time interval between

injury and the final preoperative roentgenogram and between operation and the

final postoperative roentgenogram are given in Table 18 and require no special

comments.

Ungerleider, H. E., and Gubner, R.: Evaluation ofheart size measurements. Am. Heart J. 24: 494-510, Oct 1942.
208 VASCULAR SURGERY IN WORLD WAR II

Table 17.—Location of Lesion and Age Distribution

Table 18. Interval in Months Between Injury and Preoperative Roentgenogram,

Between Injury and Operation, and Between Operation and

Postoperative Roentgenogram

Location of fistula Number of patients Age range Average

age

Years Years

Pelvis and lower extremity 131 19-45 24.

Femoral 53 19-34 22.

Popliteal 36 19-45 25.

Profunda femoris, hypogastic, obturator, superior gluteaL 20-27 22.

Vessels of leg 33 19-34 25.

Head, neck, and upper extremity 54 20-46 25.

Carotid, vertebral 14 20-46 27.

Subclavian, axillary 17 20-41 22.

Brachial 21-35 26.

Other vessels of head, neck, and upper extremity* 14 20-34 27.

Total 185 19-46 24.

*This group includes fistulas of the ulnar, radial, posterior circumflex humeral, thoracoacromial, subscapular, transverse cervical, occipital, and lingual vessels.

Interval between (in months)

Location of fistula

Number of patients

Injury and last preoperative

roentgenogram

Injury and operation

Operation and final postoperative

roentgenogram

Range Average Range Average Range Average

Pelvis and lower extremity 131 0. 8-26. 4. 1. 3-30. 5. 0. 1-8. 1.

Femoral 53 1. 2-19. 4. 1. 3-20. 4. 0. 2-8. 2.

Popliteal 36 0. 8-10. 4. 1. 8-10. 5. 0. 1-7. 1.

Profunda femoris, hypogastric, obturator, superior

gluteal 3. 0-26. 8. 4. 0-30. 9. 0. 1-2. 1.

Vessels of leg 33 1. 2-10. 4. 1. 6-14. 5. 0. 2-7. 1.

Head, neck, and upper extremity. 54 0. 7-15. 4. 1. 0-15. 5. 0. 1-6. 1.

Cartoid, vertebral 14 0. 7-10. 4. 1. 0-10. 4. 0. 2-1. 0.

Subclavian, axillary 17 1. 5- 8. 4. 1. 5- 9. 4. 0. 4-5. 2.

Brachial 1. 7- 4. 3. 2. 0- 6. 4. 1. 0-3. 2.

Other vessels of head, neck,

and upper extremity* 14 3. 4-15. 5. 4. 5-15. 7. 0. 1-6. 1.

Total 185 0. 7-26. 4. 1. 0-30. 5. 0. 1-8. 1.

*This group includes fistulas of the ulnar, radial, posterior circumflex humeral, thoracoacromial, subscapular, trans- verse cervical, occipital, and lingual vessels.
ALTERATIONS IN CARDIAC SIZE IN FISTULAS 209

MEASUREMENTS OF THE CARDIAC FRONTAL AREA

Preoperative measurements of the cardiac frontal area were made in 153

of the 185 patients in this series, postoperative measurements were made in

161, and both preoperative and postoperative measurements in 132 (Tables 19,

20, and 21).

Table 19. Proportionate Distribution of Preoperative Measurements of the

Cardiac Frontal Area

Control Measurements. It proved impossible because of the heavy workload in this vascular center to take measurements of the cardiac frontal area

in comparable group of soldiers without arteriovenous fistulas but with

otherwise similar physical and nutritional states. In the true sense of the term,

therefore, this series provides no data of control group. An analysis was

made, however, of the final postoperative cardiac measurements in 119 patients

whose fistulas had been removed by operation and whose preoperative measurements had not exceeded 115 percent of normal (Chart 25). Excluded from this

group were patients in whom there was great increase in heart size before

operation, in whom it seemed likely that hypertrophy as well as dilatation of

the heart might have occurred, and in whom some degree of cardiac enlargement might have persisted after operative removal of the fistula.

Location of fistula Number of patients

Cardiac frontal area*

<85 85-105 106+ ni+ 116+ 121+ 126+

Pelvis and lower extremity. 108 1. 36. 62. 50. 37. 27. 15.

Femoral. 39 0. 15. 84. 74. 53. 48. 28.

Popliteal 33 3. 30. 66. 51. 36. 27. 15.

Profunda femoris, hypogastric, obturator, superior

gluteal 0. 83. 16. 0. 0. 0. 0.

Vessels of leg 30 3. 59. 36. 26. 23. 6. 3.

Head, neck, and upper extremity 45 6. 55. 37. 29. 18. 11. 2.

Carotid, vertebral. 11 9. 45. 45. 27. 0. 0. 0.

Subclavian, axillary 13 0. 76. 23. 15. 0. 0. 0.

Brachial 11. 33. 55. 44. 44. 22. 11.

Other vessels of head, neck,

and upper extremity. 12 8. 58. 33. 33. 33. 25. 0.

Total 153 3. 41. 54. 43. 31. 23. 11.

•Measurements of cardiac frontal area are expressed in percentages of predicted area.
210 VASCULAR SURGERY IN WORLD WAR II

Table 20. Proportionate Distribution of Postoperative Measurements of Cardiac Frontal Area

Table 21. Proportionate Distribution of Postoperative Alterations in Cardiac Frontal Area

Location of fistula Number of patients

Cardiac frontal area

<85 85-105 106+ ni+ 116+ 121

Pelvis and lower extremity.._ 118 6. 65. 28. 18. 11. 5.

Femoral. 51 3. 64. 31. 21. 15. 7.

Popliteal

Profunda femoris, hypogastric, ob31 9. 58. 32. 25. 9. 9.

turator, superior gluteal 25. 63. 11. 0. 0. 0.

Vessels of leg 28 3. 75. 21. 10. 7. 0.

Head, neck, and upper extremity. 43 13. 63. 23. 4. 0. 0.

Carotid, vertebral 11 18. 72. 9. 0. 0. 0.

Subclavian, axillary 15 26. 46. 26. 6. 0. 0.

Brachial ...

Other vessels of head, neck, and

0. 75. 25. 0. 0. 0.

upper extremity 13 0. 69. 30. 7. 0. 0.

Total 161 8. 64. 26. 14. 8. 4.

•Measurements of cardiac frontal area are expressed in percentages of predicted area.

Location of fistula Number of

Decrease* No essen- tial change* Increase*

patients

6+ 11+ 16+ 21+ ±5 6+

Pelvis and lower extremity 99 63. 44. 28. 10. 32. 4.

Femoral 38 79. 52. 44. 13. 18. 2.

Popliteal. 29 65. 55. 31. 17. 27. 6.

Profunda femoris, hypogastric, obturator, superior gluteal 42. 42. 14. 0. 57. 0.

Vessels of leg 25 44. 20. 4. 0. 62. 4.

Head, neck, and upper extremity.. 33 42. 30. 18. 9. 54. 3.

Carotid, vertebral 44. 22. 22. 11. 55. 0.

Subclavian, axillary 10 40. 40. 30. 20. 60. 0.

Brachial 25. 25. 0. 0. 50. 25.

Other vessels of head, neck, and upper extremity 10 50. 30. 10. 0. 50. 0.

Total 132 58. 40. 25. 9. 37. 3.

•Alterationsare expressed in percentage ofchange from preoperative values.
ALTERATIONS IN CARDIAC SIZE IN FISTULAS 211

Chart 25. Distribution of measurements of cardiac frontal area {in terms of predicted area)

after operative cure of arteriovenous fistulas in 119 patients in whom the preoperative measurements had not exceeded 115 percent of the predicted. Note that the majority of the

values fall within the 85-105 percent range.

In these 119 patients (Chart 25) the postoperative measurements of the

cardiac frontal area tended to center around 95 percent of the calculated predicted values. Almost three-fourths of the patients (74.8 percent) had measurementsranging from 86 to 105 percent of predicted values. In 11.8 percent

actual measurements were less than 85 percent of predicted values, and in

13.4 percent they were higher than 105 percent of these values. When 100

percent of the predicted value was used as the presumed normal figure,

smaller number of patients (69.8 percent) fell into the ±10 percent range,
212 VASCULAR SURGERY IN WORLD WAR II

and the measurements in the remaining patients were less evenly distributed.

Only 5.0 percent of the patients then had values in excess of 110 percent while

25.2 percent had values lower than 90 percent of the predicted values.

Comparative Preoperative-Postoperative

Measurements of the Cardiac Frontal Area

Preoperative measurements were made on 153 patients (Table 19, Charts

26 and 27). Of these, 54.9 percent had measurements of the cardiac frontal

area in excess of 105 percent of the predicted values; in 11.8 percent they

exceeded 125 percent of these values. Forty-one and eight-tenths percent

had measurements between 85 and 105 percent of the predicted size, while 3.3

percent showed measurements less than 85 percent of this size.

Postoperative measurements of the cardiac frontal area were made on 161

patients (Table 20, Charts 26 and 27). In contrast to preoperative values, postoperative measurements were in excess of 105 percent of the predicted size

in only 26.7 percent of those tested, while in no instances were these measurements in excess of 125 percent. After operation almost two-thirds of the patients (64.6 percent) had measurements in the 85-105 percent of the predicted

range, while 8.7 percent had measurements less than 85 percent of the predicted size.

On 132 patients both preoperative and postoperative measurements were

made (Table 21, Chart 28). In 37.9 percent there was no essential difference

in the postoperative as compared to the preoperative values. In 3.8 percent

slight increase in cardiac size was recorded after operation. Nearly 60 percent

of the patients, however, showed reduction of percent or more in cardiac

size after operation, while in 9.8 percent of the patients the decrease was 21

percent or more.

Influence of Special Factors on Cardiac Measurements

When the preoperative and postoperative measurements of the cardiac

frontal area were compared in special categories of fistulas, wide differences

immediately became apparent (Tables 19, 20, and 21, Chart 29). As rule, patients with femoral and popliteal fistulas tended to show greater increases

in the cardiac size before operation than those with fistulas in other locations,

and patients with fistulas of the pelvis and lower extremities tended to show

cardiac enlargements more frequently than those with fistulas in the upper

part of the body. similar, but less pronounced, difference was apparent

when these two groups were compared with respect to the degree of reduction

in the cardiac size after operation.

Further analysis of the data suggested direct relationship between the

size of the fistula and the degree of cardiac enlargement. Fistulas in the

vessels of the leg, for instance, which were generally small as compared with

fistulas of the femoral and popliteal vessels, showed less cardiac enlargement

than the group with femoral and popliteal lesions. In order to evaluate this
ALTERATIONS IN CARDIAC SIZE IN FISTULAS 213

PREOPERATIVE

POSTOPERATIVE

Postoperative interval I2M25 includes all patients with measure

ments in excess of 121.)

Chart 26. Distribution of measurements of cardiac frontal area (in terms of ■predicted area in

163 patients before and in 161 patients after operative cure of arteriovenous fistula.

observation more exactly, the degree of cardiac enlargement was analyzed in 36 femoral and 31 popliteal arteriovenous fistulas of approximately the same

duration and in which the size was known (Table 22). It was evident that

those wuth larger fistulas tended to show more cardiac enlargement. When

popliteal and femoral fistulas of roughly the same size were compared, it

seemed evident that the femoral fistulas were associated with more cardiac

enlargement; this appeared logical since the femoral arteries were larger in diameter and their fistulas closer to the heart. Indeed, the increase in cardiac

frontal area was as great in the smaller femoral fistulas as in the larger popliteal

fistulas.

similar comparison of the preoperative cardiac measurements in small

number (34) of subclavian, axillary, popliteal, and femoral arteriovenous

fistulas of approximately the same diameter (7 mm. or more) and approximately the same duration (from 3.1 to 6.5 months) supported the evidence

already adduced for femoral and popliteal arteriovenous fistulas (Table 23).

Although the numbers are small, the analysis indicates that femoral fistulas
214 VASCULAR SURGERY IN WORLD WAR II

PREOPERATIVE

POSTOPERATIVE

Chart 27. Proportionate distribution of measurements of cardiacfrontal area in percentage of predicted area in 153patients before and in 161 patients after operative cure of arteriovenous fistula.

Table 22. Proportionate Distribution of Cardiac Enlargement in Relation to Size of Fistula in Patients with Popliteal and Femoral Arteriovenous Fistulas

Location of fistula Number of Size of

Cardiacfrontal area*

patients fistula 106+ 111+ 116+ 121+ 126+

Popliteal and Femoral 40

Mm.

85. 77. 55. 45. 25.

Popliteal 17 70. 64. 47. 35. 17.

Femoral 23 95. 87. 60. 52. 30.

Popliteal and Femoral 27 <8 70. 48. 33. 29. 18.

Popliteal 14 <8 64. 35. 21. 14. 14.

Femoral 13 <8 76. 61. 46. 46. 23.1

’Measurements of cardiac frontal area are expressed in percentages ofpredicted area.
ALTERATIONS IN CARDIAC SIZE IN FISTULAS 215

DECREASE INCREASE NO ESSENTIAL

CHANGE

Chart 28. Proportionate distribution of alteration in cardiac frontal area in 132 patients after operative cure of arteriovenous fistula.

are likely to be associated with the greatest increases in cardiac frontal area,

and subclavian and axillary fistulas with the least. The popliteal, axillary,

and subclavian vessels were roughly equal in size; the femoral vessels were

larger. On the other hand, the subclavian and axillary arteriovenous fistulas

were closest to the heart and the popliteal fistulas the most distant.

An analysis of the possible relationship of the duration and size of the

fistula to the preoperative measurements of the cardiac frontal area (Table

24) revealed that in 31 popliteal fistulas in which the time element was essentially the same, the size of the heart could be correlated with the size of the

fistula; smaller fistulas were associated with smaller heart size and larger

fistulas with larger heart size. Thirty-six femoral arteriovenous fistulas were

similarly studied. The fistulas associated with the greatest increase in cardiac

frontal area were larger fistulas of longer duration than those associated with

less cardiac enlargement.

330323 0—55 15
216 VASCULAR SURGERY IN WORLD WAR II

Table 23. Proportionate Distribution of Preoperative Cardiac Frontal Area in

Variously Located Fistulas Millimeters or More in Diameter and

prom 3.1 to 6.5 Months Duration

CAUDAD TO HEART

CEPHALAD TO HEART

PREOPERATIVE

CARDIAC FRONTAL AREA

POSTOPERATIVE

DECREASES IN CARDIAC

MEASUREMENTS

Chart 29. Comparative distribution of preoperative measurements of cardiac frontal area (in

percentages of predicted values) and of postoperative decreases (percentages of preoperative

values) in fistulas caudad and cephalad to the heart. The preoperative values for the fistulas of the pelvis and lower extremities caudad to the heart are based upon 108 patients and for the fistulas of the head, neck, and upper extremities cephalad to the heart in patients.

The postoperative values are based, for the corresponding fistulas, upon 99 and S3 patients,

respectively.

Cardiac frontal area*

Location of fistula <106 106-115 116+

Number of patients Percent Numberof patients Percent Numberof patients Percent

Popliteal 27. 36. 36.

Femoral 5. 38. 10 55.

Subclavian and axillary 60. 40.

•Measurements of cardiacfrontalarea are expressed in percentages of predicted area.
ALTERATIONS IN CARDIAC SIZE IN FISTULAS 217

When 22 popliteal and 28 femoral arteriovenous fistulas of large size (7 mm.

or more in diameter) were analyzed in relation to the duration of the lesion and

the increase in the measurements of the cardiac frontal area (Table 25), some

relationship between the two variables appeared to exist: The group of patients

in whom the greatest increases in cardiac size had occurred included the majority

of cases ofrelatively longest duration.

Table 24. Relationship of Duration and Size of Fistula to Preoperative Cardiac Frontal Area

Table 25. Relationship of Duration of Fistula to Preoperative Cardiac Frontal

Area in Patients with Popliteal and Femoral Fistulas of Large Size

(Diameter of mm.

Serial preoperative determinations were made in 39 patients in this series

(Table 26). In 18 the cardiac frontal area was the same at the first and last

examinations and in the changes in terms of the predicted size were less than

percent in one direction or the other. In other patients the heart size on

the last examination had decreased by from to 11 percent and in the remaining

12 it had increased by from to 33 percent. It may be of interest to note that

in of the 14 patients in which the interval between examinations was weeks

or more, an increase in the size of the heart was noted on the second examination.

Serial postoperative determinations of the heart size were made in 24

patients (Table 27). In 15 there was no essential change between the first and

last examination; in the heart had increased in size, and in there was

Location of fistula

Cardiacfrontal area 110% of predicted or less* Cardiac frontal area 111% ofpredicted or more*

Number

ofpa- tients

Duration of fistula Patients

with

fistulas

of mo. duration

or more

Number

of pa- tients

Average

size of fistula

Duration of fistula Patients

with

fistula

of mo. duration

or more

size of fistula Range Average Range Average

Mm. Months Months Percent Mm. Months Months Percent

Popliteal 15 7. 1. 6-10. 4. 40. 16 9. 2. 0-10. 4. 31.

Femoral.. 6. 2. 0-8. 4. 12. 28 9. 1. 6-19. 8. 39.

•Measurementsof cardiac frontal area are expressed in percentagesof predicted area.

Cardiacfrontal area 110%of predicted orless* Cardiac frontal area 111% of predicted or more*

Duration of fistula months Duration of fistula months)

Location of fistula <2.5 2.6-4.0 4.1+ <2.5 2.6-4.0 4.1+

Number of patients

Percent

Number of patients

Percent

Number

of patients

Percent

Number of

patients

Percent

Number of patients

Percent

Number of patients

Percent

Popliteal. 30. 30. 40. 8. 33. 58.

Femoral. 25. 75. 8. 33. 14 58.

Both.. 28. 42. 28. 8. 12 33. 21 58.

‘Measurements of cardiac frontal area are expressed in percentages ofpredicted area.
218 VASCULAR SURGERY IN WORLD WAR II

decrease of percent or more in cardiac size between the first and last postoperative examinations. In approximately two-thirds of the patients the

interval between examinations was month or more.

Table 26. Comparison of Cardiac Frontal Area in Patients in Whom More than

One Measurement Was Made Before Operation

First examination Last examination

Location of fistula Size

Duration Cardiac

size* Duration Cardiacsize*

Femoral ___

Mm.

10

Months

1. 100

Months

3. 126

Femoral 2. 123 3. 123

Femoral. 3. 81 4. 114

Femoral 1. 110 2. 110

Femoral 2. 124 3. 124

Femoral 15 9. 102 12. 122

Femoral 5. 118 6. 118

Femoral 3. 118 4. 110

Femoral 10 3. 114 4. 114

Femoral 3. 126 4. 126

Femoral __ __ 3. 106 7. 127

Femoral 10 2. 111 6. 111

Femoral __

10 3. 104 4. 124

Femoral 12 3. 121 4. 121

Popliteal 1. 105 3. 116

Popliteal 5. 95 6. 108

Popliteal 10 2. 127 3. 127

Popliteal 4. 108 5. 108

Popliteal 1. 93 2. 93

Popliteal 4. 114 5. 110

Popliteal 4. 119 121

Popliteal ______ 10 3. 125 4. 125

Popliteal 4. 110 6. 130

Popliteal 10 6. 132 8. 132

Popliteal 10 3. 105 4. 112

Popliteal 10 2. 113 4. 102

Popliteal- 15 3. 125 4. 125

Profunda femoris__ 5. 92 6. 92

Superior gluteal <5

<5

6. 100 6. 92

Obturator 3. 116 5. 107

Geniculate ___ <6 5. 103 6. 103

Posterior tibial <5

<5

2. 101 4. 97

Posterior tibial- 1. 97 2. 97

Posterior tibial <5 2. 84 3. 90

Posterior tibial. 3. 90 4. 90

Subclavian. 10 3. 97 4. 100

Axillary. 3. 88 3. 90

Internal carotid 1. 94 3. 115

Ulnar. ____

7. 107 15. 118

‘Measurements of cardiac frontal area are expressed in percentages of predicted area.
219 ALTERATIONS IN CARDIAC SIZE IN FISTULAS

Table 27. Comparison of Cardiac Frontal Area in Patients in Whom More Than

One Measurement Was Made After Operation

Finally, the response of the pulse, systolic and diastolic blood pressure,

and pulse pressure to temporary occlusion of the fistula was correlated with

the frontal cardiac measurements in terms of the predicted heart size (Chart

30). Only 20 to 30 percent of the patients who showed minimal or moderate

response to occlusion of the fistula had distinct degrees of cardiac enlargement,

while between 47 and 69 percent of those who showed maximal response to it

also showed maximal increases in the size of the heart.

COMMENT

Although it is now well recognized that arteriovenous fistulas are likely

to cause an increase in the cardiac output, enlargement of the heart, and in

some instances cardiac failure, it is interesting to note that these potentialities

have been appreciated only during the last 25 years.

Location of fistula

First examination Last examination

Interval

after operation

Changes in cardiac size from

preoperative values*

Interval

after operation

Changes in cardiac

size from preoperative values*

Months Months

0. 12% decrease. 6. 19% decrease.

0. 21% decrease. 2. 21% decrease.

2. 4% increase 3. 4% increase.

0. 14% decrease 3. 16% decrease.

0. 12% decrease 4. 17% decrease.

1. 4. 17% decrease.

0. 8% decrease 2. 16% decrease.

0. 30% decrease. 2. 30% decrease.

1. 21% decrease 2. 16% decrease.

1. 12% decrease. 4. 12% decrease.

1. 15% decrease 2. 15% decrease.

0. 4% decrease 7. 4% decrease.

0. 13% decrease. 8. 13% decrease.

0. 16% decrease. 1. 16% decrease.

0. 0. 9% decrease.

0. 2% decrease 1. 6% decrease.

1. 3. 1% decrease.

1. 4% decrease 1. 0.

0. 1. 0.

0. 4% decrease. 4. 20% decrease.

0. 16 increase 1. 8% increase.

0. 24% increase. 2. 24% increase.

1. 13% decrease 1. 13% decrease.

0. 8% decrease 1. 20% decrease.

•Alterations are expressed in percentages of variation from the preoperative value.
220 VASCULAR SURGERY IN WORLD WAR II

<106%

106-115%

M6%

OF PREDICTED HEART SIZE

PULSE RATE

DECREASE

SYSTOLIC

BLOOD

PRESSURE

INCREASE

PERCENTAGE OF

CASES DIASTOLIC

BLOOD

PRESSURE

INCREASE

PULSE

PRESSURE

DECREASE

MINIMAL MODERATE MAXIMAL

MAGNITUDE OF RESPONSE

Chart 30. Comparative measurements of cardiac frontal area {in percentages of predicted value)

in relation to magnitude of response of pulse and blood pressure to temporary occlusion of

the fistula. The measurements are based upon 145 patients.

In discussion of arteriovenous fistulas in 1915, Osier wrote:

... we all agree, think, with the conclusion arrived at by Soubbotitich, senior surgeon

of the Belgrade State Hospital, from his experience in the Balkan War, ‘that arteriovenous aneurysms should be operated upon, as they offer small prospect of spontaneous

cure, although they often remain stationary for long time and cause relatively little

trouble.’

Osier, Sir W.: Remarks on arterio-venous aneurysm. Lancet 1: 949-955, May 16.
ALTERATIONS IN CARDIAC SIZE IN FISTULAS 221

Osier’s convictions on the matter, however, must have been lukewarm

at best, since in reference to one of his own patients he wrote:

The tumor had increased, and the question was whether it was safe to leave him alone.

This was the policy urged strongly. Twice he narrowly escaped operation. [Italics not

in original.]

When he enumerated the end results of arteriovenous fistulas Osier did

not mention the possibility of cardiac strain and failure, although later in the

same paper he did state:

Remote effects on the general circulation are rare, particularly in aneurysms of the

vessels of the head and arms. One of my patients died from heart disease which

may have had some connection with his long-standing lesion.

As Reid wrote in 1925:

...

it has taken the profession long time to establish cause and effect between

arteriovenous fistulas, in vessels smaller than the aorta, and the cardiac disturbances

they produce. So often we remain blind to the insidious conditions that shorten the

duration of human lives. Although Osier for years followed two cases of arteriovenous

aneurysms (one axillary, the other femoral) in which the patients died from cardiac

disease at the early ages of 29 and 46, he was never, unless possibly shortly before his

death, convinced of the causal relationship existing between the two conditions; and for

long time he counselled against operations on arteriovenous aneurysms.

Since Osier was the acknowledged leader of his profession, there can be

little doubt, as Reid intimates, that the best medical opinion of his day was

in agreement with his point of view.

Between 1920 and 1924 Reid, Matas, and Holman all pointed out the

profound effects of arteriovenous fistulas upon the heart. Their clinical experience was necessarily limited by the infrequency of these lesions, but their

observations were confirmed by the important experimental studies of Reid

and Holman. Since that time number of instances of cardiac enlargement

and cardiac failure in association with arteriovenous fistulas have been placed

on record, particularly in recent years. Though most of the instances of

frank cardiac failure have occurred in patients with large arteriovenous fistulas

of long duration, number have been recorded in which failure occurred soon

after the appearance of the fistula. Mason, for example, reported remarkable case in which failure occurred within few weeks after the appearance of

traumatic subclavian arteriovenous fistula.

Reid, M. R.: Abnormal arteriovenous communications, acquired and congenital; effects of abnormal arteriovenous

communications on the heart, blood vessels and other structures. Arch. Surg. 11: 25-42, Jul 1925.

Reid, M. R.: Effect of arteriovenous fistula upon the heart and blood vessels. Bull. Johns Hopkins Hosp. 31:

43-50, Feb 1920.

Matas, R.: On the systemic or cardiovascular effects of arteriovenous flstulae; general discussion based upon

the author’s surgicalexperience. Tr. South. S. A. 36: 623-681, 1923.

(1) Holman, E.; The physiology of an arteriovenous fistula. Arch. Surg. 7: 64-82, Jul 1923.

(2) Holman, E.: Experimental studies in arteriovenous fistulas; cardiac dilatation and blood vesselchanges. Arch.

Surg. 9; 856-879, pt. 2, Nov 1924.

See footnote 4, above.

See footnote 6, above.

Mason, J. M.: Extreme cardiac decompensation following traumatic arteriovenous fistula ofleft subclavian vessels.

Am. J. Surg. 20; 451-473, May 1933.
222 VASCULAR SURGERY IN WORLD WAR II

Because most recorded cases of arteriovenous fistulas concern individuals

or small groups, the literature supplies little information concerning the incidence of cardiac enlargement in patients with this condition. Holman 10

noted that cardiac dilatation and hypertrophy, although they had been mentioned in only percent of the 447 cases collected by Callander, 11 had been

present in of the 21 cases which he himself reviewed from the Johns Hopkins

Hospital.

Postoperative decreases in the cardiac measurements have also been

recorded. Pendergrass 12 examined 32 patients in whom arteriovenous fistulas

had been removed surgically and found that 27 showed an average decrease

of 1.18 cm. in the cardiac diameter. One of the remaining patients had an

increase in cardiac size after operation and in the other patients there was

no essential change.

The method proposed by Ungerleider and Gubner 13 for measuring the

frontal area of the heart has proved as reliable as any other method devised

for this purpose and was used in this study. In calculating the predicted

frontal area, the height and weight of the patient on admittance to the hospital

were employed and the values so calculated were used in each patient for determining the percent of the predicted value in all subsequent examinations.

Had the predicted value been recalculated at each subsequent examination,

apparent decreases in the cardiac frontal area would probably have been

observed in most patients even if no change had actually occurred because

most of the patients gained weight after they had been admitted to the vascular

center, and, according to the tables for estimation, the predicted frontal area

for patient of any given height increases as the weight increases.

It is unfortunate that no “normal” values in similar group of young

soldiers without fistulas and in comparable state of nutrition were available

for study. The tables used for determination of the predicted cardiac frontal

area use 100 percent as normal, and it is generally accepted that values which

differ by more than 10 percent from those predicted should be regarded as

abnormal. Had this 100 percent been used as normal in this series, large

number of the postoperative measurements would have seemed less than normal.

An analysis of the final postoperative measurements of the cardiac frontal

area in 119 patients cured of arteriovenous fistulas showed that they did indeed

tend to center around 95 percent of the predicted values rather than 100

percent. Those which were beyond the limits of zf 10 percent of the control

values were evenly distributed, about one-half above and about one-half

below these levels. The 119 patients used for analysis did not include any in

10 See footnote (1), p. 221. 11 Callander, C. L.: Study of arteriovenous fistula with an analysis of 447 cases. Ann. Surg. 71: 428-459, Apr 1920. 12 Pendergrass, R, C.; Cardiac changes in arteriovenous fistula. Am. J. Roentgenol. 53: 423-431, May 1945. 13 See footnote 1, p. 207.
ALTERATIONS IN CARDIAC SIZE IN FISTULAS 223

which there was marked preoperative enlargement since it was felt that in such patients hypertrophy as well as dilatation might have occurred, with

some degree of enlargement persisting after operation.

In these studies from tbe vascular center of Mayo General Hospital evidence of enlargement of the heart was demonstrable in about 50 percent of the

185 young patients with peripheral arteriovenous fistulas of relatively short

duration. This fact was confirmed by evidence of measurable reduction in

cardiac size after operation in comparable percentage.

The data derived from this investigation tend to confirm certain opinions,

previously expressed, as to factors important in the development of cardiac

enlargement in the presence of arteriovenous fistulas. These opinions, although based primarily upon experimental work, were supplemented, at least

in part, by clinical observations. The conclusions drawn at this vascular

center may be stated as follows:

1. In patients with arteriovenous fistulas some relationship appeared to

exist between the degree of cardiac enlargement and the size of the fistula,

particularly when it was located in vessels of the pelvis and lower extremities.

It should be noted, however, that the number of patients involved in this

study was small.

2. relationship was also evident between the duration of the fistula

and the degree of cardiac enlargement. When appropriate samples of femoral

and popliteal fistulas were used for comparison, with variable factors properly

controlled, it was evident that cardiac enlargement varied directly with the

duration of the lesion. Moreover, when roentgenograms were made in series

at intervals of weeks or more before operation, 50 percent of the patients in

this group showed on the last examination demonstrable increase in cardiac

size as compared with the earlier examination.

3. The data in this series concerning changes in the size of the heart in

association with femoral and popliteal arteriovenous fistulas tend to support

the opinion, rather generally held, that the nearer the fistula is to the heart,

the greater is the likelihood of early cardiac enlargement. Not too much

importance, however, can be attached to this relationship since the caliber of

the involved vessels may also have played part. Certain of the experimental

work cited to support the thesis that the distance of the fistula from the heart

has an important influence on the associated cardiac enlargement can be challenged for the same reason, that is, failure to take into consideration the size

of the artery selected for communication with the vein. As rule, the closer

to the heart the fistula was created in these experimental studies, the larger

was the artery selected for the communication. It is apparent that if the

diameter of the fistula exceeds that of the parent artery, the blood flow through

the fistula will be limited in part by the size of that artery.
224 VASCULAR SURGERY IN WORLD WAR II

4. These data also demonstrated that another consideration was more important in the production of cardiac enlargement than the proximity of the

fistula to the heart, namely, whether it was cephalad or caudad to the heart.

Both the frequency and degree of cardiac enlargement were greater in fistulas

of the pelvis and lower extremities than in fistulas of the head, neck, and upper

extremities. In this connection, it is curious that in years past number of

authors, although they had only limited number of patients on whom to

base the observation, made the same point. Thus Osier, 14 who, as previously

pointed out, was not impressed by the possible relationship between arteriovenous fistulas and cardiac strain, stated that remote effects upon the general

circulation were extremely uncommon, “particularly in aneurysms of the

vessels of the head and arms.”

The data in this study seem to permit two clinical conclusions. The

first is that marked change in the pulse or blood pressure upon temporary

occlusion of an arteriovenous fistula is likely to be associated with an early

and significant increase in the frontal area of the heart. The second is that

without other information it is possible to gain some idea of the likelihood of

early cardiac enlargement from the location of the fistula alone. Though

considerable increase in the size of the heart may occur relatively soon after

the development of an arteriovenous fistula involving any reasonably large

vessel in any portion of the body, the alteration is particularly likely to be

associated with fistulas in the great vessels caudad to the heart.

14 See footnote 2, p. 220.
CHAPTER VII

Arterial Aneurysms and Arteriovenous Fistulas

Technica Co nsideration in Their Surgical

Management, With Special Reference to Exposure of the Blood Vessels

Daniel C. Elkin, M. D.

and Harris B. Shumacker, Jr., M. D.

The safe and successful accomplishment of operations on blood vessels

requires careful anatomic exposure. Young surgeons assigned to the vascular

centers established in the Zone of Interior were frequently woefully lacking

in anatomic knowledge. In years past, textbooks have dealt with anatomic

considerations as matters of first importance and devoted considerable space

to proper approaches to the blood vessels and methods of ligation. When

World War II began, however, textbooks of surgery were concerned for the

most part with anatomy as applied to diagnosis and treatment, and the young

military surgeon could get no adequate guidance from them. Though many

of these men had served internships and even surgical residencies they lacked

anatomic knowledge as it relates to the peripheral nerves, blood vessels, and the musculature of the extremities. To overcome this lack it was necessary for skilled vascular surgeons assigned to the centers to train these officers not only in the specialized techniques

of vascular surgery, but often in the elementary details of such techniques.

In the following pages are set forth the important principles and techniques

taught and practiced in the vascular centers.

GENERAL PRINCIPLES

One of the cardinal principles of the surgery of aneurysms is that incisions

must provide easy and complete access to the vessels involved. The planning

of an approach which permits isolation and control of the involved vessels is

often more important than the surgical treatment of the lesion itself. Furthermore, the incision must be so placed that by lengthening it the vessels distal

and proximal to the site of the suspected lesion are made accessible without

difficulty. Unless the plan of exposure is an integral part of every procedure,

hemorrhage may so interfere that the operation cannot be carried out successfully; even death of the patient may result. Whenever the exposure and control of major vascular trunks are regarded as preliminary steps to the repair of

aneurysms and arteriovenous fistulas, the hazards of operation are greatly

reduced.
226 VASCULAR SURGERY IN WORLD WAR II

These considerations do not obviate in any sense, however, the advisability

of planning skin incisions which yield good plastic result, which do not cross

normal skin folds and creases, and which minimize the hazards of keloid

formation, scarring, and contractures—provided such incisions sacrifice nothing

essential in regard to the exposure of the vessels. Adequate exposure is not

necessarily achieved by an incision which lies directly over the vessels involved; only rarely does properly placed plastic incision offer any real limitation upon

the achievement of easy and complete access to the vessels.

VESSELS OF THE LOWER EXTREMITY

Femoral Vessels

The guide to the superficial femoral vessels is the sartorius muscle which

in the upper portion of the thigh lies lateral to the vessels, and in the middle

and lower portion overlaps the vessels in their course in Hunter’s canal. The

upper popliteal and lower femoral vessels are best reached through an incision

just anterior to the sartorius muscle. When the knee is flexed and the thigh

rotated externally, the sartorius is easily displaced posteriorly upon opening

the deep fascia (Fig. 17).

For lesions of the common femoral artery, and occasionally for those of

the proximal portion of the femoral or profunda femoris artery, an oblique

incision just below Poupart’s ligament is preferred. If the lesion is too high

to permit adequate exposure without proximal extension of longitudinal

incision, it is preferable to curve the incision up along the inguinal fold rather

than to cross the crease.

Popliteal Vessels

Although it is common practice to explore the popliteal vessels through

longitudinal incision crossing the popliteal crease, high percentage of patients

thus treated subsequently develop heavy scars or keloids, contractures, and

even ulcerative lesions. These sequelae are disabling, their remedy by plastic

procedures is time-consuming and not always successful, and exposure of the

popliteal vessels can quite as well be secured by more desirable methods.

Lesions of the first portion of the popliteal and of the femoropopliteal

vessels can be exposed by longitudinal anteromedial incision extending down

to the knee. When the thigh is rotated externally and the knee flexed, the

sartorius muscle is relaxed and easily retracted. The femoral vessels are then

accessible proximal to the point at which they pass under the adductor tendon

and the popliteal vessels are accessible to the point at which they emerge

beneath this tendon.

When the lesion lies more distally, in the midpopliteal space, some type of

transverse incision crossing the popliteal space in one of the natural creases is

used (Fig. 18). simple transverse incision is sometimes adequate, particularly

when large saccular aneurysm is approached by the intrasaccular route and
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 227

Figure 17. Exposure of lower femoral and popliteal vessels by medial approach

anterior to sartorius muscle.

the blood supply is controlled by tourniquet. More often the incision must

be extended upward along the medial aspect of the thigh and downward along

the lateral surface of the leg (Fig. 18A). The skin flaps are reflected and the

fascia incised longitudinally in the midline. The biceps is retracted laterally

and the semimembranosus and semitendinosus are retracted medially. After

the tibial and peroneal nerves are identified, which is not difficult, the vein

and artery are readily accessible.

When the lesion is in the distal portion of the popliteal space, exposure

by retraction or division of the heads of the gastrocnemius muscle is difficult.

Such procedure entails definite hazard since the innervation of the gastrocnemius, plantaris, and popliteus muscles may be injured.

The difficulty is obviated and exploration made easy by the use of an Lishaped incision crossing the lateral half of the popliteal space and extending

downward along the posterolateral aspect of the calf (Fig. 18C and D). The

fascia is divided beneath the skin incision. The lateral head of the gastrocnemius along with the plantaris is retracted, as is the medial head. The popliteal
228 VASCULAR SURGERY IN WORLD WAR II

Figure 18. Skin incisions for exploration of popliteal vessels. A. Incision for lesion in popliteal vessels in midpopliteal space. B. Incision for lesion higher in popliteal fossa.

C, D. Incisions for lesions of distal popliteal vessels. E. Modified incision useful for exposure of associated nerve lesion.

artery and vein and the tibial nerve are thus brought into view and can be

followed as they cross over the popliteus muscle and pass through the tendinous

arch of the soleus muscle (Fig. 19).

When the lesion is in that portion of the vessels covered by the soleus

muscle, the skin incision must be extended down the leg. Exposure of the

vessels generally necessitates division of the lateral fibers of the soleus attached

to the fibula, with or without division of that portion arising from the head of

the fibula. Sometimes the vessels can be exposed satisfactorily by incising

the muscle longitudinally directly over the vessels.

Vessels of the Leg

In general, exposure of vascular lesions in the lower extremity can be

accomplished without difficulty by the use of properly placed longitudinal

incisions which do not cross skin creases and which therefore heal without

sequelae. This is particularly true of lesions of the lower third of the leg which

are easily reached by direct approach along the posteromedial aspect. The

incision is begun one fingerbreadth posterior to the border of the tibia and can

be carried upward by detaching portion of the soleus muscle from its origin

on the tibia.

Lesions of the posterior tibial vessels and of the anterior tibial and peroneal

vessels in the upper part of their course present different problem. To distinguish clinically which of these vessels is involved is frequently impossible

because of their close proximity to each other, but difficulties of exposure are

the same for all. The tibia and fibula are closely apposed in this area and there

is dense interosseous membrane between them. Hemorrhage is serious
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 229

Figure 19. Exposure of the popliteal vessels. The lateral and medial heads of the gastroc

nemius are retracted and nerve and vessels are seen lying upon popliteus muscle and as they

enter the soleus.

possibility. The rich collateral anastomosis which develops as the result of an

arteriovenous communication, together with dilatation of the vessels including

those which perforate the interosseous membrane, demands direct visualization of these vessels and their careful ligation and division. Otherwise the

retraction of vascular channels through the interosseous membrane may
230 VASCULAR SURGERY IN WORLD WAR II

result in serious or even uncontrollable hemorrhage. This would necessitate

second incision along the front of the leg, or the removal of the fibula in the

presence of hemorrhage and at an inopportune time during the course of the

operation. Deliberate removal of the upper portion of the fibula to secure

adequate exposure is often, therefore, the part of wisdom.

At the vascular centers in World War II the incision used for exposure of

the posterior tibial and upper portion of the anterior tibial and peroneal vessels

was modification of the technique described by Henry in 1927. In this

procedure the upper portion of the fibula is removed subperiosteally which

insures continued stability of the knee joint. An additional advantage of

this method is that the peroneal nerve, which is frequently injured concomitantly with the blood vessels, can be exposed and treated as necessary through

the same incision.

Continuous spinal is the anesthetic of choice for this operation. The

patient lies on the unaffected side with the knee slightly flexed. pheumatic

tourniquet is applied to the thigh but is not inflated unless severe hemorrhage

occurs.

The incision is begun about inches above the head of the fibula and

carried distally as far as may be indicated by the position of the aneurysm.

After the skin and superficial fascia are divided at the upper end of the incision,

the deep fascia is opened at the medial edge of the biceps tendon. The common peroneal nerve is exposed, and rubber strip passed around it for aid in

immobilization (Fig. 20). Division of the deep fascia is continued downward

along the course of the nerve at the posterior margin of the biceps tendon.

The fascial origin of the peroneus longus muscle, which lies directly over the

groove in which the nerve passes forward across the neck of the fibula, is

divided. definite plane, the lateral intermuscular septum, which lies between the soleus muscle posteriorly and the peroneus longus muscle anteriorly,

is easily developed. When the muscles are separated the lateral border of

the fibula immediately comes into view. The periosteum is readily stripped

from the fibula by sharp dissection, aided by periosteal elevator, and the

fibula divided by means of Gigli saw. The removal of the head subperiosteally is more difficult and is best carried out by dissection with sharp knife.

The blade of the knife is kept directly against the bone and the peroneal nerve

is retracted completely out of the field of incision. The removal of the head

and of the upper portion of the fibula exposes the lower end of the popliteal

artery with its terminal branches, namely, the posterior tibial, anterior tibial

(Fig. 21), and peroneal vessels. These are easily seen when the soleus muscle

is retracted posteriorly and the peroneus longus anteriorly.

As the first step in excision of the arteriovenous fistula, the artery proximal

to the fistula is secured. ligature is passed around it to control any possible

bleeding, but is left untied. The vessels distal to the lesion are isolated,

Henry, Arnold K.: Exposure of Long Bones and Other Surgical Methods. Bristol, John Wright and Sons, Ltd,

1927.
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 231

Figure 20. Resection of head of fibula for exposure of tibial and peroneal vessels. Note sharp

dissection of periosteum covering head of fibula and complete mobilization of common

peroneal nerve.

ligated, and divided. Following this the proximal artery is ligated and divided.

The fistula is then removed from below upward, all communicating vessels

being ligated and divided. The proximal vein is divided as the last step in the

operation. It is of utmost importance that the region of the fistula be avoided

until its principal blood supply is completely controlled.

The resected portion of fibula is not replaced. The question of the stability of the knee joint naturally arises following removal of the insertion of

the fibular collateral ligament, but none of the patients in whom the operation

was performed in the vascular centers had any complaints referable to the

knee joint on the operated side. Furthermore, examination failed to reveal

any loss of stability. Comparison of the fibular collateral ligaments by palpation, with the ligament under stress, usually disclosed as tense ligament

on one side as on the other.

Whenever possible, incisions on the sole of the foot are to be avoided since

the scar is usually painful when the foot is bearing weight. Approach to the

plantar vessels is through an incision on the medial aspect of the foot. The

330323 0—55——16
232 VASCULAR SURGERY IN WORLD WAR II

Figure 21. Exposure of arteriovenous fistula of posterior tibial vessels by removal of upper

third of fibula. Insert shows line of incision.

abductor hallucis muscle is detached from its origin after which the vessels,

with the tibial nerve, are easily traced into the deeper structures of the foot

(Fig. 22),

VESSELS OF THE UPPER EXTREMITY

Axillary Vessels

For lesions involving the axillary vessels an incision is made over, and

parallel to, the upper fibers of the pectoralis major muscle beginning about

the midportion of the clavicle. If the first portion of the axillary vessels is to

be exposed, usually all that is necessary is to separate the upper fibers of the

pectoralis major through this type of incision and to retract or transect the

muscle through its insertion, the pectoralis minor. If the distal portion of

the axillary vessels is involved, the incision described is continued out over the

insertion of the pectoralis major muscle and this muscle is divided through

its tendinous insertion (Fig. 23).

Often the incision used for exposure of the first portion of the brachial

vessels is adequate for the exposure of the distal end of the axillary vessels.

The incision begins over the insertion of the pectoralis major muscle, curves

down the inner aspect of the arm distal to the axilla to the region of the neurovascular bundle, and then downward for short distance over the course of
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 233

Figure 22. (After Henry.) Exposure of plantar vessels through medial approach, which is

facilitated by detachment of abductor hallucis muscle from its origin.

these vessels (Fig. 24). When the skin flaps are reflected the distal portion of

the axillary vessels and the first portion of the brachial vessels are readily

accessible. Incision through the axilla is thus avoided. This is most desirable since keloids, heavy scars, and disabling contractures are particularly

troublesome in this region. An additional advantage of the incision described

is that it permits exposure of any concomitant nerve lesions.

Vessels of the Anfecubital Fossa

The brachial vessels are satisfactorily approached for most of their course

on the inner aspect of the arm through longitudinal incisions overlying their

course. The biceps muscle is used as guide. Lesions in the first portion

of the brachial vessels are best handled by an incision which does not cross

the axilla. This incision is also used for exposure of the subclavian and axillary

arteries (q. v.).

Lesions in and near the antecubital fossa are exposed through incisions

similar to those employed in the popliteal fossa. transverse incision is

made across this space in the line of natural skin crease. Depending upon

the requirements in the special case under treatment, it is extended upward
234 VASCULAR SURGERY IN WORLD WAR II

Figure 23. Incisions for exposure of innominate, subclavian, and axillary vessels

Figure 2J+. Incision for exploration of distal portion of axillary,

and first portion of brachial, vessels.

for short distance along the anteromedial aspect of the arm or downward

along the anterolateral aspect of the forearm (Fig. 25). The skin flaps are

reflected. The communications between the cephalic and basilic veins are

divided and the lacertus fibrosus severed. The cephalic vein and the lateral

antebrachial cutaneous nerve are retracted laterally, and the basilic vein and

medial antebrachial cutaneous nerve, medially. The brachial artery and vein,

with the median nerve, then come into full view (Fig. 26) and can easily be

exposed down to point below their bifurcation intoradial and ulnar branches.
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 235

Figure 25. Incisions for exposure of vessels in antecubital fossa. A. Usual incision. B. Incision for lesion presumed to he in proximal portion of ulnar vessels. C. Incision for lesion of brachial vessels just proximal to antecubital crease. D. Incision for exploration

of distal end of brachial, or proximal end of radial, vessels.

When the lesion is in the proximal portion of the radial vessels it is sometimes helpful to supplement an anterolateral longitudinal incision by curving

it across portion of the antecubital space.

One of us used these incisions in 11 aneurysms of the radial and ulnar

vessels. They proved entirely satisfactory. Prompt healing occurred in

all, and in none was there any scarring or contractures. The only untoward

occurrence was superficial slough about cm. in diameter in one case in

which the corner of an L-shaped incision was perhaps traumatized during

operation. The slough, however, did not involve the entire thickness of the

skin and epithelization was rapid.

Lesions of the lower portion of the brachial artery and of the upper portion of the radial and ulnar arteries can be approached through an S-shaped

incision in the cubital space. Separation of the brachioradialis and pronator

teres muscles will expose the radial artery in the upper portion of its course,

Shumacker, H. B., Jr.: Incisions in surgery of aneurysms, with special reference to exploration in the antecubital

and popliteal fossae. Ann. Surg. 124: 586-598, Sep 1946.
236 VASCULAR SURGERY IN WORLD WAR II

Figure 26. Exposure of fistula between brachial artery and vein in antecubital space. The

communications between the basilic and cephalic veins have been divided, and the lacertus

fibrosus has been severed. Note exposure of cutaneous and median nerves.

and separation of the flexor carpi ulnaris and the flexor digitorum sublimis

will reveal the ulnar artery throughout its course in the forearm.

VESSELS OF THE SCALP

Cirsoid aneurysms of the scalp may arise independently or may be preceded by congenital angiomatous vascular abnormality. Since trauma,

frequently inconsequential, may be the starting point, one might expect many

of them to follow injury by military missiles. In all, however, only nine

aneurysms of this kind were observed at the vascular centers during World

War II.

Cirsoid aneurysm, which is also known as serpentine or racemose aneurysm,

may originate in congenital telangiectases, nevi, or angiomas, particularly if

intermediary trauma or long continued irritation has occurred. Multiple

communications between vessels may, however, follow trauma in the absence

of preexisting vascular lesion. The term cirsoid is generally limited to

lesion which is in effect diffuse arteriovenous fistula formed by multiple

anastomoses between contributing arteries and outgoing veins.
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 237

The possibility of an intracranial extension of such lesion or of the

extracranial manifestation of primary intracranial varix must be borne in

mind whenever cirsoid aneurysm is encountered.

variety of methods has been employed in the management of cirsoid

aneurysms of the scalp, including carotid ligation, ligation of the multiple

vessels connected with the lesion, obliteration through galvanocauterization or

by the injection of thrombosing solutions, and extirpation. The method last

named is undoubtedly more certain of cure and therefore the procedure of

choice. It is performed as follows:

As preliminary step, the principal artery (arteries) leading to the lesion

is independently ligated. horseshoe flap of scalp is turned down to expose

the lesion from the underside; care is taken to include the galea in the flap.

This step amounts to carrying the incision down to the pericranium and reflecting with the lesion all tissues superficial to it. Hemostasis is obtained by

digital pressure and by individual ligation and division of each vessel as it is

encountered in the incision. The main vessels, including the central portion

of the lesion, are completely excised from the underside of the flap. Particular

care is taken not to buttonhole the skin. After excision of the lesion the flap

is replaced with interrupted stitches of silk in the galea and in the skin.

Case 1. This 25-year-old soldier sustained an injury to the right parietal region in 1937,

when he was struck on the head by fist during an altercation. Following this small

pulsating hematoma, 0.5 cm. in diameter, developed which gave him no trouble. On

12 March 1945 while in combat training he was accidentally struck on the right side of his

scalp by the elbow of his opponent. Three hours later he noticed that the mass was considerably increased in size, although it was neither painful nor tender. Within the next

month the swelling increased rapidly and he became conscious of discomforting pulsation

in his scalp, and throbbing, buzzing sensation in his left ear. He was admitted to Ashford

General Hospital on 23 April 1945.

On examination, large tortuous system of convoluted blood vessels covered the whole

right side of his scalp (Fig. 27A). The main tumor mass was centered in the right parietal

region and the vessels which radiated to and from it were apparently derived mainly from

both superficial temporal, frontal, and the left occipital veins and arteries (Fig. 27B). From

the center tumor in the right parietal region vessels radiated over the entire scalp. These

appeared to be venous and were readily compressible, although all of them pulsated. Over

the right parietal region harsh, continuous bruit and the thrill could be heard. The bruit

was transmitted throughout the scalp but was readily obliterated by pressure of the right

carotid vessels in the neck.

Operation was performed on May 1945. Preliminary to excision of the aneurysm the

right external carotid artery was ligated and the left occipital and left superficial temporal

arteries were ligated and divided. horseshoe-shaped incision, with its base above the right

ear, was then turned downward. The incision was carried through the galea and numerous

large tortuous vessels were ligated and divided as they were reached. The galea was then

opened and mass of dilated vessels removed from the underside of the flap. In spite of

previous ligations there was considerable bleeding during the operation which was controlled

by sutures and coagulation. The flap was replaced by suturing the galea and skin with interrupted sutures of silk.

Recovery was uneventful and months after operation there was no evidence of recurrence. (Fig. 27C and D.)
238 VASCULAR SURGERY IN WORLD WAR II

Figure 27. (Case 1.) and show cirsoid aneurysm of the scalp condition before operation,

May 1945. C. and D. Appearance of head months after operation.

VESSELS IN THE NECK

Although the great vessels of the neck are frequently exposed by longitudinal incisions along their courses, the resulting scars are often heavy and wide

and associated with keloid formation and actual contractures. On the other

hand, general experience with oblique skin incisions following natural skin

creases of the neck has been that scars are inconspicuous and never cause
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 239

contractures or deformity. When such incisions are properly placed, exposure

of the carotid artery and jugular vein is entirely adequate. Localization of

the level of the lesion is usually possible prior to exploration. If this is done,

and if the skin incision is properly placed, the whole procedure is simple. The

upper and lower skin flaps are widely mobilized, the fascia is incised along the

anterior border of the sternocleidomastoid muscle which is retracted posteriorly,

and the carotid sheath is opened longitudinally. The vessels above, below,

and at the site of the lesion can thus be exposed adequately. The vagus

nerve can also be visualized and protected against injury.

Resection oj the Clavicle. In the approach to the great vessels at the base

of the neck (that is, the subclavian, axillary, carotid, innominates, and their

branches), the clavicle frequently prevents adequate exposure and control of

the vessels proximal and distal to the vascular lesion. The safety of vascular

surgery in this region, however, depends largely upon the accuracy with which

isolation of these vessels is accomplished. Removal of portion of the clavicle

is often the solution of the problem. This procedure greatly facilitates all

vascular operations at the base of the neck, does not interfere with local

motion, produces no noticeable deformity, and leaves no residual pain. During

World War II this technique was employed in almost 50 cases at the vascular

centers in the Zone of Interior with uniformly good results. Resection of the

medial half of the clavicle with its sternal articulation improves the exposure

of lesions of the base of the neck and the superior mediastinum. Exposure

of the subclavian and axillary vessels requires resection of only the central

third of the bone.

Incision is made over the most prominent portion of the clavicle to be

resected (Fig. 28) and is extended as necessary along the course of the vessels.

When skin flaps are reflected the clavicle, the manubrium, the sternum, and

the muscles attached to these structures are readily accessible. Incision of

the periosteum on the anterior surface of the clavicle, away from the sites of

muscular attachment, greatly reduces the amount of bleeding. The periosteum

strips freely in this area, but the transverse scapular vessels run close to the

posterior surface of the clavicle and are easily injured if the periosteum is torn.

If the clavicle itself forms part of the false sac of an arterial aneurysm, as it

not infrequently does, its removal may be accompanied by profuse bleeding

which must be controlled at the site of the opening by digital pressure. The

mobilized portion of the bone is divided with Gigli saw. If the sternal end

is removed the cartilage should be excised with it.

vertical incision beneath the sternal end of the clavicle will expose the

innominate and carotid vessels and the first portion of the subclavian artery

and its branches. The sternum is divided in the midline down to the level of

the second interspace and is transected at this level. It is then spread apart

with traction upon bone hooks, or is separated with rib spreader. Either

method provides good visualization of the vessels. vertical incision through

the central portion of the clavicular bed will expose the subclavian vessels
240 VASCULAR SURGERY IN WORLD WAR II

Figure 28. Resection of clavicle subperiostally to expose aneurysm of subclavian artery.

and the brachial plexus. Division of the anterior scalene muscle facilitates

exposure of the first and second portions of the subclavian artery. It also

facilitates exposure of the vertebral artery and the thyrocervical trunk.

Extension of the incision laterally, with the cephalic vein as landmark, and

division of the costocoracoid membrane, reveals the route to the axillary

vessels.

Closure of the wound is effected by layers. For the repair of the periosteum,

interrupted sutures of fine silk are used.

The resected segment is not replaced. Experience has shown that results

are poor if the resected bone is reinserted and fixed in place by approximating

it to the remaining bone with wire or other sutures. When this is attempted,

proper immobilization is often not secured and painful nonunion or malunion

occurs so commonly as to make the procedure eminently unsatisfactory.

Other complications such as osteomyelitis and subluxation of the sternoclavicular joint may result. In fact it is sometimes necessary to remove the

replaced portion of the clavicle to give the patient relief.

At the conclusion of the operation the dressing is reinforced with adhesive

tape, the arm and forearm being left free. The patient is kept in bed for
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 241

weeks. He is asked to lie flat on his back and to hold his shoulders well back.

(No external apparatus to insure immobilization is used.) During the third

week he is allowed to move about, but is encouraged to rest considerable

part of the time on his back.

There is little discomfort after this operation, and activity is not associated

with pain. The area of the clavicular defect rapidly becomes firm and on

clinical examination the absence of the bone cannot be detected, even on

careful palpation. There is little external deformity and asymmetry is less

than when the resected segment of clavicle is replaced. Resection of the

articular portion of the clavicle makes no difference in the postoperative results.

The patient returns to normal activity within to weeks.

Although new bone can be palpated in the clavicle within few weeks of

operation, several months must elapse before it can be demonstrated by roentgenogram. During this time, as already mentioned, patients are active and

have no discomfort on motion. These results suggest that the concept of

the function of the clavicle as fulcrum to provide better lateral motion of

the arm should be revised. The suggestion is supported by the fact that

the occasional congenital absence of this bone is known to be of no great consequence, and that in many carnivora it is normally rudimentary.

In case observed at Mayo General Hospital excessive bony regeneration

had occurred at the site where the periosteum of the clavicle had been divided.

While the patient had no complaints at time of disposition, it is conceivable,

on the analogy with the excessive callus formation which sometimes follows

fractures of the clavicle, that pressure upon the brachial plexus might occur

later. In view of this possibility the periosteum should be so transected

that the incision does not lie over this plexus.

Replacement oj the Clavicle by Bone Chips. Although patients who have

had the clavicle removed have normal configuration of shoulders, normal

motion, and are entirely comfortable, regeneration of the bone is slow and

it would be desirable to hasten it if this could be accomplished without undue

risk. For this reason, one of us devised the plan of filling the periosteal bed

with bone chips secured from the excised bone. In the patients in which

the method was employed at the vascular center of Mayo General Hospital,

the results were excellent.

In each instance the clavicle was excised subperiosteally and care taken

to preserve the periosteum intact. In one patient the periosteum was also

transected to facilitate exposure. The bone was divided with Gigli saw. The

excised segment was kept in sterile physiologic salt solution until the vascular

phase of the operation had been completed, and was then converted into small

bone chips, to mm. in diameter, with rongeur. These chips were packed

into the periosteal bed, sufficient quantity for this purpose being obtained

Shumacker, H. B., Jr.: Resection of clavicle with particular reference to use ofbone chips in periosteal bed. Surg.,

Gynec. Obst. 84 245-248, Feb 1947.
242 VASCULAR SURGERY IN WORLD WAR II

from one-half to two-thirds of the resected bone. The periosteum was closed

with interrupted sutures of fine silk.

Postoperative treatment followed the usual regimen after resection of the

clavicle. Definite firmness was noted in the region of the excised bone earlier

than in patients who had been subjected to similarresections without replacement of bone chips. Osseous regeneration was rapid and complete. Beginning

callus formation was evident in patients weeks after operation; complete

regeneration was observed in all patients by the 18th postoperative week.

Roentgenologic studies in 10 patients in whom the excised bone was not replaced by bone chips showed in most instances no callus formation at periods

ranging from to 34 weeks after operation. In these patients, furthermore,

regeneration sometimes proceeded from the ends of the remaining bone rather

than throughout the periosteal bed, as happened when bone chips were used.

In patient eburnation of the bone-ends 34 weeks after operation made it

doubtful that union would be achieved at all.

VESSELS WITHIN THE MEDIASTINUM

Reports of the successful treatment of vascular lesions of the vessels which

lie within the mediastinum are not common, though almost every conceivable

type of operative approach has been employed since Valentine Mott first

ligated the innominate artery in 1818 in an attempt to cure traumatic

subclavian aneurysm. In Greenough’s review of the literature on the subject,

published in 1929, the fact is emphasized that safety can be achieved only by

adequate resection of the overlying bony framework. In only 37 of the 91

cases of innominate ligation or attempted ligation which Greenough collected

was resection, or osteotomy, of the overlying bones performed. Inadequate

exposure of the vessels was the primary factor in number of the 18 fatalities

in this group.

Technical Considerations in

Exposure of Vessels in the Mediastinum

In Greenough’s review of the operations performed upon the innominate

artery it is interesting to note the wide variety ofprocedures employed to expose

the vessel. In 11 patients portion of the clavicle and the manubrium was

resected. In 11 others only part of the clavicle was resected; in patient

this procedure was combined with partial resection of the first costal cartilage.

Other maneuvers included sternoclavicular disarticulation; splitting of the

sternum in the midline; partial excision of the manubrium, clavicle, and first

rib; and resection of the manubrium with or without excision of the first two

costal cartilages.

Mott, V.: Reflections on securing in ligature the arteria innominata, to which isadded case in which this artery

was tied by surgical operation. Med. and Surg. Register, New York 1: 9-54, 1818.

Greenough, .: Operations on innominate artery; report of successful ligation. Arch. Surg. 19: 1484-1544, pt. Dec

1929.
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 243

The operation described by Bardenheuer illustrates exposure by resection

of bone. The inner part of the clavicle and first rib are removed on one side

and the manubrium is sectioned transversely about an inch below the superior

border. The opposite clavicle and the first and second ribs on that side are

then divided and the freed manubrium is excised. Various modifications of

the procedure have been employed.

Exposure of about the same extent is obtained by the osteoplastic operation

of Kocher. The manubrium is reflected as flap attached to the costal

cartilages on one side after division or disarticulation of the clavicles, the first

and second cartilages on one side, and transection of the sternum at the level

of the second interspace. The exposure devised by Sauerbruch and Schumacher for mediastinal explorations has also been used for vascular operations

in the mediastinum. It requires splitting of the sternum longitudinally down

to the level of the third interspace and cutting it across into this interspace.

In spite of the excellent exposure thus secured of the arch of the aorta and

the proximal and midportions of the innominate vessels, it is impossible even

with wide retraction of the divided sternum to obtain adequate visualization

of the subclavian and carotid arteries or of lesions hidden under the upper part

of the manubrium and the sternoclavicular joint.

Most textbooks of surgery in discussions of aneurysms and other lesions

of the innominate artery describe methods of exposure directed toward ligating

that vessel by resection of the clavicle and disarticulation of its medial end.

This exposure, however, is inadequate in the presence of an aneurysm or arteriovenous fistula near the aorta in which constant risk of hemorrhage makes adequate exposure particularly imperative. Manipulations must be conducted

under full vision because the vessels are dilated and thin-walled. Each case

must be considered an individual problem and effort made to choose the ideal

operativeapproach. To illustrate: Within short period, three cases involving

innominate aneurysms and arteriovenous fistulas were reported and in each

different approach was used. One of us resected the inner half of the clavicle,

the second costal cartilage and the inner portion of the accompanying rib,

divided the manubrium, and excised portion of its right half. Trent, 10 after

resection of the second rib and cartilage and division of the third, used transpleural approach. Lindskog 11 excised the proximal portion of the second costal

cartilage, partially divided the sternum by rongeur at this level, split the manubrium vertically with Gigli saw introduced from above, and divided the clavicle.

An exposure employed at Mayo General Hospital which proved extremely

satisfactory, is carried out as follows: An incision is made from the midportion

of the clavicle down over the sternoclavicular joint to the midline. From

Bardenheuer: Die Resection des Manubrium Sterni. Deutsche med. Wchnschr. 11; 688-690, 1885.

Kocher, Theodor: Textbook of Operative Surgery. New York, The Macmillan Co., 1911.

Sauerbruch, F., and Schumacher, E. D.: Technik der Thoraxchirurgie. Berlin, J. Springer, 1911.

Elkin, D. C.: Arteriovenous aneurysm, the approach to the innominate vessels. J.A.M.A. 129: 26-27, Sep 1945.

10 Trent, J. C.: Ligation of the innominate artery for innominate aneurysm using rubber bands; report of case.

Surg., Qynec. Obst. 82: 463-470, Apr 1946.

11 Lindskog, O. E.: Surgery of the innominate artery. New England J. Med. 235: 71-76, Jul 1946.
244 VASCULAR SURGERY IN WORLD WAR II

this point it is continued down over the sternum to the level of the third or

fourth interspace. The platysma is divided. The inner third of the clavicle

is resected subperiosteally by disarticulation of the sternal end and division of

the other end with Gigli saw. The sternal portion of the sternocleidomastoid

muscle is divided, as is portion of its clavicular origin. The sternohyoid and

sternothyroid muscles are similarly severed near their points of origin. It is

necessary ordinarily to divide these only on the side on which the clavicle is

removed. finger is gently passed behind the manubrium from above; through

this maneuver it is usually possible to separate the manubrium from underlying

structures. If blunt dissector is used for the purpose, dissection must be

cautious and under the constant guidance of the palpating finger to avoid

trauma to the underlying vessels. The periosteum of the sternum is incised

anteriorly in the midline and the sternum split down to the level of the second

or third interspace. The Shoemaker sternal shears are ideal for this purpose.

The Lebsche knife is less satisfactory, since the bone tends to split in advance

of the cut and not always in the midline.

Once the sternum has been divided for some distance its edges can be retracted with bone hooks. Underlying structures can then be palpated satisfactorily and decision made as to whether division of the sternum should be

carried out at the second or third interspace to provide the required exposure.

The sternum can also be freed more completely from underlying tissues. After

complete incision of the periosteum and freeing of the outer borders, the

sternum is divided across into both interspaces at the appropriate level. The

halves of the divided sternum are now widely retracted. The loose areolar

tissue and the remains of the thymus gland are pushed to the side or retracted,

and the great vessels thus brought into view (Fig. 29). small rib spreader is

substituted for the bone hooks at this point.

It must be borne in mind in all mediastinal surgery that there is wide

variation in the position of the mediastinal structures in relation to the

overlying bony framework. The arch of the aorta is occasionally as high

as the superior border of the manubrium. The pericardium is sometimes

barely in view. The superior vena cava may be of considerable length, while

in other cases the innominate veins appear to join more caudally into short

vena cava.

After the necessary vascular surgery is accomplished, the wound is closed

in layers. The sternum is reapproximated with wire sutures placed through

drill holes or with silk sutures placed in the periosteum. The clavicular

periosteal bed is then carefully closed with interrupted silk sutures, or prior

to suturing, it may be filled with bone chips from the excised portion of the

clavicle to hasten bony repair. The muscles, fascia, and skin are brought

together with silk sutures. The skin incision is entirely satisfactory and there

is normal range of shoulder motion (Fig. 30) when this technique is used.
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 245

Figure 29. Operative exposure of vessels of superior anterior mediastinum by division of sternum

and resection of inner third of left clavicle.

Technical Considerations in Management

of Vessels in Mediastinum

In 1945, one of us analyzed 38 reported cases of attempted surgical treatment for innominate aneurysms (36 cases) and arteriovenous fistulas (2 cases). 12

In these, 18 deaths occurred. Thirteen took place among the 20 patients

treatedprior to 1924, and in the 15 treated after that date (the date was not

mentioned in patients reported by Matas, of whom died). Undoubtedly

inadequate exposure played an important role in these fatalities. Causes of

12 Shumacker, H. B., Jr.; Surgical cure of innominate aneurysm. Surgery 22: 729-739, Nov 1947.
246 VASCULAR SURGERY IN WORLD WAR II

Figure SO. Normal range of shoulder motion in patient submitted to exposure of blood vessels

in superior anterior mediastinum by technique shown in Figure 29. In this patient the

clavicular periosteal bed was filled with bone chips.
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 247

death included tracheal obstruction, uremia, infection, cerebral ischemic

difficulties, and hemorrhage and shock. Hemorrhage and shock were reported as causing death in patients and would also seem responsible in or

others in which the cause was not given.

With present methods of therapy some of these causes are preventable.

Adequate operative exposure, gentle dissection of vessels, and transfusions of

whole blood have reduced the hazard of bleeding. Aseptic technique, chemotherapy, and antibiotics have reduced the danger of infection. While cerebral complications are still danger, this hazard can be reduced to minimum by repeated preoperative compression of the carotid artery carried out until the

patient can tolerate occlusion for long period. In certain instances it may

be advisable, before operation for innominate aneurysms, to perform preliminary ligation of the carotid artery with removable metal band, or with

fascial or tape ligature. No instance of gangrene of the upper extremity has

been reported after such operations, but other evidences of ischemia have not

infrequently been observed. Before permanent ligation the efficacy of the

collateral circulation should always be tested by observation of the hand

during temporary occlusion of the artery.

There are too few cases in each category of treatment in Shumacker’s collected series to permit conclusions about the safety and effectiveness of the

various methods. If the artery could be safely and securely repaired, repair

would naturally be the method of choice, but it is doubtful that this method can

be employed except in occasional cases. It was used in only of the 38 cases

collected from the literature and was not practical in any of the cases observed

at the vascular centers in World War II. The best procedure from the standpoint of safety to the patient and likelihood of cure of the lesion seems to be

proximal and distal ligation (Table 28), combined, when feasible, with excision

of the sac, or with evacuation of the thrombus within the sac. Distal ligation

will usually involve ligation of the carotid and subclavian arteries. In such

cases, as in all instances of arterial surgery, it is wise to divide and transfix the

arteries rather than to ligate them in continuity. Opinions differ whether the

concomitant vein should be ligated when occlusion of major artery is necessary.

Of these 38 cases reported up to 1945 only had aneurysms involving the

innominate vessel at its point of origin. One of these patients died before

ligation could be accomplished; the other, reported by Trent, 13 survived.

Several unreported fatalities have also followed attempts at ligation. Unless

constriction with rubber band, as suggested by Trent, proves the answer to

the problem—experience with this method in aneurysms of the aorta suggests

that it may end in disaster—some other more indirect method of controlling

the aneurysm must be sought. Babcock’s surgical production of carotidjugular arteriovenous fistula 14 is, according to Matas, hazardous operation

13 See footnote 10, p. 243. 14 (1) Babcock, W. W.: new treatment for thoracic aneurysm. Ann. Clin. Med. 933-942, 1926.

(2) McCarthy, P. A.: Treatment of aneurysms of thoracic aorta and innominate artery by distal arteriovenous

anastomosis. Ann. Sing. 91: 161-196, 1930.

330323 0—55 17
248 VASCULAR SURGERY IN WORLD WAR II

Table 28. Analysis of Results of Various Operative Procedures in Patients With

Innominate Aneurysms and Arteriovenous Fistulas

likely to be followed by functional difficulties. 15 Distal ligation of the carotid

and subclavian arteries by the method of Brasdor-Guinard 16 has produced

some excellent results 17 but is not generally applicable and the moderate chance

of relief offered is quite out of proportion to the gravity of the risk involved.

Wiring combined with coagulation, as developed by Blakemore and King, 18

seems the method of choice when direct surgical intervention on the aneurysm

is not feasible. It cannot be considered curative measure, but is likely to

arrest the expansion of the aneurysm and to bring about relief of symptoms.

Possibly combination of wiring and coagulation, with distal ligation of the

carotid and subclavian arteries, may yield better results than wiring and coagulation alone. Once the sac wall has been reinforced by an increase in the intramural thrombus following this procedure there should be little hazard associated

with distal ligation. After distal ligation there should be good possibility of

obtaining complete saccular thrombosis with further wiring, though this outcome would be impossible with wiring alone.

ls Matas, R.; On the treatmentofaortic aneurysm by method of jugulo-carotidanastomosis; discussion. New Orleans

M. S. J. 84 445-454, Dec 1931. 16 Matas, R. In Keen, W. W.; Surgery, Its Principles and Practice. Philadelphia, W. B. Saunders Co., 1920. 17 (1) Baldwin, J. F.: Aneurysm of the innominate; synchronous ligation of subclavian and common carotid with

long survival; unusual incision. Am. J. Surg. 5: 517, Nov 1928. (2) Schwyzer, A.: Aneurysm of innominate artery. Ann. Surg. 96: 666-669, Oct 1932. 18 Blakemore, A. H., and King, B. Q.: Electrothermic coagulation of aortic aneurysms. J. A. M. A. Ill; 1821-1827,

Nov 1938.

Procedure Numberof patients Died Unimproved Improved

or cured

Arterial aneurysms:

Attempted ligation

Proximal ligation

Partial proximal ligation

11

Suture of artery

Ligation of innominate and carotid

Ligation of innominate and subclavian

Ligation of innominate, carotid, and subclavian.

Arteriovenous fistulas: Transvenous suture; ligation of vein

Proximal and distal ligation of artery and distal

ligation of vein

Exclusive of preliminary ligations of the carotid and subclavian arteries, 38 operations were performed on 36 patients.

In 1, carotid and subclavian ligation had been performed 10 months previously.

One also had preliminary carotid ligation.

Following ligation of the innominate, the lesion recurred in patients. At the secondoperation in 1, the Innominate,

carotid, and subclavian were ligated and the sacexcised. Thiswas followed by cure. At the second operation in the

other, the carotid and subclavian were ligated. This was followed by cure, but years later recurrence took place with

rupture and death.

The sac was opened and evacuated, partially excised, and entirely excised in case each.
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 249

In view of the limited number of reports in the literature of surgical repair

of lesions of the innominate artery, and particularly in view of the small number

of successful cases reported, histories of certain of the patients with these

lesions observed in the vascular centers in the Zone of Interior in World War

II are herewith presented.

Case 2. 25-year-old soldier was stabbed in the right upper chest with sharp-pointed

barber scissors 11 November 1943. He became unconscious from loss of blood and was

treated for shock by transfusions of plasma and whole blood. Recovery was prompt and he

was returned to full duty in days. When he was reexamined April 1944, murmur was

discovered in the anterior part of the chest. His only complaint was dyspnea on exertion.

He was hospitalized at once and subsequently transferred to the vascular center at Ashford

General Hospital.

Examination at this center on November 1944 revealed small healed wound on the

anterior wall of the chest just below the right clavicle and inch lateral to the sternal border.

In this region could be felt well-defined continuous thrill, which was less distinct in the neck

and along the clavicle. loud, continuous murmur, intensified in systole, was audible.

The bruit was transmitted over the entire anterior part of the chest, both shoulders, and

both sides of the neck. It was also heard over the posterior part of the thoracic wall.

Neither the thrill nor the bruit could be obliterated by pressure. The blood pressure in

the left brachial artery was 135 mm. of mercury systolic and 50 diastolic and in the right

140 mm. of mercury systolic and 40 diastolic. The venous pressure in the left and right

cubital veins was 210 and 220 mm. of water respectively. teleoroentgenogram of the

heart which had been made October showed transverse diameter of 16.3 centimeters.

After month of rest second teleoroentgenogram, made few days after admittance to

Ashford, showed that this measurement had decreased to 15.2 centimeters. (Figs. 31A

and B.)

Operation was performed 18 January 1945. An incision beginning at the midportion

of the clavicle on the right was carried medially to the sternum and downward to the fourth

rib. The skin, with the pectoral muscles, was reflected laterally. The inner half of the

Figure 31. (Case 2.) Roentgenograms showing successive changes in size of heart in traumatic

arteriovenous fistula involving innominate vessels. A. Eleven months after injury. B.

Twelve months after injury and after month of rest. C. One month after correction of

fistula.
250 VASCULAR SURGERY IN WORLD WAR II

clavicle was resected subperiosteally and disarticulated at the sternoclavicular joint (Fig.

32). The second costal cartilage was resected together with about inches of the second

rib. The space beneath the manubrium sterni was entered by blunt dissection and the right

half of the manubrium divided, its connection with the first rib being left intact. portion

of the right half of the manubrium was removed with rongeur. The pleura was dissected

back by blunt dissection from the midline under the sternum, and the first rib with the

attached portion of manubrium was retracted upward and outward. The internal mammary artery and vein, with their branches, were ligated and divided. The regional fat and

remains of the thymus gland were removed. The innominate vessels were thus brought

into view. After considerable dissection fistula was found between the innominate artery

and the two innominate veins at their point of junction just above the arch of the aorta.

Both veins were greatly dilated, as was the artery proximal to the fistula. false sac had

been produced by local dilatation of the veins at the point of the fistula.

Figure 32. (Case 2.) Exposure of innominate vessels for correction of arteriovenous fistula. A. Removal of portion of clavicle, first and second ribs, and sternum. B. Fistula with

false venous sac. C. Transverse section showing false sac and communication between

ai tery and vein. D. Ligation and division of affected vessels.

The right innominate vein distal to the fistula was ligated and divided. The false sac

was separated from the aorta to which it was firmly bound, and the innominate artery

doubly ligated at its point of origin from the aorta. The thrill and bruit ceased completely

when this step of the procedure had been concluded. After ligation of the artery the pulse

rate dropped from 84 to 72 beats per minute and the blood pressure rose from 136 mm. of

mercury systolic and 60 diastolic to 156 mm. of mercury systolic and 100 diastolic. The

innominate artery distal to the fistula was then doubly ligated. It was not thought feasible,

however, to ligate the left innominate vein or the superior vena cava. Complete excision
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 251

of the fistula was considered, but it would have required ligation and division of both innominate veins, the superior vena cava and the innominate artery, and would have introduced the risk of cerebral edema. The operation was therefore discontinued at this point.

Since no branches of the innominate artery communicated with the fistula it was hoped

that the communication would be eliminated by what had already been done.

The sternum with the attached first rib was replaced and sutured with tantalum wire.

The musculocutaneous flap was replaced with interrupted silk sutures.

At the end of the operation, which required hours, the pulse rate was 68 beats per

minute and the blood pressure 140 mm. of mercury systolic and 82 diastolic. The hand

and fingers were warm.

Recovery was uneventful except that it was necessary to aspirate collections of blood

beneath the pectoral muscles on three occasions. The temperature did not rise above

normal at any time during the patient’s convalescence and the highest pulse rate was 100

beats per minute. The hand and fingers on the affected side were always warm. Teleoroentgenograms of the heart made on 13 February 1945, 3% months after last preoperative

determination, showed the transverse diameter to be 13.1 cm., reduction of 2.1 cm. (Fig.

31C). The venous pressure in the cubital veins on the same date was 154 mm. of water

on the left and 234 mm. on the right. Hand, arm, and shoulder movements were all within

normal range. Examination of the chest 17 May 1945 revealed neither bruit nor thrill

and the patient was considered cured.

Case S. 35-year-old officer was wounded 19 August 1944 by shell fragments which

caused large avulsed wound of the left thigh and small wound in the right infraclavicular

area near the sternum. When he arrived at general hospital in the Zone of Interior he

complained of buzzing, throbbing sensation in the right sternoclavicular area, but had

noted no other symptoms. Examination revealed an arteriovenous fistula in this area and

he was transferred to the vascular center at Mayo General Hospital.

Examination at this center revealed continuous thrill and murmur, most prominent

just below the sternal end of the clavicle. The bruit was transmitted downward toward

the heart, outward over the course of the subclavian and axillary vessels, and upward into

the neck, though in the latter region it was heard somewhat less clearly. Neither thrill

nor bruit could be eliminated by digital compression. There were no evident circulatory

changes in the right upper extremity. The electrocardiogram revealed no abnormality.

Roentgenograms revealed the presence of small fragment of metal below the sternoclavicular

joint, otherwise they showed nothing informative.

Exploration 16 February 1945 through the incision described in Case revealed fistula

between the internal mammary artery and the overlying innominate vein. The shell fragment was imbedded in the posterior wall of the vein. The vessel was indurated and scarred

in this area. The fistula was excised with quadruple ligation of the affected vessels.

Convalescence was uneventful and upon examination 10 months after operation, the

patient appeared cured.

Case 4- 24-year-old soldier was injured by shell fragments 20 October 1944. He

received penetrating wounds of the left malar region, the left side of the neck and the left

supraclavicular fossa. The shell blast caused temporary loss of consciousness. Shortly

after injury he lost his hearing on the left side and became hoarse. He was found to have

fracture of the maxilla and massive hemothorax. The fracture was reduced through

Caldwell-Luc approach and the hemothorax was treated by thoracentesis. As result,

his hearing began to improve, but distressing tinnitus and hoarseness persisted. He also

developed throbbing, aching pain in the left arm, and subsequently persistent left ulnar

hypesthesia. Decortication of the left lung was performed and after recovery he was transferred to the vascular center of Mayo General Hospital.

The patient was admitted to this vascular center March 1945 with diagnosis of

left carotid aneurysm. At this time he complained of abnormal pulsation in the left side
252 VASCULAR SURGERY IN WORLD WAR II

of the neck, throbbing pain in the left arm, numbness in the left ulnar area, tinnitus in the

left ear, watering in the left eye, and hoarseness.

Examination revealed pulsating mass at the base of the left side of the neck. No

thrill could be demonstrated, but there was loud systolic bruit. The bruit could be obliterated by digital compression. Pressure over the inner part of the mass interrupted carotid

pulsation and reduced the radial pulse. No circulatory disturbance of the left upper extremity was evident, but left ulnar hypesthesia was demonstrable. The patient also presented left recurrent laryngeal paralysis and bilateral deafness of the nerve type. The

blood pressure was 116 mm. of mercury systolic and 70 diastolic. Electrocardiograms

gave no evidence of abnormality and roentgenograms showed nothing informative. The

reactive hyperemia test, with the left subclavian artery occluded, gave evidence of good

collateral circulation.

The condition was diagnosed as traumatic aneurysm of the subclavian or the common

carotid artery. After repeated digital occlusion of the carotid artery, which was tolerated

without symptoms, operation was performed May 1945. large subclavian aneurysm

was found over which the left vagus nerve was stretched. Except that it was thinner than

normal the nerve seemed uninjured. The carotid artery was not involved.

The operative approach described in Case was used. The first portion of the subclavian artery was isolated medial and inferior to the sac and tape placed about it. The

subclavian artery was isolated distal to the sac and dissected back toward the involved area

beneath the aneurysm. When the artery was occluded proximally and distally the aneurysmal sac, though it ceased to pulsate, continued to fill rapidly with bright arterial blood.

This was demonstrated by needle aspiration. Since it was evident that the vertebral artery

also opened into the sac, it was feared that simple proximal and distal ligation of the subclavian artery would not effect cure. The vertebral artery, however, was inaccessible

because of the overlying aneurysmal sac and the adjacent scarring. The sac was therefore

carefully freed back to its mouth during temporary occlusion of the subclavian artery on

either side of the aneurysm, after which it was opened widely. Back bleeding was prevented by digital pressure while the subclavian artery was ligated just proximally and

distally. The vertebral artery could then be dissected free and ligated. The sac was totally

resected after the overlying innominate, subclavian, and internal jugular veins had been

ligated and divided.

The patient was in good condition throughout the procedure, but remained drowsy

afterward. There was no paralysis of the extremities. About hours after operation he

complained of severe headache. He became first stuporous, then comatose, and death

occurred 14 hours after operation. At necropsy extensive encephalomalacia of the left

cerebellum was found. No embolus was demonstrated, there was no thrombosis of the

left vertebral artery, and the circle of Willis was normal.

Case 5. 25-year-old soldier was struck in the right suprasternal region by small shell fragment 14 July 1944. There was no external bleeding, but thoracentesis was required

twice because of hemothorax. For while he progressed satisfactorily, but days after

injury when told that he was being returned to duty he became very hoarse and for several

days could not speak at all. Four months later, after he had been passed through several

replacement centers and hospitals, including psychiatric installation, right recurrent

laryngeal paralysis and mass in the anterior mediastinum were discovered. He arrived

in the Zone of Interior 10 December 1944.

The patient reached the vascular center of Mayo General Hospital 22 December 1944.

By this time he had regained his normal voice, but complained of constant sense of oppression accentuated by bending forward and localized in the upper anterior part of the chest,

also of substernal pain on deep inspiration, and some weakness of the right upper extremity.

He stated that this extremity was often darker in color than the left and that the veins of

the hand often appeared distended. He attributed weight loss of some thirty pounds to

poor appetite.
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 253

Examination revealed loud systolic bruit in the right supraclavicular fossa. similar

sound was present to lesser extent in the suprasternal notch and to the right of, and over,

the upper sternum. Pulses in the upper extremities were about equal in force. Blood

pressure was 134 mm. of mercury systolic and 80 diastolic in the right arm and 146 systolic

and 90 diastolic in the left. No color changes were noted in the extremities and sweating

was normal, but the veins of the right hand were somewhat distended. In room at 22° C.

the fingers of this hand were from to degrees cooler than those of the left hand. Oscillometric readings revealed that the oscillations were equal in both arms, but slightly less at

the right wrist than at the left. Tracings of the ergograph revealed some weakness of the

right hand. traumatic arterial aneurysm with right recurrent laryngeal palsy was suspected. He withstood prolonged right carotid compression repeatedly without difficulty.

Laryngoscopic examination showed paralysis of the right vocal cord. Electrocardiograms

revealed no abnormality. Roentgenograms demonstrated mass in the upper right section

of the anterior mediastinum (Fig. 33A).

Figure S3. (Case 5.) Roentgenograms showing innominate aneurysm. A. Approximately

months after injury. B. Fifteen days after partial ligation of innominate artery.

Note that the aneurysm is unchanged in size. C. Eleven weeks after second operation, at

which complete correction of the vascular lesion was accomplished.

Exploration was carried out 15 February 1945 through sternum-splitting incision

The sternum was divided down to the level of the third interspace and across into the interspace on both sides. This approach permitted the exposure of large saccular aneurysm

of the innominate artery. The lesion originated about cm. distal to the origin of the vessel

and involved considerable portion of its length. When the artery was occluded proximally

with rubber-shod clamp, the right hand immediately became extremely pale and cold, and

neither color nor warmth returned during the 15-minute period of occlusion. Because of

this observation it was thought unwise to carry out complete ligation. The artery was

therefore constricted to about one-half its diameter with strip of fascia secured with interrupted mattress sutures of silk; over this band of cellophane was placed. At the conclusion of the procedure the radial pulse was smaller on the right than on the left, and oscillometric studies showed oscillations in the right arm reduced by about 40 percent as compared with the left.

By the 15th postoperative day, oscillometric studies showed that the discrepancy

between the two arms had completely disappeared. The bruit in the right side of the chest

had, however, increased in intensity and was now the same as at the time of admittance.

Roentgenograms revealed no reduction in the size of the aneurysm (Fig. 33B). It was

thought possible that the band placed about the artery had given way, but, whatever the
254 VASCULAR SURGERY IN WORLD WAR II

reason, there was no evidence at this time that the artery was partially constricted. In

view of the ischemia which had occurred during complete temporary arterial occlusion, it

was decided to perform sympathectomy in the hope that it might render the collateral circulation adequate. The operation was performed April, and thereafter the right hand

was warmer and had better color than the left.

The mediastinum was again explored June. At the first operation the proximal

artery had been readily accessible, but not the subclavian which lay beneath the retracted

right side of the manubrium and the sternoclavicular joint. At the second operation, in

order to provide better exposure, division of the sternum was supplemented by resection of

the inner third of the right clavicle subperiosteally and by section of the anterior scalene

muscle. Exposure by this method revealed that the entire aneurysm, which lay in the right

side of the mediastinum, extended cm. above the upper border of the divided manubrium

and was about 10 cm long and cm. in diameter. It lay lateral to the artery and was

partially covered by the innominate vein.

The subclavian, internal jugular, and innominate veins were divided between transfixing ligatures and the intervening segment removed. Isolation of the proximal artery

was difficult because of the scarring in the vicinity of the previous partial arterial ligation.

In the process of isolating the artery the sac was torn just at its origin. Bleeding was effectively controlled by digital pressure while clamp was placed across the innominate artery,

and the carotid and subclavian arteries were divided between transfixing ligatures of silk.

The proximal innominate artery was then ligated with umbilical tape and transfixed and

ligated with silk just distal to the tape. The aneurysm was now completely stilled and

there was no bleeding. The sac was opened widely and large amount of laminated thrombus removed. Fibrin foam was placed in the wound before closure. The sternum was

brought together with three wire sutures, and the clavicular periosteal bed, the fascia, and

the skin closed with silk sutures. Two pints of whole blood were administered during the

operation and the blood pressure did not fall below 130 mm. of mercury systolic.

Two hours after operation nonpulsatile hematoma appeared in the wound. The

wound was opened, the clot evacuated, and the skin sutures replaced after thorough irrigation. Otherwise, the postoperative course was uneventful and the end result was satisfactory in every way except for persistence of slight general weakness and slight fatigability

of the right hand. When the patient was separated from service in September 1945 he still

had vocal cord paralysis, though he spoke well. Roentgenograms showed no mass in the

area formerly occupied by the aneurysm (Fig. 33C).

Case 6. 27-year-old soldier received shell-fragment wounds in the right thigh, left

buttock, back, and posterior aspect of the neck 28 January 1945. He was evacuated to the

Zone of Interior and was admitted to the vascular center of Mayo General Hospital with

diagnosis of right subclavian arteriovenous fistula.

When admitted to the hospital he complained of buzzing sensation in the right sternoclavicular area, numbness in the right ulnar distribution, and hyperhidrosis of the right hand.

Examination revealed continuous thrill centered over the sternoclavicular area, and

continuous bruit so loud that it masked all respiratory sounds in the chest. Neither

bruit nor thrill could be obliterated by digital compression. In comparison with the left

hand, the right hand was cooler and oscillometric studies showed reduction of oscillations.

Blood pressure in the right upper extremity was slightly reduced: 142 mm. of mercury

systolic and 76 diastolic. The electrocardiogram revealed no abnormality, and roentgenogram revealed nothing remarkable except for metallic foreign body under the sternal

end of the right clavicle.

Exploration on 13 June disclosed an arteriovenous fistula between the subclavian

artery at its point of origin and the innominate vein at the point at which it received the

internal jugular and the two subclavian veins. large anomalous vein entered the vena

cava proximally. The five veins involved could all be ligated without special difficulty.
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 255

The subclavian artery was ligated just distal to the fistula as it emerged from the innominate artery; the vertebral and internal mammary arteries, which originated in proximity to the

fistulous opening, were also ligated. The distal subclavian artery and veins were divided

between transfixing ligatures and part of the venous sac excised.

Convalescence was uneventful. Excellent circulation in the right upper extremity was

maintained.

Case 7. 24-year-old soldier sustained shell-fragment wounds of the abdomen, chest,

hands, right forearm and arm, and right leg 24 January 1945. These were debrided, an

exploratory laparotomy performed, and numerous thoracenteses done for bilateral hemothorax. Upon the diagnosis of an arteriovenous fistula he was evacuated to the vascular

center of Mayo General Hospital, arriving there 21 May 1945.

Examination revealed continuous murmur audible over the upper anterior part of

the chest and maximal over the right border of the sternum at the level of the second interspace. No thrill was palpable. There were no circulatory disturbances of the extremities.

Blood pressure was 124 mm. of mercury systolic and 60 diastolic. Electrocardiograms

showed nothing abnormal. Roentgenograms of the chest revealed mass in the upper

anterior mediastinum. The impression was that the condition was an arteriovenous and

saccular aneurysm, probably involving the innominate vessels.

It was impossible to close the fistula by compression and thus test the collateral circulation to the right upper extremity. The patient, however, tolerated carotid compression

without symptoms. Dorsal sympathectomy was performed July and followed by mediastinal exploration 17 September through an approach as described in Case 2.

The upper portion of the mediastinum was found to be filled with firm, pulsating

aneurysmal mass about by cm. in size. Associated with this was continuous thrill.

The carotid and subclavian arteries and the internal jugular veins could be identified at the

upper pole of the mass on each side; they appeared to emerge from the aneurysm itself.

The superior vena cava was free proximally but disappeared into the mass about cm.

from its cardiac end. The superior border of the arch of the aorta was fused with, and

partly buried beneath, the mass. Apparently the arteriovenous and saccular aneurysm

involved the innominate vessels, the origins of both carotid and subclavian arteries, the

terminal portions of the internal jugularveins, the superior vena cava, and possibly the arch of

the aorta. Since surgical extirpation was obviously impossible the wound was closed at once.

Convalescence was uncomplicated and the patient after his recovery was able to do

light work about farm.

Case 8. 24-year-old soldier was injured in the left thigh, leg, arm, and scapular area

by shell fragments 10 December 1944. femoral fracture and compound fracture of the

tibia and fibula were incurred. Following debridement of the wounds, the left upper and

lower extremities were placed in plaster casts. Soon after injury an arteriovenous fistula

in the left sternoclavicular region was found and the patient evacuated to the vascular

center of Mayo General Hospital. He arrived at this center in May of 1945.

Examination disclosed that the femoral fracture had progressed satisfactorily, but that

osteomyelitis had developed following the compound fracture of the tibia and fibula. The

patient had no complaints referable to the fistula, but left ulnar paralysis was present and

he complained of weakness of the left upper extremity. continuous thrill was palpable

and loud continuous bruit was heard over the left anterior chest wall and the left side of

the neck, most prominently in the sternoclavicular region. Neither bruit nor thrill could

be obliterated by digital compression. The fingers on the left hand were cooler than on the

right, and pulses and oscillometric readings presented evidence of reduced circulation in the

left upper extremity as compared with the right. After treatment on the orthopedic service

and left ulnar neurorrhaphy, dorsal sympathectomy was performed 30 August because of

the evidence of reduced circulation in the left upper extremity and the impossibility of

testing the collateral circulation.
256 VASCULAR SURGERY IN WORLD WAR II

preoperative diagnosis of arteriovenous fistula of the proximal portion of the subclavian vessels was made, and on 16 September mediastinal exploration was undertaken.

fistula was found between the subclavian artery just distal to the vertebral branch, and

the innominate vein near its distal end. After the vessels had been isolated proximally

and distally and the fistula dissected free and transfixed, it was discovered that there was

also present saccular aneurysm arising from the posterior surface of the artery opposite

the fistulous opening. The artery was badly damaged over considerable distance. It

was therefore ligated on either side of the aneurysm. The innominate, internal jugular,

subclavian, and internal mammary veins were divided and the aneurysm and fistula excised.

After an uneventful convalescence the patient was returned to the orthopedic service

for further treatment for osteomyelitis.

VERTEBRAL VESSELS

During World War II, 13 arteriovenous fistulas of the vertebral vessels

were observed at the vascular centers in the Zone of Interior. This was an

unusual experience. The collected reviews of Matas in 1893, 19 of Perrig in

1932,20 and of Heifetz in 1945,21 indicate that up to the date last named only

67 instances of this type of aneurysm had been recorded in the literature. The

differentiation between arteriovenous fistulas and false arterial aneurysms is

not brought out in all of these cases, but it seems clear that the great majority

were aneurysms. Arteriovenous fistulas involving the vertebral artery therefore seem to be among the most uncommon of arterial injuries, probably

because of the protection afforded by the peculiar anatomic location of that

vessel. The outcome is also not clear in all reported cases, but apparently

more than half of the patients died as the direct or indirect result of the vascular condition. This is much higher death rate than is associated with aneurysms or arteriovenous fistulas in almost any other location, and the explanation, again, seems to be the anatomic position of the vessels, with the resulting

difficulties at operation.

Diagnosis of aneurysms and fistulas of the vertebral vessels is difficult to

make. It was made with certainty in only of the 13 patients observed at

the vascular centers in World War II, though suspected in others. The most

common erroneous diagnosis is fistula between the internal jugular vein and

the branches of the external carotid artery. Vertebral arterial lesions may

also be confused with fistulas arising from other branches of the subclavian

artery, particularly the inferior thyroid, transverse scapular, and transverse

cervical vessels. Differentiation can usually be made on the basis of whether

or not the bruit disappears on compression of the common carotid artery. If

it does not, the vertebral vessels should be suspected as the site of the lesion;

They lie deep in the neck, and obliteration of the bruit by pressure is difficult

although not impossible.

19 Matas, R.; Traumatisms and traumatic aneurisms of the vertebral artery and their surgical treatment; report of

cured ease. Ann. Surg. 18: 477-521, 1893. 20 Perrig, H.: Zur Anatomic, Klinik und Therapieder Verletzungenund Aneurysmen der ArteriaVertebralis. Beitr.

z. Klin. Chir. 154 272-307, 1931. 21 Heifetz, C. J.; Traumatic aneurysm of first portion ofleft vertebral artery; case report. Ann. Surg. 122: 102-110,

Jul 1945.
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 257

At operation, confirmation of the diagnosis of vertebral arteriovenous

fistula can usually be made by process of exclusion. When the other vessels in the neck are isolated and temporarily occluded without effect on the thrill

and bruit, the chances are that the vertebral artery is involved. Occasionally,

however, collateral circulation is so ample that the bruit persists even during

proximal occlusion of the vertebral artery and vein.

Technical Considerations in Exposure of Vertebral Vessels

To comprehend the difficulties in exposing the vertebral artery, dis- cussion of its anatomic location is necessary. The extracranial portion of the

artery is divided, for descriptive purposes, into three parts:

The first (extraforaminal) portion is about cm. long. It arises from the

subclavian artery and ascends, on each side of the neck, to the lowermost

foramen in the transverse process usually of the sixth cervical vertebra. This

part of the vessel runs upward and backward between the longus colli and the

anterior scalene muscles. Between it are the transverse process of the seventh

cervical vertebra and the sympathetic chain. In front are the vagus nerve,

the internal jugular vein, and the sternomastoid muscle which lies in front of

the internal jugular vein. The upper portion of the first part of the vertebral

artery is crossed by the inferior thyroid artery as it passes medially. It does

not enter the foramen in the transverse process of the seventh cervical vertebra, but lies in front of it.

The second portion of the vertebral artery passes upward through the

transverse processes of the upper six cervical vertebrae. In this part of its

course it lies anterior to the cervical nerves and inferior to the anterior scalene

muscle. It is surrounded by venous complex which terminates below in the

vertebral vein. Overlying this part of the artery and slightly to its medial

side is the internal jugular vein and, more superficially, the sternomastoid

muscle. In the upper part of the second portion of the vertebral artery the

spinal accessory nerve is found about fingerbreadths below the mastoid

process. Underneath the sternomastoid muscle the dense prevertebral fascia

covers the levator scapulae muscle which arises from the transverse process

of the upper four cervical vertebrae and therefore directly overlies the vertebral

vessels in their course through the upper four foramina.

The third portion of the vertebral artery begins at the point at which it

emerges from the foramen of the atlas. It turns backward and lies in groove

on the upper surface of the atlas where it is covered by the semispinalis capitis

in the suboccipital triangle. The guide to the artery in this portion of its

course is the transverse process of the atlas which can easily be palpated

fingerbreadth below, and fingerbreadth in front of, the tip of the mastoid

bone. The vessel is more easily identified when the sternomastoid muscle is

detached from its origin.

Approach to any portion of the vertebral vessels is difficult because of the

deep position and the vital nature of the surrounding structures. Approach to
258 VASCULAR SURGERY IN WORLD WAR II

each portion, moreover, must be considered separately because the anatomy of

each portion varies.

In the first portion, exposure is best achieved through an incision parallel

with the fibers of the sternomastoid muscle directly over the interval between

the sternal and clavicular heads of that muscle. After incision of the deep

fascia, the heads of the muscle are separated and retracted (Fig. 34). Some of

the fibers may be divided transversely if better exposure is necessary. The

internal jugular vein, when it is encountered in the depth of the incision, is

retracted medially and the triangular interval between the longus colli and the

anterior scalene muscles is developed. The inferior thyroid artery, which will

be found running upward and medially and crossing in front of the vertebral

artery in this region, must be carefully isolated. The vertebral artery arises

medial to the inferior thyroid artery and can be identified in this location by its

pulsation. The vertebral vein lies anterior to the artery, and on the left the

thoracic duct passes in front of it. This portion of the vertebral artery must

always be identified as preliminary to operations on the vessel anywhere in

its course. ligature passed around it, but left untied, is protection against

hemorrhage later in the operation, though it will only diminish bleeding, not

control it, because of the rich anastomotic blood supply in the vertebral system.

Ligation of the artery should not be done at this point in the operation since

the thrill and bruit would thus be obliterated and identification of the fistula

thus become more difficult.

The second portion of the vertebral artery is reached by an incision along

the anterior border of the sternomastoid muscle. After the deep fascia is

opened the muscle is retracted laterally and the carotid sheath identified and

retracted medially. It is usually necessary to divide the omohyoid muscle as

it passes across the carotid sheath. The anterior scalene muscle, which arises

from the transverse processes of the third, fourth, fifth, and sixth cervical

vertebrae, is retracted laterally and may be detached from its origin in order

to expose fully the transverse processes through which the vertebral vessels

pass. The interval between the transverse processes is less than fingerbreadth, which makes ligation in this region particularly difficult unless one

(or more) of the transverse processes is removed with rongeur. If this is

done ligature may be passed about the vessel preferably on an aneurysm

needle, or the vessel may be occluded by the use of heavy metal clips.

Exposure of the upper portion of the second part and of the third part of

the vertebral vessels is much more difficult than exposure of the other portions.

The technique suggested by Henry 22 is most satisfactory. The patient lies

on his back with his neck extended and his chin turned to the side opposite

the involved vessels. An incision is made along the anterior border of the

sternomastoid muscle from the middle of the neck to the mastoid process. The

deep fascia is opened. The insertion of the sternomastoid muscle is cut away

22 See footnote 1, p. 230.
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 259

Figure 34■ Surgical approach to fistula between lower portions of the right vertebral vessels

from the bone and the muscle reflected laterally. The spinal accessory nerve

is isolated and mobilized as it passes laterally and downward beneath the

sternomastoid muscle (Fig. 35). Once the sternomastoid muscle is reflected,

the tip of the transverse process of the atlas is easily identified. The prevertebral fascia is divided from above downward, the origin of the levator

scapulae muscle cut away from the atlas and axis, and turned downward.

Further dissection exposes the vertebral artery and surrounding venous plexus

in the interval between the atlas and axis, as well as in its third portion.

Whenever necessary, the transverse processes of the cervical vertebrae

should be removed in order to expose completely the lesion and its contributing

vessels. If the lesion is close to the origin of the vessels from the subclavian

artery, resection of the inner third of the clavicle facilitates control of the blood

supply. This is useful step when the lesion is in the intraforaminal portion of
260 VASCULAR SURGERY IN WORLD WAR II

Figure 35. Surgical approach to fistula between upper portions of the left vertebral vessels.

the artery. Before it is carried out, however, the slips of the scalene, the longus

colli, and longus capitis muscles which are attached to the transverse processes

must be stripped away by sharp dissection and the use of periosteal elevator.

In three cases observed at the vascular centers the overlying transverse processes

could be removed without injury to the underlying vessels by gently depressing

the vessels during the excision of the bony processes with small rongeur.

If there is difficulty in controlling the spinal branches, the branches can be

isolated and either ligated with silk or clipped with silver clips. When this is

not possible, bleeding can be controlled by packing with muscle or fibrin foam.

Technical Considerations in Management of Vessels

There was no evidence of cerebral circulatory difficulties inany of the cases

observed at the vascular centers. All of the patients had practiced prolonged

carotid compression before operation and could withstand it for practically

half an hour without symptoms. The abundant collateral circulation about

the vertebral vessels in the neck and the communication in the circle of Willis

would lead one to assume that cerebral ischemia would not usually follow

ligation. One of us, however, observed case in which aneurysmorrhaphy of
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 261

large subclavian aneurysm required ligation of single vertebral artery, but of

no other vessel supplying the brain. 23 The patient died within 24 hours, and

necropsy revealed homolateral cerebellar necrosis without evidence of thrombosis or embolism.

In the 13 patients with vertebral arteriovenous fistula treated in the vascular centers of the Zone of Interior in World War II, the lesion was known

to be located in the first portion of the vessel in patients, in the second portion

in 6, and in the third portion in 3. No attempt was made in any instance to

repair the fistula. The position of the vessels as well as their small size precluded the effort. Anatomic reasons prevented actual excision of the fistula

except in instances, and obliteration of the fistula was therefore usually

accomplished by proximal and distal ligation of the vessels and by the placing of mass ligatures.

Since arteriovenous fistulas involving the vertebral artery are so rare, three case reports from the experience at Ashford General Hospital are

herewith presented.

Case 9. On 28 June 1944, soldier was struck in the right arm and neck by multiple fragments of an artillery shell. There was profuse bleeding from all wounds. The neck

wound was debrided and healed promptly. Approximately weeks later he noted buzzing

sensation in the left side of the neck, but did not hear any noise. He reported this to his

medical officer who made diagnosis of arteriovenous fistula. On admittance to the vascular

center of Ashford General Hospital months later, examination revealed that there was

small scar overlying the upper portion of the left sternomastoid muscle about cm. below

the angle of the mandible. There was continuous bruit and thrill heard and felt over this

area which were transmitted up the scalp to the parietal region and into the neck to the

clavicle. Deep pressure failed to obliterate the bruit and thrill. It was thought that this

was an arteriovenous fistula of the second portion of the left vertebral vessels.

On 30 December 1944, the first portion of the vertebral artery was ligated and divided.

This caused the thrill and bruit to be almost completely obliterated. On February 1945,

an incision was made from the level of the thyroid cartilage upward along the anterior

border of the sternomastoid muscle to the mastoid process and then turned backward

severing the sternomastoid from the skull at its insertion. The muscle was retracted laterally

and the third cervical nerve and the spinal accessory nerve isolated. The levator scapulae

muscle was detached from its origin from the atlas, axis, and third and fourth cervical

vertebrae. The vertebral vessels were then isolated between the transverse processes of the

atlas and axis. The sensory branch of the second cervical nerve overlying the vessels was

dissected free and the vertebral artery divided between ligatures. Several smaller vessels

in this region were also ligated. The vein was not ligated. This stopped the thrill, but

bruit was still present. As time passed the bruit increased in intensity.

On 25 April 1945, the scar on the left side of the neck was excised and the sternomastoid

muscle retracted laterally. The transverse processes of the first, second, third, and fourth

vertebrae were exposed. The levator scapulae muscle was detached from the transverse

process of the atlas and the spinalis group of muscles freed from the transverse processes of

the exposed vertebrae by sharp and blunt dissection. The lateral roofs of the foramina

transversarium of the third and fourth cervical vertebrae were removed by rongeur. This

exposed the vertebral vessels for distance of or centimeters. The fistula was apparently

23 Shumacker, H. B., Jr.: Arteriovenous fistulas of the cervical portion of the vertebral vessels. Surg., Qynec.

Obst. 83: 625-630, Nov 1946.
262 VASCULAR SURGERY IN WORLD WAR II

at the level of the inferior border of the canal of the third vertebra. Ligatures were passed

about the vessels proximal and distal to the fistula, and the vessels ligated. Silver clips were

applied above and below the fistula. This caused the bruit and thrill to disappear completely.

At the time of discharge months later there had been no recurrence of the bruit

or thrill.

Case 10. soldier was wounded in July 1944 by fragments of high explosive shell.

There was wound below and behind the right mastoid process and one on the back of the

right hand. He was unconscious for 15 minutes and bled profusely from the neck wound.

The wounds were debrided and he was returned to England where the fragment was removed

from the right hand. Forty-three days after injury he was returned to combat duty. Four

months later he was evacuated because of combat exhaustion. Upon routine physical

examination the presence of an aneruysm of the right side of the neck was discovered and he

was returned to the United States. The patient was admitted to the vascular center of Ashford General Hospital 21

November 1945. His only complaint at that time was of buzzing sensation in his right

ear when lying on that side. Examination revealed healed wound just posterior to the

upper third of the right sternomastoid muscle. In this region thrill was felt and continuous bruit heard. The bruit was transmitted throughout the neck, upward behind the

ear. In was easily obliterated by pressure over the right common carotid artery. Upon

obliteration of the fistula the pulse fell from 80 to 72 beats per minute and the blood pressure

rose from 120 mm. of mercury systolic and 68 diastolic to 120 systolic and 80 diastolic.

diagnosis of arteriovenous fistula of the internal carotid artery and internal jugular vein

was made.

On December 1945, an incision was made parallel to the anterior border of the right

sternomastoid muscle. Since it was thought that the fistula involved the internal carotid

artery, the carotid vessels were identified at their bifurcation and ligatures passed about the

common, internal, and external carotid arteries. Occlusion of these vessels singly or in

combination did not diminish the bruit. Compression at slightly lower level in the neck

obliterated the thrill. Dissection was carried out interiorly and the vertebral artery

identified. It was found that occlusion of this vessel stopped the bruit and thrill. Ligatures

were passed about the vertebral vessels. The incision was then extended upward with

detachment of the sternomastoid, longus colli, splenius capitis, and levator scapulae muscles

from their origins. In this manner the transverse processes of the upper two cervical

vertebrae were exposed. The transverse processes of the second cervical vertebra were

removed and ligature passed about the vertebral vessels at this point. Occlusion of the

vessels did not result in cessation of the thrill. The third transverse process was similarly

removed with isolation of the vessels at the level of the third cervical vertebra. Compression

at this point resulted in cessation of the thrill. The vertebral vessels were then ligated at

the site of the second and third transverse processes. mass ligature was tied in the interval

between these sutures with further obliteration of segment of vessel. Slight bleeding was

encountered at this time due to the tearing of small branches of the vertebral artery. Further

to insure occlusion, tantalum clip was applied at the site of the fistula. The vertebral

artery was doubly ligated in its first portion and tantalum clip applied at the point at

which it entered the sixth vertebra.

Recovery was uneventful. There was no recurrence of the bruit. At the time of the

patient’s discharge months later, there was no evidence of recurrence of the fistula.

Case 11. soldier was wounded in action 18 December 1944, when he was struck in

the left side of the neck by shell fragment. The wound of entrance was just inferior and

posterior to the angle of the mandible. There was no wound of exit. There was no excessive bleeding and no loss of consciousness. The wound was allowed to heal by second

intention. There was marked diminution in the hearing of the left ear after the injury, and

he was conscious of continuous buzzing in that ear. He was evacuated to the United
EXPOSURE AND MANAGEMENT OF BLOOD VESSELS 263

States and admitted to the vascular center of Ashford General Hospital November 1945.

Examination revealed scar about cm. in diameter just inferior and posterior to the angle

of the left mandible. There was small sinus in the region of this scar from which limited

amount of serous fluid could be expressed. continuous bruit transmitted to the base of

the neck, was heard over this region. It could not be obliterated by occlusion of the common

carotid artery or by pressure anywhere in the neck. diagnosis of vertebral arteriovenous

fistula was made.

On 31 January 1946, 6-cm. transverse incision was made above the medial end of the

left clavicle. The two heads of the sternomastoid muscle were separated and the vertebral

artery isolated near its origin from the subclavian. Occlusion of this artery did not obliterate

the bruit, however it did diminish it. This wound was covered, and 10-cm. longitudinal

incision was made along the medial edge of the sternomastoid muscle extending from the

level of the thyroid cartilage upward to the mastoid process, then curved laterally over the

mastoid process so that the sternomastoid muscle was detached at its insertion. The spinal

accessory nerve was isolated and the sternomastoid muscle reflected outward and downward.

The splenius capitis muscle was reflected downward from the transverse process of the atlas.

This exposed the vertebral vessels between the axis and atlas. Compression of the vessels

in this region did not obliterate the bruit, although it did diminish it. It was then felt that

the fistula involved the third portion of the vertebral vessel. The rectus capitis muscle

was detached from its origin to the transverse processes of the atlas and axis and reflected

downward. This exposed only approximately cm. of the third portion of the vessels. It

was therefore necessary to remove the transverse process of the atlas in order to expose

adequately the third portion of the vessels. The vessels were then mass ligated distally and

proximally to the fistula with two ligatures which were passed about the vessels. This

caused the thrill to disappear completely, but the bruit was still slightly audible. It was

assumed that there were branches between the proximal and distal ligatures. Three other

sutures were passed about the vessels between the proximal and distal ligatures and this

caused the bruit to disappear completely. The vessels were not divided. The divided

muscles were approximated with interrupted silk sutures.

The postoperative course was uneventful. There was no evidence of recurrence of the

bruit or thrill months after operation.

THE ILIAC VESSELS

Approach to the iliac vessels is through retroperitoneal incision. The

peritoneum and abdominal contents are displaced medially to obtain exposure

of the ureter in its lower portion. Lesions of the distal external iliac vessels

are approached through an oblique incision just above Poupart’s ligament.

The fascia of the external oblique muscle is divided and the external ring

opened. The internal oblique muscle and the transversalis fascia are divided

in the direction of their fibers. The iliac vessels are then readily exposed above

the inguinal ligament, and the femoral vessels can be exposed below the

ligament, if necessary. If exposure is inadequate, the inguinal ligament can be

transected to obtain more complete exposure and resutured at the close of the

procedure. Closure of the wound is carried out as in herniorrhaphy.

330323 0—55 18
CHAPTER VIII

Arterial Aneurysms and Arteriovenous Fistulas

Maintenance of Arterial Continuity

Norman E. Freeman, A4. D.* and

Harris B. Shumocker, Jr., M. D.

Though the principles which underlie vascular repair, the precautions

which must be observed, the hazards entailed, and the methods applicable,

have since been established by experimental investigations upon laboratory

animals, actually the first closure of an arterial defect was carried out upon

man. Indeed this lateral closure was performed some 125 years before another

successful instance of arterial repair in man or experimental animal was

accomplished. Dozens of workers contributed to the evolution of the reparative techniques now employed, but Carrel’s beautifully planned and executed

experiments perhaps served more than any other investigation to revive and

maintain interest in the use of these measures in the management of both

arterial aneurysms and arteriovenous fistulas.

The first clinical application of the principles of arterial repair seems to

have been made in 1759 when Hallowed, acting on Lambert’s suggestion,

closed small wound of the brachial artery by placing pin through the margins, elevating the lacerated area, and twisting thread about the pin. The

next reported successful arterial repair in man was performed in 1886 by

Postempski, who, by lateral arteriorrhaphy, repaired rent in the femoral

artery which he had made accidentally while draining an abscess. By 1903

Hopfner was able to collect from the literature reports of 30 successful

operations in which reparative techniques had been used.

In 1888 Matas introduced endoaneurysmorrhaphy, method of intrasaccular suture. This technique was first applied “while operating upon traumatic brachial aneurysm which had resisted proximal and distal ligature.”

It was subsequently systematized as method and carried out also in other

•Associate Clinical Professor of Surgery, University of California School of Medicine. Formerly Lt. Colonel, MC,

AUS.

Lambert, R.: Wound of artery treated by pin suture. Med. Obs. Soc. Phys., London, 1762, vol 2, p. 360-364.

Carrel, A.: Surgery of blood vessels. Bull. Johns Hopkins Hosp. 18: 18-28, Jan 1907.

See footnote 1, above.

Postempski, P.: La sutura del vasi sanguigni. Arch. Soc. Ital. chlr. Roma 3; 391-395, Apr 1886.

Hopfner, E.: Uber Gefassnaht, Oefasstransplantationen und Replantation von amputlrten Extremitaten. Arch,

f. klin. Chlr. 70: 417-471, 1903.

Matas, R.: Traumatic aneurysm of the left brachial artery; incision and partial excision of sac; recovery.

Phila. Med. News 53 462-466, Oct 1888.
ARTERIAL REPAIR 265

cases of popliteal and femoral aneurysms. In 1903 Matas recommended

restoration of the circulation through the damaged artery as the ideal treatment for arterial aneurysms. In the following year Bickham suggested that

the Matas endoaneurysmorrhaphy be employed for the intravascular repair

of arteriovenous fistulas and recommended transvenous closure of the defects

in the vascular walls as practical method of preserving the continuity of both

artery and vein.

The first end-to-end arterial suture in man was reported by Murphy in

1897. The lesion was traumatic arteriovenous fistula. He closed the wound

of the vein, resected the damaged portion of the artery, and accomplished

successful end-to-end anastomosis by invaginating the proximal into the

distal segment. In the same year Djemil-Pascha 10 also reported two successful

cases in which this technique was used. Although the first end-to-end arterial

sutures in man were performed by the invagination method devised by

Murphy, it subsequently became apparent that direct approximation of the

divided ends of the artery was superior method.

In 1906, shortly after Carrel 11 and his associates had demonstrated the

possibility of arterial repair by transplantation of vein, Goyanes 12 treated

syphilitic popliteal aneurysm by proximal and distal ligation and then reestablished the blood flow by anastomosing the femoral artery to the distal

end of the divided femoral vein and the proximal end of the divided popliteal

vein to the distal segment of the popliteal artery. Good circulation was

maintained through the venous segment and into the popliteal artery, and

feeble dorsalis pedis and posterior tibial pulses were palpable during the brief

(6-day) postoperative period of observation. In 1907 Lexer 13 reported case

in which he repaired traumatic axillary aneurysm by excising it and then

suturing segment of the saphenous vein into the arterial defect. The patient

died of an unrelated cause (delirium tremens) on the fifth postoperative day,

but necropsy revealed that the vein graft was intact and the brachial artery

patent. Lexer subsequently employed the same technique in several other

cases. The first successful vein graft to be recorded in the American literature

was performed by Bernheim 14 in 1916. He used such graft to bridge defect

in the popliteal artery following excision of syphilitic aneurysm.

Matas, R.: Operation for the radical cure of aneurysm based upon arteriorrhaphy. Ann. Surg. 37: 161-196, Feb

1903.

Bickham, W. S.: Arteriovenous aneurisms. Ann. Surg. 39; 767-775, May 1904.

Murphy, J. B.: Resection of arteries and veins injured in continuity; end-to-end suture; experimental and clinical

research. Med. Record N. Y. 51: 73-88, Jan 1897. •°Djemil-Pascha: Uber die Arteriennaht. Kongress Moskow. Centralblatt f. chir. 24: 1048, Aug 1897, No. 39.

11 Carrel, A., and Guthrie, C. C.; Uniterminal and biterminal venous transplantations. Surg., Qynec. Obst. 2:

266-286, Mar 1906. 12 Goyanes, J.: Nuevos trabojas de cirugia vascular; sustitucion plastica de las arterias por las venas, arterio-plastia

venosa, aplicada, como nuevo mfitodo, al tratamiento de los aneurismas. Slglo m6d. 53 561-564, Sep 1906.

13 Lexer, E.: Die ideale Operation des arteriellen und des arteriell-venosen Aneurysma. Arch. f. klin. Chir. 83;

459-477, 1907. 18 Bemheim, B. M.: Ideal operation for aneurisms of the extremity; report of case. Bull. Johns Hopkins Hosp. 27;

93-95, Apr 1916.
266 VASCULAR SURGERY IN WORLD WAR II

Between World Wars and II increased knowledge regarding the peripheral

circulation radically altered the surgical approach to arterial lesions. The

surgeon of the Second World War was far better equipped to handle casualties

with vascular injuries than was the surgeon of the First World War. It is

true that results achieved in the treatment of acute arterial injuries were little,

if any, better in World War II than in the earlier war. On the other hand, the

record of the vascular centers established in the Zone of Interior in the Second

World War for the definitive treatment of arterial injuries was extremely

impressive. This record can be attributed in part to better understanding of

fundamental physiologic mechanisms and to developments in the basic medical

sciences. In addition, advances in anesthesiology, chemotherapy, and adjuvant

supportive measures, particularly the use of whole blood transfusions, played

an important role. From the standpoint of technique, of course, the good

results obtained could be attributed to the careful and general application of

Halsted’s principles concerning the handling of tissues and to the surgical

teachings of Matas, particularly to his emphasis on the importance of the

preservation of all collateral vessels.

In general the surgical methods for the management of arterial aneurysms

which were being employed at the outbreak of World War II were:

1. the endoaneurysmorrhaphy devised by Matas;

2. measures designed to produce clot in the aneurysmal sac or to induce

the formation offibrous tissue about it and thus prevent further expansion and

possible rupture;

3. obliteration of the sac by closure of the offending vessel;

4. extirpation of the aneurysm-bearing portion of the artery; and

5. extirpation of the lesion combined with some procedure which permitted

maintenance or reestablishment of the continuity of the affected artery.

Surgical methods for the management of arteriovenous fistulas were in

general;

1. mass ligation of the fistula; 2. quadruple ligation and division of the main vessels with excision of the

fistula;

3. transvenous closure of the arterial opening; and

4. repair of the opening in both artery and vein.

While it had long been recognized that the ideal method of management

of arterial aneurysms and arteriovenous fistulas involving important arteries

was some procedure which would permit the maintenance or restoration of the

continuity of the affected artery, the general feeling was that operations of this

kind were fraught with too much risk to justify their extensive clinical use.

However, technical improvements in vascular surgery and the development of

the means of combating postoperative thrombosis had begun to alter this

situation, and by the time World War II commenced the total number of clinical

cases in which some type ofreparative surgery was being performed was on the

increase.
ARTERIAL REPAIR 267

In World War II the large numbers of patients with arterial lesions and

their concentration in the three vascular centers in the Zone of Interior where

they were cared for by experienced vascular surgeons, permitted the selection

of numerous cases for reparative surgery. This chapter is concerned with

report of that experience at the vascular centers of DeWitt General Hospital

and Mayo General Hospital.

CRITERIA FOR SELECTION OF CASES

The attitude of the surgeon, perhaps more than any other single consideration, determines whether or not reparative procedures shall be applied in the

management of arterial aneurysms and arteriovenous fistulas. At the vascular

center of Mayo General Hospital it was originally the practice to use this

method of treatment only in those cases in which it was reasonably certain that

normal arterial structure could be utilized and in which the operation could be

performed without undue difficulty. An examination of those cases in which

the lesion involved the arteries upon which the main blood supply to part is

dependent and in which repair is most desirable—innominate, common carotid

and extracranial portion of the internal carotid; the subclavian, axillary, brachial, iliac, common femoral, and popliteal arteries—revealed that only

reparative procedures had been carried out in the first 138 cases handled at

this center. This amounted to 2.9 percent. After this assessment of the

situation it was decided that repair would be carried out in every instance in

which it could possibly be performed without sacrificing collateral arteries and

without leaving in situ obviously badly damaged portions of arteries. This

altered approach resulted in the use of reparative procedures in 30 of the last

57 cases handled in this vascular center (52.6 percent). At DeWitt General

Hospital this altered approach resulted in the use of reparative procedures in

23 of 67 patients operated upon for arterial lesions between June and November

of 1945 (34.3 percent).

In few cases reparative surgery was undertaken when the outcome was

questionable because of the degree oflocal damage and the presence of infection,

but this was done in the hope that success would follow and the indications for

reparative methods would be, thereby, extended. While it is true that almost

all of the failures occurred in this group, it is also true that results in many of

the questionable cases were successful.

Problems of Arterial Repair

Although the attitude of the surgeon is of paramount importance in the

application of reparative procedures to the surgery of aneurysms and fistulas,

the anatomic situation revealed at operation often precludes reparative surgery.

In the first place there may be thrombosis of the distal artery. In number of

cases this has made impossible any arterial repair. According to Bigger, 15

Bigger, I. A.: Treatment of traumatic aneurysms and arteriovenous fistulas. Arch. Surg. 49: 170-179, Sep 1944.
268 VASCULAR SURGERY IN WORLD WAR II

calcification of the wall of the artery in the area to be sutured represents the

most important contraindication to repair. Extensive arterial obliterative

disease has also often made arterial repair impossible, though this factor was

not of importance in the aneurysms and arteriovenous fistulas observed during

World War II because most of them were of traumatic origin. However, repair under unfavorable circumstances was sometimes attended with success.

In one case treated at vascular center in the Zone of Interior, vein graft was

successful in spite of extensive medionecrosis of the popliteal artery (Table 32,

Case 32).

In traumatic lesions, extensive damage to the artery is often determining

factor in preventing restoration of continuity, at least by the simpler means

such as lateral arteriorrhaphy or end-to-end anastomosis. In contrast to the

limited injury to the artery which is the rule when aneurysms or fistulas have

resulted from stab wounds, for example, there is generally extensive injury

when these lesions have resulted from shell fragments, land mines, or bullets, as was the case in almost all of the patients observed at the vascular centers.

There is frequently gross and much more often microscopic injury to the

artery, not only in the immediate neighborhood of the aneurysm or fistula,

but some distance from it. Whether the damage which is evident only on

microscopic examination is real threat to successful arterial repair is still an

unsettled question. The military experience of World War II did not solve

this problem.

fairly common contraindication to end-to-end suture or vein graft is

the presence of an important collateral vessel so near the end of the undamaged

portion of the artery that to utilize these methods of repair would mean to

sacrifice the collateral vessel. Except in the occasional case in which circumstances are such that continuity of the artery can safely be maintained by some

simpler procedure such as ligation and transfixion of fistula, definitive surgery

should not be undertaken without good evidence that the collateral circulation

is entirely satisfactory. It is almost never the part of wisdom to sacrifice

sizeable collateral vessel in order to achieve preservation of the artery. This

principle was never violated in the cases observed in the vascular centers in

the Zone of Interior during World War II. Arteriovenous communications are frequently not simple fistulas but are

associated with one or several saccular aneurysms as well. Sometimes these

aneurysms arise from the veins or from the fistula itself, but often they originate

in the artery and can be corrected only by excision of the involved segment.

When this is necessary, unless the ends of the vessel can be mobilized sufficiently

to permit approximation, vein transplant is the only means of restoring an

arterial vessel. Such transplant is an ingenious means of bridging an arterial

defect, but the threat of thrombosis is probably greater when this technique

is employed than when end-to-end suture or lateral arteriorrhaphy is employed.

It should be noted that associated nerve lesions requiring suture were not

considered contraindication to arterial repair. Nerve lesions were present
ARTERIAL REPAIR 269

in number of the combat-incurred vascular lesions discussed in this chapter

but they presented few difficulties of management. The usual procedure was

(1) to dissect free the involved nerve or nerves, (2) to excise the aneurysm or

fistula totally or subtotally, (3) to accomplish arterial repair, and (4) to perform

the necessary nerve surgery.

The chief local factors which endanger the success of the repair appear to

be damage to the wall of the artery (a determining factor in repair in many of

these lesions which were of traumatic origin), infection, and lumen of such

small diameter as to make difficult accurate approximation of the parts.

TECHNICAL CONSIDERATIONS IN VASCULAR REPAIR

The general principles of vascular surgery were carefully observed in all

reparative operations. Asepsis was strictly maintained. All the vessels were

handled gently to avoid local injury, and the intima was always kept moist

with physiologic salt solution or mineral oil. Nontraumatizing methods were

employed to occlude the blood supply—rubber-shod serrefine artery clamps

were used at Mayo, rubber tubing clamped close to the vessel wall by means

of fine curved hemostats at DeWitt. The edges of the vessels were carefully

brought together with fine suture material in such way as to approximate

intima-to-intima. Care was always taken not to allow the adventitia to fall

within the suture line.

Complete control of the arterial supply to an arteriovenous fistula is

essential for repair. Occlusion of the principal afferent and efferent arteries

often does not suffice. At the vascular centers the use of sterile stethescope

at the time of operation was found to be invaluable in confirming the completeness of the control of the arterial components. Persistence of bruit signified

that some additional arterial supply was present.

Complete control of the venous component facilitates the repair, but such

control may require prolonged and tedious dissection and may result in destruction of collateral vessels. In patients at the vascular center of DeWitt

General Hospital, control of the arteries alone was achieved. At the moment

of severing the connection between the artery and the vein or the aneurysmal

sac, digital pressure was used to control the venous bleeding. Suture of the

open vein was then readily accomplished. In patients at this center, after

the afferent and efferent arteries had been isolated, pneumatic tourniquet,

which had previously been placed about the extremity at higher level, was

inflated. This procedure was not especially useful since the venous system in

the presence of an arteriovenous fistula is capacious and therefore already full

of blood. In all of these cases retrograde bleeding necessitated digital pressure

in addition to the use of the tourniquet. In several instances the venous

pressure appeared to be even higher when the tourniquet was used than when

it was not.
270 VASCULAR SURGERY IN WORLD WAR II

Careful inspection of the wall of the damaged portion of the artery was

another important phase of the reparative procedure. The incidence of

additional points of damage of the arterial wall in the presence of arteriovenous

fistulas is high. After irrigation of the lumen of the artery, the entire wall

was carefully inspected both from within and from without. Two defects

each, for instance, were present in arteries of of the patients in the DeWitt

General Hospital series, the first communicating with the main vein and the

second with an aneurysmal cavity or another vein. In seventh patient

three venous communications were present. One objection to the transvenous

method of closure is that additional defects or weak points in the arterial wall

may be overlooked.

At the vascular center of DeWitt General Hospital excision of the damaged

arterial wall was the preferred method. After excision of part of the arterial

wall the resultant defect was closed by approximation of its edges. Usually,

in the presence of an arteriovenous fistula, the artery, especially the proximal

portion, has become so dilated that sufficient length is readily available. The

preference at this installation was to use any sound portion of the arterial wall,

even to one-sixth of the circumference (Case 13) rather than to perform

complete transection of the vessel with end-to-end anastomosis. In 11 patients

at this center portion of the arterial wall was excised. The use of the wall of

the sac, or of segment of vein, to reconstruct the arterial wall was not practiced

on the ground that this tissue, which is largely fibrous, cannot withstand the

increased pressure to which it is subjected in its new location. The recurrence

of the arterial aneurysm in patient at the DeWitt General Hospital (Case 11)

was thought to be an illustration of the futility of using anything but normal

arterial wall in the repair.

Transverse closure of the defect in the arterial wall sometimes produces

distortion of the wall and turbulence of the blood stream. Auscultation over the

vessel at the suture line occasionally reveals loud, sharp, systolic murmur

which may be audible through the skin and soft tissues even after healing has

taken place. It was the experience at DeWitt General Hospital where 16

patients were treated by this method of repair, that in the absence of diastolic

component the murmur is without significance. The distortion of the vessel

which may be produced by the transverse closure is, in fact, likely to be

advantageous: The greater diameter at the point of closure may serve to prevent

thrombosis and thus may increase the likelihood of successful repair.

At DeWitt General Hospital approximation of the edges of the incised

vessels was facilitated by manipulating the rubber tubing and clamps which

had been placed above and below the fistula to occlude the artery. If this

maneuver did not work, additional relaxation was obtained by dissecting the

artery up to the point of origin of the nearest branch. However, no important

collateral vessel was sacrificed.

At the vascular center of Mayo General Hospital in instances of arteriovenous fistula in which the fistula was not closed by ligation and transfixion or
ARTERIAL REPAIR 271

by lateral arteriorrhaphy, the affected segment of both artery and vein, together

with the fistula, was excised. Repair was then accomplished by end-to-end

suture or by vein transplantation. The same procedures were employed in number of instances following excision of aneurysms.

At this center when end-to-end suture or interpolation of vein graft was

carried out, the procedure was facilitated by first placing interrupted mattress

sutures according to the suggestion of Frouin. 16 It was felt that sutures

could be spaced more accurately at equidistant points than could traction

sutures according to the method of Carrel. 17 It was not felt necessary to

utilize an instrument for holding the sutures such as that devised by Horsley. 18

At DeWitt the practice was to suture the opening into the vein after

severing the connection between the artery and the vein or aneurysmal sac.

When the artery had been disconnected the opening into the vein was closed

longitudinally with running stitch. This procedure was employed mainly for

the purpose of simplicity in dealing with the venous component of the fistula

since it is rarely necessary to repair the vein. In one patient (Table 29, Case 4)

the continuity of the left innominate vein was deliberately preserved since the

thoracic duct empties into it. No instance of thrombophlebitis or pulmonary

embolism was encountered at this center although thrombosis occurred in

few cases. These complications therefore seem to be no more of hazard after

suture of the vein than after its ligation.

In contrast to the practice of suturing the opening into the vein as practiced

at DeWitt, it was the policy at the vascular center of Mayo General Hospital

to divide and ligate the vein rather than repair it.

Although differences of opinion concerning the best suture material for

vascular surgery still exist, it has long been established that only the finest

nonabsorbable sutures should be used. Silk, which is generally preferred, was

used in all instances at DeWitt General Hospital. Silk suture material was

not available at Mayo General and No. 120 cotton suture material was substituted. That this material is satisfactory is shown by the many successful

cases in the Mayo series.

Practically every type of suture has been recommended for vascular surgery including continuous sutures, interrupted sutures, continuous mattress

sutures, interrupted everting mattress sutures, and continuous cobbler’s sutures.

At Mayo interrupted everting mattress sutures were used for all reparative

operations because they gave satisfactory assurance of accurate, intimal approximation without interposition of adventitia and because such anastomoses

could be accomplished without noticeable constriction. Fine straight or curved

artery needles were used.

18 Frouln, A.: Sur la suture des valsseaux. Presse m£d. 16: 233-236, 1908. 17 Carrel, A.: La technique opfrtolre des anatomoses vasculaires et la transplantation des visceres. Lyon mfd. 98;

859-864, 1902. 18 Horsley, J. Shelton: Surgery of the Blood Vessels. St. Louis, C. V. Mosby Co., 1915.
272 VASCULAR SURGERY IN WORLD WAR II

Table 29. Ligation and Transfixion of Fistula—Data on 13 Patients With

Arteriovenous Fistulas

At DeWitt General Hospital running stitch was usedwhich passed through

all layers. The suture material was usually doubled back on itself and tied

at the point of origin. No. 0000 silk, passed through sterile mineral oil, was

used on an atraumatic needle. Bleeding from the suture line was seldom of

any consequence and usually stopped spontaneously. When it did not, an

additional stitch of No. 00000 silk was added.

Mechanical aids were not used in the reparative operations in any case in

these two series. Permanent nonabsorbable intraluminal prosthesis are doomed

to failure because of thrombosis, and no need was felt for the employment of

removable glass splints or soluble rods in these cases. For various reasons the

vitallium tubes introduced by Blakemore, Lord, and Stefko 19 were not used;

The sutured vessel has no permanent, rigid, nonabsorbable, partially constricting ring about it, as does vessel repaired by the vitallium tube method,

and in the hands of those experienced in vascular surgery the suture method

carries less risk of subsequent hemorrhage and the occurrence of thrombosis is

not significantly increased. Moreover, the nonsuture method is attended with

certain difficulties. In several cases at the Mayo General Hospital in which

its use was contemplated, vein of suitable size could not be found. In one

or two other cases the tubes could not be used because their length would have

necessitated occlusion of collateral vessel which lay near the damaged portion

of the artery. In one case in which vein graft had been completed by the

18 Blakemore, A. H.; Lord, J. W., and Stefko, P.: Severed primary artery in war wounded; nonsuture method ofbridging arterial defects. Surgery 12: 488-508, Sep 1942.

Case

No.

Age of

patient Location of lesion Duration

of lesion

Preoperative sym- pathectomy

Anticoagulant

therapy

Diameter of fistula

Postoperative

observation

Results

Months Mm. Months

36 Carotid at bifurcation. 9.0 1.5 Excellent.

31 Common carotid 4.0 10 1.0 Excellent.

22 Common carotid 4.5 1.0 Excellent.

26 Popliteal, middle 3d._ 9.0 4.0 Excellent except for

slight edema of ankle.

35 Popliteal, middle 3d 9.0 1.0 Excellent.

19 Popliteal, distal 3d 6.0 2.0 Excellent except for

slight edema ofankle.

45 Popliteal, middle 3d 10.0 1.0 Excellent.

20 Femoral, middle3d. 9,0 1.0 Excellent.

27 Femoral, proximal 3d 11.0 1.0 Excellent.

10 25 Femoral, proximal 3d 6.0 1.0 Excellent.

11 32 Femoral, proximal 3d 7.0 1.0 Excellent.

12 23 Femoral, proximal 3d Unknown 1.5 Excellent.

13 21 Axillary, distal 3d 4.5 1.0 Recurrence in days;

excision weeks later,

good results.

Single 50-mg. dose of heparin at time of operation.
ARTERIAL REPAIR 273

nonsuture method, brisk hemorrhage occurred as the wound was being

closed because the tube slipped out of the proximal artery even though it had

been tightly anchored in place with several silk ligatures.

Even when arterialrepair had been planned and was thought to be practical,

the endeavor was made, in every case in these two series, to make certain that

collateral circulation was adequate. Furthermore, as much care was used at

operation to preserve all collateral vessels as if ligation of the affected artery

were to be carried out. In retrospect it would seem to be wise to reexamine

the collateral circulation at the time of operation during temporary occlusion

of collateral arteries in cases in which by sacrificing one or more of them the

repair of the main artery might be accomplished. Reparative procedures

might have been undertaken in number of other cases if this special technique

had been used routinely and the efficacy of the collateral circulation established

at the time of operation.

VASCULAR REPAIR AT DEWITT GENERAL HOSPITAL

Analysis of Data

Between June and November 1945 restoration of the continuity of the

artery was attempted in 23 patients with aneurysms and arteriovenous fistulas

at the vascular center of DeWitt General Hospital. (During this period 67

patients with arterial injuries were treated by surgical intervention.) This

number (23) includes patient with arteriovenous fistula of the abdominal

aorta which, because of its rarity, is described in detail later in the volume.

(See Chapter IX.)

Successful results were achieved in 18 of the 23 cases, including, in addition to the fistula involving the abdominal aorta, lesions of the common

carotid artery, of the popliteal artery, of the superficial femoral artery,

and each of the subclavian, brachial, and posterior tibial arteries. Longitudinal suture was employed in instances, end-to-end anastomosis in 1,

and transverse suture in 15.

Failure occurred in of the 23 cases. In patient treated by transvenous

suture, initial success was followed by recurrence of the lesion. In another

patient, this one treated by transverse suture, initial success was also followed

by recurrence which necessitated subsequent excision of the fistula. The

remaining patients, in all of whom the operation failed, were treated by

transverse suture, transvenous suture, and end-to-end anastomosis, respectively.

For two reasons anticoagulant therap} was not used in any of the patients

operated on at DeWitt General Hospital; It was believed that (1) the reestablishment of an adequate lumen was sufficient to prevent thrombosis, and

(2) complications which could conceivably arise from the use of these agents

contraindicated their employment.

In all of the cases classified as successful, continuity of the artery was

demonstrated either by the presence of normal arterial pulsations distal to
274 VASCULAR SURGERY IN WORLD WAR II

the site of repair or by arteriogram. Patency of the vein was demonstrated

by phlebogram in patients in whom the venous wall was repaired by longitudinal suture, and venous obstruction was demonstrated by the same method

in other patients. The status of the vein in the remaining patients is not

known.

Methods of Repair

Four techniques of repair were used at this center; (1) longitudinal suture, (2) transvenous suture, (3) end-to-end anastomosis, and (4) transverse suture.

In view of the limited number of successful cases of arterial repair on record

in the literature, case histories of certain patients treated by this method at

the vascular center of DeWitt General Hospital are presented herewith. These

are representative of the various types of reparative procedures employed at

this center. Longitudinal Suture

Case 1. 23-year-old infantry sergeant was wounded by shell fragments 21 November

1944. Approximately weeks later pulsating mass was discovered on the anterior aspect

of the right thigh. This increased in size for period and then remained stationary.

The patient was transferred to the vascular center of DeWitt General Hospital. At

the time of admittance physical examination disclosed the presence of large tumor on the

anteromedial aspect of the right thigh. Over it loud, continuous bruit could be heard.

An arteriogram taken February 1945, showed large arteriovenous aneurysm involving

the superficial femoral artery and vein. This aneurysm measured 13 by 8.5 cm. in diameter.

phlebogram taken March 1945, demonstrated displacement of the saphenous vein to

the medial side of the thigh.

After sufficient time had been allowed for the development of collateral circulation,

an operation was performed 28 June 1945. Continuous spinal anesthesia was used. An

incision was made over Hunter’s canal above the aneurysm. After the dilated superficial

femoral artery had been encircled with rubber tubing, the incision was carried down the thigh

over the aneurysmal sac, and the sartorius muscle reflected medially to expose the superficial

femoral artery and vein below the sac. The artery at this level was also encircled by rubber

tubing. No attempt was made to control the blood flow through the femoral vein.

The artery was dissected free from the aneurysmal sac and venous bleeding from the

opening into the sac controlled by digital pressure. The defect in the arterial wall measured

approximately 1.5 cm. in length. It was closed with continuous stitch of No. 0000 silk

on an atraumatic needle. During this phase of the procedure the lumen of the vessel was

irrigated with physiologic salt solution. After completion of the suture, the lower and then

the upper rubber tubes were released. Good expansile pulsation across the suture line was observed.

The sac was then opened widely and bleeding from the two orifices of the femoral vein

controlled by digital pressure until the ends could be dissected free from the sac and ligated

individually. No effort was made to excise the sac. rubber tissue drain was brought out

from the lower end of the wound, and the wound was then closed in layers.

The circulation to the foot and leg appeared to be excellent after operation. An arteriogram taken 27 July 1945 demonstrated the patency of the superficial femoral artery although

the lumen was considerably diminished at the point at which the defect had been repaired.

Although pulsations of the peripheral arteries were normal, oscillometric readings

months after operation showed that there was still some impairment of circulation. Seven

months after operation the patient still complained of aching in the leg after walking six

blocks.
ARTERIAL REPAIR 275

Case 2. 23-year-old infantryman was wounded in the right side of the neck 13

February 1945 by shell fragment. Immediately after injury he noted hoarseness.

Debridement was performed, followed by secondary closure of the wound. few hours

later he noted thrill in the region of the wound. slight ptosis of the right eyelid was

also observed. All symptoms and signs persisted up to the time he was admitted to DeWitt

General Hospital.

Physical examination at that time revealed the classical signs of an arteriovenous

fistula involving the right side of the neck just above the clavicle. Laryngoscopic examination showed, in addition, paralysis of the right vocal cord. Pressure upon the fistula caused

paroxysm of coughing. The bruit could be made to disappear by applying pressure over

the common carotid artery behind the clavicle. This procedure did not produce any symptoms of cerebral ischemia.

An operation was performed August 1945, with the patient under intratracheal nitrous

oxide-ether-oxygen anesthesia. transverse incision was made above the right clavicle.

The muscles were divided close to their insertion and the greatly dilated internal jugular

vein exposed. The inferior thyroid vein was divided and the common carotid artery, which

appeared about normal in size, dissected free. Compression with piece of rubber tubing

did not entirely obliterate the bruit heard over the fistula. Dissection was therefore carried

above the fistula, and the common carotid artery isolated and surrounded by second piece

of rubber tubing. Compression of the artery both above and below the fistula reduced the

bruit, but did not completely abolish it. Digital palpation revealed the presence of another

large artery lying beneath the fascia lateral to the jugular vein. This artery, which proved

to be the inferior thyroid, was divided above and below the fistula. Following this procedure

no bruit was audible when the contributory vessels were compressed. Accordingly, the

jugular vein was ligated above and below the fistula and the carotid artery dissected away

from the aneurysm. The defect in the wall of the carotid was closed with longitudinal

running stitch and the segments of the jugular vein, with the aneurysm which lay posterior

to it, excised.

The wound was closed in layers without drainage. Good pulsation was present in the

distal part of the carotid artery hour after suture. Convalescence was uneventful. When

the patient was discharged weeks after operation pulsation of the right temporal artery was

normal. This pulsation was not affected by compression of the left carotid artery though

it was obliterated when compression was made on the right side of the neck. Six months

later the patient reported that his only residual symptoms were hoarseness and some drooping

of the right eyelid. There was no evidence of recurrence of the aneurysm and he was able to

exercise as much as he desired.

Comment. Longitudinal closure of the defect in the arterial wall was

successfully accomplished in these patients. When the opening is small,

distortion of the arterial wall by suture is not great. In larger defects, however, distortion of the normal contour resulting from suture may curtail the

volume of blood flowing through the restored artery. Reinforcement of the

suture line by the use of part of the sac wall may still further reduce the

caliber of the vessel. Waugh 20 reported case in which the diameter of the

vessel was reduced one-half by this procedure. The maintenance of full

volume flow of blood past the suture line seems to be of importance in preventing subsequent thrombosis at this site.

20 Waugh, W. O.; Arteriovenous aneurysm of the popliteal vessels; arterlorrhaphy under heparin. Brit. J. Surg.

31: 192-193, Oct 1943.
276 VASCULAR SURGERY IN WORLD WAR II

Transvenous Suture

Case 3. 28-year-old infantry private was wounded in left knee by rifle bullet 13 March

1945. There was considerable hemorrhage initially and bleeding recurred on several occasions. He was admitted to the vascular center of DeWitt General Hospital April 1945.

At this time there was considerable swelling of the left calf and ankle. pulsating mass

was present in the popliteal space over which was observed the characteristic thrill and

bruit of an arteriovenous fistula. Pulsations about the left ankle were absent and oscillometric readings showed marked decrease in the circulation. An arteriogram 12 April

revealed an arteriovenous fistula at the level of the head of the fibula. Dye was presept in

the veins on both sides of the artery, but the significance of this observation was not realized

until later. Lumbar sympathectomy performed 13 August was followed by improvement in

the collateral time and in the circulation to the left foot.

The vascular operation was performed 13 September 1945. Continuous spinal anesthesia was used. The involved vessels were exposed between the heads of the gastrocnemius

muscle in the lower portion of the popliteal space where the popliteal artery lay between

the two veins. Without separation of the veins from the artery the entire vascular bundle

was encircled by rubber tubing both above and below the fistula. Each vein was opened

in turn and its communication with the artery visualized. The opening on each side was

approximately mm. long. Each was closed longitudinally, according to the Matas-Bickham

technique,21 using running stitch of No. 0000 silk on an atraumatic needle. The sutures

were tied outside of the vein. When the upper tube was released small amount of bleeding

from the artery into one of the veins was observed and two additional stitches were taken in

the suture line within this vein. At the conclusion of this procedure there was no further

bleeding.

The incision on the posterior surface of the vein was closed with running longitudinal

stitch, after which all of the blood vessels were released. Auscultation revealed very

faint continuous bruit in the region of the fistula. Further dissection failed to disclose its

source and it was assumed that it resulted from the turbulence of the blood stream as it

passed over the suture lines. The wound was closed without drainage.

Following the operation the posterior tibial pulse was excellent and oscillometric readings

showed considerable improvement in the circulation to the left leg and foot. Auscultation,

however, revealed the same faint continuous bruit with systolic accentuation heard during

the operative procedure.

The patient was then sent on convalescent furlough. Upon his return he stated

that while walking one day he had suddenly felt something snap and upon palpation had

noticed recurrence of the thrill. When he was reexamined loud continuous bruit was

audible.

The second vascular operation was performed 17 November 1945. longitudinal

incision was made posterior to the head of the fibula and was extended upward medially to

the biceps tendon. The peroneal nerve was exposed and retracted laterally and the lateral

head of the gastrocnemius muscle retracted posteriorly to expose the popliteal vessels as

they passed through the ring of the soleus muscle. An aneurysm measuring cm. in diameter

was found at this point. The artery above the aneurysm was freed and encircled by

piece of rubber tubing, compression of the artery by this tubing obliterated the bruit.

The head of the soleus muscle was then divided close to its attachment to the head

of the fibula and retracted posteriorly together with its nerve and blood supply. The

popliteal artery was thus exposed below the aneurysm. At this point there was moderately

dilated vein lying over the artery. It was possible to observe the turbulent flow of mixed

arterial and venous blood in it. This vein was divided and ligated in order to expose the

popliteal artery below the fistula. The artery was again encircled by piece of rubber

21 See footnotes 6, p. 264, 7, and 8, p. 265.
ARTERIAL REPAIR 277

tubing. The proximal and distal arteries were divided and ligated; the component veins

were treated similarly and the aneurysm excised. Examination of the specimen revealed

two openings from the artery, small one, communicating with small vein, which had

apparently been overlooked at the original operation, and larger one which was the result

of rupture of the artery into the vein at the point where it had been sutured at the original operation.

Recovery from the second operation was without complications, but thereafter the circulation to the left foot was definitely decreased. Oscillations at the ankle were less than

one-fourth of those on the normal side. In spite of this fact, the circulation was fairly well

maintained and the patient was able to walk as many as three blocks before signs of intermittent claudication developed.

Case 4. 24-year-old sergeant was struck by shell fragment just above the left

clavicle 29 July 1944. It was noted after the initial debridement that the left radial pulse

was absent although it subsequently returned. The patient stated that from the time of

the injury he believed the temperature of the left upper extremity was lower than that of

the right upper extremity. Except for difficulty in articulation for the first few days after

injury, he had no complaints. However, loud continuous bruit was audible over the left

sternoclavicular joint.

When he was admitted to the vascular center at DeWitt General Hospital in October

1944, his venous pressure was 16.4 cm. of water on the left side and 13.4 cm. on the right

in the antecubital vein. The circulation time was 20 seconds on the left and on the right.

At examination, attempts to compress the aneurysm by pressure in the supraclavicular

region were unsuccessful. In spite of the fact that the aneurysm was close to the heart,

no evidence of cardiac enlargement was noted during long period of observation.

An operation was performed 10 September 1945 with the patient under endotracheal

nitrous oxide-ether-oxygen anesthesia. transverse supraclavicular incision was made on

the left side and extended down over the manubrium to the second rib, thence laterally to

the costochondral junction (Fig. 36). The muscles attached to the clavicle and the sternum

were divided close to their insertions. The internal jugular vein was thus exposed and the

turbulent mixing of arterial and venous blood characteristic of arteriovenous fistula could

be observed. Pressure on the junction of the internal jugular and subclavian veins stopped

the bruit in the fistula.

The common carotid artery on the left side was then exposed; its pulsation was found to

be feeble and its wall thick. Occlusion of this artery, however, did not eliminate the thrill

in the aneurysm. Further dissection revealed greatly dilated innominate vein which

it was impossible to expose adequately without opening the thorax. Accordingly, the medial

2.5 inches of the left clavicle were resected subperiostially, and the sternoclavicular articulation left intact. The tissues were then freed beneath the sternum in the midline and the

manubrium split to the upper border of the second rib and then cut transversely at this level.

The left half of the manubrium was now readily retracted laterally to expose the thymus

lying on the large dilated innominate vein. Some branches of this vein were ligated and

divided. The innominate vein and left carotid artery were retracted medially to expose

the left subclavian artery as it arose from the arch of the aorta. The subclavian artery

was considerably larger than the carotid, its walls were thin and the pressure within it seemed

to be low. It was encircled by fine catheter fitted to Bethune tourniquet. Compression

of the subclavian artery at the arch of the aorta obliterated the thrill in the aneurysm.

The bruit also ceased abruptly as soon as the subclavian artery was compressed but after

short interval it was again faintly audible. The recurrence of the bruit was thought to be

indicative of collateral circulation.

The internal jugular vein was then divided above its junction with the subclavian.

Dissection on the medial side of this vein revealed large lymphatic duct which entered

the jugular vein at its junction with the subclavian. The phrenic nerve was retracted
278 VASCULAR SURGERY IN WORLD WAR II

Figure 36. (Case 4.) Transvenous repair of arteriovenous fistula involving left subclavian

artery and innominate vein. Insert shows surgical approach to lesion.

medially and the scalenus anticus muscle divided in order to expose the second portion of

the subclavian artery. The internal mammary artery was carefully preserved, but the

costocervical and the thyrocervical trunks were ligated. The subclavian artery distal to the

fistula was greatly reduced in caliber; it was encircled in this location by piece of rubber

tubing. The first portion of the subclavian artery just proximal to the origin of the vertebral

artery was then exposed and encircled by second piece of rubber tubing. When the subclavian artery had been compressed just proximal to the vertebral artery and distal to the

fistula, and the vertebral artery had also been compressed, the bruit was abolished and the

innominate vein no longer filled with arterial blood.

The subclavian and innominate veins were then occluded by additional pieces ofrubber

tubing after which the innominate vein was opened on its anterior aspect close to the junction

of the jugular with the subclavian vein and flushed out with physiologic saline solution.

It was now possible to see an aperture which measured approximately cm. in length lying

over the subclavian artery (Fig. 36). The opening from the artery into the vein was sutured

from within the vein by the Matas-Bickham technique, using No. 0000 silk. The suture was

started from outside the vessel and was passed into the lumen; then, after the opening had

been closed with running stitch, it was doubled back on itself and its ends brought outside

of the vein to be tied at the starting point. After this suture had been completed, the distal

artery, the vertebral artery, and the proximal artery were released in that order. Some

slight bleeding into the vein was controlled by an additional stitch. The incision on the

anteromedial surface of the innominate vein was closed with running longitudinal stitch.

The divided halves of the manubriumwere approximated with two steel wire sutures and the

muscles and superficial tissues closed in layers.
ARTERIAL REPAIR 279

wound infection necessitated incision and drainage weeks after the original operation,

but recovery thereafter was satisfactory. Although there were no signs of circulatory

insufficiency of the left upper extremity, the radial pulse continued to be markedly diminished

and oscillometric readings showed reduced circulation on this side. Six weeks after operation

phlebogram demonstrated the patency of the left innominate vein. Five months after

operation the patient reported that he had noticed no recurrence of the fistula. He stated,

however, that he was short of breath and that he experienced precordial pain on exercise.

Since there was no cardiac enlargement even before operation it seemed unlikely that the

fistula could have caused serious cardiac disturbance.

Comment. Transvenous suture, although it has been considered logical

procedure, has two decided drawbacks: (1) Since the artery need not be fully

mobilized, second, or even third, communication may be overlooked. This

complication, which has been reported by Reid and McGuire, 22 accounted for

the persistence of the arteriovenous fistula in Case of this series. (2) The

arterial wall may be weakened or defective either close to the fistula or at

some other point. Without careful scrutiny, both from within and from

without, this damaged area may be overlooked. Subsequent rupture with

the formation of an aneurysm may result.

End-to-End Anastomosis

Case 5. 25-year-old infantryman, shortly after being wounded in the left thigh 15

January 1945, showed signs of an arteriovenous fistula. When admitted to the vascular

center at DeWitt General Hospital 15 July 1945, examination revealed the characteristic

signs of an arteriovenous fistula. An arteriogram taken on 20 July showed an aneurysmal

sac lying to the medial side of the femoral artery with communication into the lower

femoral and popliteal veins. Sympathectomy was performed 30 July. After this operation,

the collateral circulation improved and appeared to be adequate.

The vascular operation was performed 23 August 1945. longitudinal incision was

made over the lower part of the adductor canal and the femoral artery exposed above and

below the fistula. The aneurysm was found on the lateral side of the artery. After digital

compression of the veins the artery was dissected free from the aneurysm and from the veins.

The opening into the vein was closed with longitudinal running stitch. Two large defects

were present in the arterial wall. Because so little sound arterial wall remained the damaged

portion was excised and an end-to-end anastomosis performed. After release of the rubber

tubing expansile pulsation was transmitted across the suture line. The wound was closed

without drainage.

The peripheral pulses were good after operation and at the left ankle an oscillometric

reading of units was noted in comparison to reading of units on the uninjured side.

The excellent peripheral pulses and the practically normal circulation encouraged the belief

that successful repair had been accomplished, but an arteriogram taken weeks after operation showed that the segment had been completely obliterated and that the circulation was

being carried on entirely by means of collateral vessels.

Case 6. 28-year-old infantryman was wounded in the left thigh by rifle bullet 28

February 1945. The wound of entrance was inches below Poupart’s ligament. Debridement was carried out while the patient was in the forward area. Later an arteriovenous

fistula was discovered in the traumatized area of the thigh. The patient was admitted

to the vascular center of DeWitt General Hospital July 1945. An arteriogram taken

22 Reid, M. R., and McGuire, J.: Arteriovenous aneurysms. Ann. Surg. 108: 643-693, Oct 1938.

330323 0—55 19
280 VASCULAR SURGERY IN WORLD WAR II

September 1945 showed communication between the femoral vessels just distal to the

profunda.

An operation was performed October 1945. semilunar incision, with its center at

the wound of entrance, was made over the upper portion of the thigh. The common femoral

artery was exposed below Poupart’s ligament. It was greatly dilated and its walls were thin.

The artery was encircled by piece of rubber tubing, compression of which obliterated the

thrill in the arteriovenous fistula although slight bruit remained audible. The artery

was also exposed below the profunda femoris and temporary ligature placed about it, but

further auscultation revealed that the aneurysm involved the superficial femoral artery

below this second temporary ligature. Dissection was accordingly carried farther down the

thigh by retracting the sartorius muscle medially and exposing the femoral artery in Hunter’s

canal. When the artery was occluded both proximally and distally the bruit was completely

abolished. The artery was separated from the vein by sharp dissection. Rather brisk

venous bleeding was controlled by digital pressure until the femoral vein could be sutured.

Examination now showed that the wall of the femoral artery had been destroyed over

very wide range and that it showed perforations, one on the lateral and one on the medial side.

The artery was therefore divided and the damaged portion excised. In order to obtain

sufficient relaxation to permit suture, the artery had to be dissected free below for distance

of inches and upward to the point at which the profunda femoris left it. An end-to-end

anastomosis was then performed; continuous running stitch of No. 0000 silk was used.

After release of the rubber tubing there was some bleeding which was controlled with additional stitches. At the conclusion of the operation good pulsation was transmitted across the suture line. The wound was closed without drainage.

The peripheral pulses remained excellent and convalescence was uneventful. Oscillo- metric readings showed no diminution of the circulation on the injured side. An arteriogram

and phlebogram taken months after operation demonstrated patency of the vessels. The patient reported months after operation that he had been working steadily, but that

he had pain in the lower part of the leg when standing for long time or when walking for

some distance. There was no swelling in the limb and the circulation was good.

Comment. End-to-end anastomosis was successful in the second of these

cases. Obliteration occurred in thefirst case. The patient recovered, however,

since the collateral circulation was abundant and little vascular insufficiency

resulted.

Transverse Suture

Case 7. 24-year-old infantryman was wounded in the neck, arms, and legs by multiple mortar fragments April 1945. Subcutaneous emphysema of the neck developed,

but subsided spontaneously. Subsequently characteristic signs of arteriovenous fistula

were observed on the left side of the neck at the level of the thyroid cartilage. These signs

persisted up to the time he was admitted to the vascular center at DeWitt General Hospital

27 May 1945. Laryngoscopic examination showed, in addition, paralysis of the left vocal

cord. Three months after the injury compression of the common cartoid artery below the

fistula produced no evidence of cerebral ischemia.

An operation (Fig. 37) was performed 23 July 1945. Local anesthesia was used. An

oblique incision (Fig. 37A) was made parallel to the skin creases at the level of the thyroid

cartilage. Dissection was carried down medially to the sternomastoid muscle, and the

common carotid artery was isolated below the fistula. rubber tube was placed about the

artery at this point. The common carotid artery was again isolated and similarly treated

above the fistula. The jugular vein was greatly dilated. It was dissected free and heavy

black silk thread placed about it both above and below the fistula. The vagus nerve was

then freed to the point at which it was incorporated in the scar between the carotid artery
ARTERIAL REPAIR 281

and the jugular vein. Procaine hydrochloride (1 percent) was injected into the vagus nerve

above the line of scar tissue. With the common carotid artery compressed both above and

below the fistula, the vagus nerve was dissected free and the communication between the

artery and vein opened. The communication measured cm. in diameter On inspection of the defect in the arterial wall, which was on the posterolateral side, it

was noted that the media was defective in the region of the aperture. The defective portion

of the wall was excised. After relaxation of tension had been accomplished, the defect in the

arterial wall was closed in transverse direction (Fig. 37E) by running stitch doubled back

on itself. When the rubber tubing was released, pulsation took place across the suture line.

There was no evidence of narrowing of the vessel. The jugular vein was divided between

ligatures. The two ends of the vagus nerve were united after excision of the damaged segment. When, at the conclusion of the operation the carotid artery was again examined,

good pulsatile flow could be demonstrated above the suture line. The wound was closed

in layers without drainage.

Recovery occurred without complications and the patient was discharged from the

hospital month after operation. It was possible, in the postoperative period, to demonstrate the patency of the left common carotid artery by noting that the temporal pulse on the

left side was unaffected by compression of the right common carotid artery but could be

obliterated by compression of the artery on the left side. Six months after operation no

swelling had recurred in the neck, but normal voice had not yet returned. The patient

reported he was still unable to work and that he could not exercise as much as he would like

because he was “short-winded.”

Case 8. 21-year-old infantryman sustained many wounds of the chest, abdomen,

and right leg from mortar shell fragments 21 December 1944. During his hospitalization it

was discovered that he had an arteriovenous fistula in the right popliteal space. On his

admission to DeWitt General Hospital 28 March 1945, the diagnosis was confirmed.

preoperative arteriogram 22 May showed considerable reflux of dye into the dilated popliteal

vein. The communication between the artery and the vein seemed to be at the superior

level of the patella. Lumbar sympathectomy was performed July 1945. After this operation the collateral circulation appeared excellent.

The vascular operation was performed August 1945. Continuous caudal anesthesia

was used. Z-shaped incision was made with the transverse bar across the popliteal crease. The incision was deepened along the tendon of the semimembranous muscle. Many small

veins were encountered which entered the greatly dilated popliteal vein. Rubber tubing

was placed about the entire vascular bundle including both the artery and the vein. Dissection was then carried out below the fistula and the popliteal artery isolated and encircled by

section of rubber tubing. The popliteal vein was surrounded by heavy silk cord. Further

dissection above the aneurysm resulted in separation of the artery from the vein so that each

could be controlled independently. When the component vessels had been occluded the

artery was dissected from the vein and the communication severed. The defect measured

cm. in length. The opening in the wall of the vein was closed with longitudinal running

stitch. Since the arterial wall was found to have been damaged for about one-half its

circumference, wedge-shaped portion of the lateral wall was excised and the defect closed in

transverse direction with continuous suture of No. 0000 silk placed through all coats of

the vessel. Some bleeding followed release of the occlusive rubber tubing, but was controlled with suture. There was only slight reduction in the diameter of the artery at the

point of suture and vigorous pulsation was noted below the suture line after release of the

rubber tubes. At the conclusion of the operation the posterior tibial pulse was full and

bounding. The wound was closed without drainage.

Normal pulses were present during the postoperative period at the right ankle and

oscillometric readings showed that the circulation on the right side was almost equal to that

of the left. An arteriogram 24 August showed practically no distortion at the suture line.
282 VASCULAR SURGERY IN WORLD WAR II

Figure 37. (Case 7.) Carotid-jugular arteriovenous fistula. A. Location of incision.

B. Control of circulation through component vessels. C. Division of fistula. D. Excision of damaged portion of arterial wall.

E. Transverse repair of defect in carotid artery.

F. Completion of repair.
ARTERIAL REPAIR 283

Reexamination months after operation disclosed normal peripheral circulation and

months after operation the patient reported that he was able to walk several miles without

difficulty.

Case 9. 22-year-old corporal was struck by shell fragment 18 July 1944 just above

the right calvicle. In addition, he sustained severe wounds of both legs and the left forearm.

Amputation of the left forearm was necessary. He was admitted to DeWitt General Hospital

March 1945 with classical signs of an arteriovenous fistula at the base of the neck on the

right side. It was difficult to obliterate the bruit by pressure above the clavicle. In spite

of the length of time between injury and operation there were no signs of cardiac damage.

An operation was performed 20 August 1945 with the patient under endotracheal

nitrous oxide-ether-oxygen anesthesia. supraclavicular incision was made. The muscles

attached to the sternum and clavicle were divided at their insertion in order to expose the

internal jugular vein. Both the right and left inferior thyroid veins were divided and ligated,

and the deep cervical fascia incised. The internal jugular vein was retracted laterally

and dissection carried down behind the clavicle to expose the innominate artery. This

artery was encircled by piece of rubber tubing fitted to Bethune tourniquet. Occlusion of the artery caused marked decrease in the bruit over the fistula. Compression of the

common carotid artery did not affect the bruit. The rubber tubing was then transferred

to the subclavian artery just proximal to the origin of the vertebral artery. The scalenus

anticus muscle was divided, after retraction of the phrenic nerve medially, to expose the

second portion of the subclavian artery. The communication appeared to involve the

internal jugular vein and the subclavian artery just proximal to the origin of the thyroid axis.

The jugular vein was divided and its upper portion ligated. After compression of the subclavian artery proximal and distal to the fistula the vein was dissected free from the artery

to expose small opening approximately 0.5 cm. in diameter. This opening was closed

transversely with interrupted stitches of No. 0000 silk. Good pulsation was present in the

artery distal to the suture line after release of the occluding rubber tubing. The jugular vein

was ligated close to its junction with the right subclavian, and the wound was closed in layers

without drainage.

Convalescence was uneventful and at the time of the patient’s discharge from the hospital the right radial pulse was normal.

Case 10. 27-year-old soldier was wounded by shell fragments in the right thigh,

trunk, and face 20 January 1945. During his convalescence from these wounds an arteriovenous fistula of the right femoral vessels was noted. He was admitted to the vascular

center at DeWitt General Hospital 18 May 1945. An arteriogram (Fig. 38A) taken 20 May

1945 revealed an arteriovenous fistula in the upper portion of the superficial femoral vessels

on the right side and, in addition, small aneurysm on the lateral aspect of the artery.

lumbar sympathectomy was performed August because of impaired circulation. Following this operation there was considerable improvement in the collateral circulation.

The vascular operation was performed 13 September 1945. The superficial femoral

artery was exposed in the upper third of the thigh. Rubber tubes were placed about the

artery both above and below the fistula. pneumatic tourniquet was then inflated and

the artery dissected away from the vein and from the aneurysm. The aneurysm was found

on the posterolateral side of the artery while the opening between the artery and the vein

was on the posteromedial side. The opening into the vein was closed with longitudinal

running stitch. The pneumatic tourniquet was then deflated.

The defect in the arterial wall was approximately 1.5 cm. long. The damaged portion

of the wall, including the segment between the openings into the vein and the aneurysm,

was excised. Approximately three-fourths of the circumference was lacking and in order

to approximate the two ends it was necessary to free the artery both above and below the

fistula for approximately 1.5 inches. No large branches were found. Because of the location of the arterial defect, the suture line was oblique rather than transverse or longitudinal.
284 VASCULAR SURGERY IN WORLD WAR II

Figure 38. (Case 10.) A. Preoperative arteriogram showing arteriovenous fistula involving

upper portions of superficialfemoral vessels, with small aneurysm on lateral aspect of artery.

B: Postoperative arteriogram following diagonal suture. Note normal continuity of superficial femoral artery.

There was small amount of bleeding from the suture line after release of the rubber tubing,

and an additional stitch was added. Slight distortion of the arterial wall on the side opposite

the repair was noted. No attempt was made to remove the aneurysm. The wound was

closed without drainage.

Convalescence was uneventful. Oscillometric readings before operation had shown

maximum of units on the right side and on the left, but after repair of the femoral artery

the readings were units on the right side and 3.5 on the left. An arteriogram taken

months after repair showed normal continuity of the superficial femoral artery (Fig. 38B).

phlebogram demonstrated patency of the femoral vein. Four months after operation,

however, the patient reported that he was not able to exercise as much as he desired because

his leg became swollen below the knee if he walked too much. There was no recurrence of

the arteriovenous fistula nor was there any evidence of swelling in the region of the aneurysm.

Case 11. 26-year-old infantryman was wounded in the left thigh by shell fragments

30 March 1945. He complained of numbness and tingling in his left foot. pulsating

mass appeared cm. below the inguinal ligament, directly beneath the scar of the wound.

He was evacuated to the Zone of Interior and admitted to the. vascular center of DeWitt

General Hospital. Examination at this center revealed systolic thrill and high-pitched

bruit, but there was no diastolic component to the murmur. An arteriogram 10 August

revealed an aneurysm about cm. in diameter arising from the upper portion of the superficial femoral artery. Lumber sympathectomy was performed October 1945.

The vascular operation was performed 18 October 1945. The superficial femoral

artery was exposed above the aneurysm medial to the sartorius muscle. The artery was

encircled by rubber tubing. Compression on this tubing caused the aneurysmal sac to

collapse. The artery below the aneurysm was then exposed and tube placed about it to

control the retrograde circulation. With both the proximal and distal arteries occluded,

the sac was exposed and incised. After removal of the clots and fresh blood the opening of

the afferent and efferent portions of the artery were observed to be approximately cm.

apart.
ARTERIAL REPAIR 285

The artery was freed from the sac by sharp dissection. There was considerable scar tissue present, as well as some edema. With the aid of traction applied by means of the

rubber tubes, the orifices of the artery could be approximated. After cutting away excess

portions of the sac, the opening was closed in transverse fashion with continuous running

stitch. In addition numerous interrupted stitches of silk were used to approximate the

scar tissue in the wall of the sac so as to take tension from the suture line. Upon release of

the constricting tubing, pulsatile blood flow took place across the suture line. The artery

in this location appeared to be quite small and contracted and there was considerable distortion of the superficial femoral artery at the site of suture. The wound was closed without

drainage.

The postoperative course was uneventful. Readings taken by oscillometer showed the

circulation at the left ankle to be about two-thirds of that of the normal contralateral ankle.

An arteriogram weeks after operationrevealed considerable distorion of the femoral artery.

Three months after operation the patient reported recurrence of the bruit. It was assumed,

in view of the considerable degeneration and fibrosis of the arterial wall in the region of the

aneurysm, that the scar tissue had given way and that the vascular lesion had recurred.

Further treatment was believed to be contraindicated owing to the degeneration of the

arterial wall.

Case 12. 29-year-old officer was wounded in the left thigh by mortar fragments

11 November 1944. He sustained compound fracture of the left femur. Six weeks later

an arteriovenous fistula was discovered close to the site of the fracture. He was admitted

to the vascular center at DeWitt General Hospital May 1945. An arteriogram taken

25 May disclosed simple arteriovenous fistula justbelow the fracture line. It also revealed

considerable distortion of the superficial femoral vein. This was attributed to scar tissue

about the fracture. Lumbar sympathectomy performed 13 September was followed by

satisfactory improvement in the collateral circulation.

The vascular operation was performed 18 October 1945. Continuous spinal was the

anesthetic of choice. An incision was made over the femoral vessel and the sartorius muscle

was retracted medially. The superficial femoral artery was exposed above the fistula and

rubber tubing was placed about it. Compression of the artery at this point obliterated

the bruit of the fistula. The artery was exposed below the fistula and controlled by rubber

tubing in this location also. All the small branches of the artery were carefully preserved.

The vessels at the site of the fistula were bound down in scar tissue. The communication

was exposed by sharp dissection and the artery cut away from the vein during digital compression of the superficial femoral vein above and below the fistula.

The vein was irrigated with physiologic salt solution and closed longitudinally. The

defect in the artery measured cm. in length. Its edges were composed of dense scar tissue.

The damaged portion of the artery was excised in an elliptical fashion and the opening closed

in transverse direction with continuous running stitch. There was no bleeding from

the suture line after release of the rubber tubing. The suture line occupied approximately

three-fourths of the circumference of the vessel and caused considerable distortion. However, good expansile pulsation was transmitted across the suture line. The wound was

closed without drainage.

After healing had taken place oscillometric readings showed that there was greater

pulsation on the affected side than on the normal side. An arteriogram made after recovery

showed some distortion of the superficial femoral artery, but also showed that the lumen

had been preserved. Three months after operation the patient reported that there had been

no recurrence. His activities were still limited because of the stiffness of his knee resulting

from the prolonged period of traction, and he stated that the leg tired more readily than

normally.
286 VASCULAR SURGERY IN WORLD WAR II

Case IS. 23-year-old soldier was struck by fragments from defective mortar shell

24 September 1945and incurred multiple wounds of the neck, left shoulder, and arm. One fragment penetrated the left arm just above the elbow and lodged beneath the skin on the

medial side. Immediately after injury wrist drop and some weakness of the left hand

developed. He was transferred to regional hospital after debridement of the wounds.

At this installation pulsatile swelling was noted in the region of the brachial artery above

the elbow. As this mass increased in size, progressive paralysis of the median nerve developed. The patient was evacuated to the Zone of Interior and admitted to the vascular

center at DeWitt General Hospital 17 October 1945. At that time, pulsations in the vessels

at the left wrist could not be detected by means of an oscillometer. Because of the increasing size of the pulsating hematoma and the resulting compression of the median nerve,

operation was performed days later.

longitudinal incision was made on the medial aspect of the arm above the elbow and

was curved slightly outward at the lower angle of the wound. When the deep fascia was

opened some discoloration of the fat was noted. pneumatic tourniquet previously applied

about the arm was inflated and the hematoma incised. It contained some fresh blood and old

clots. The median nerve was exposed and dissected free from the aneurysm. It was found

to have become stretched and flattened out as it passed over this tumor. Rubber tubes

were passed about the brachial artery above and below the laceration in the wall and the

artery separated from the aneurysm. The tourniquet was then released and no further

bleeding occurred. The damaged portion of the arterial wall was then excised leaving not

more than one-sixth of the circumference intact. The two sections of the artery were

approximated and the defect in the wall closed in transverse direction; continuous stitch

of No. 000000 silk was used. All layers of the arterial wall were included. Though there

seemed to be considerable spasm of the proximal portion of the artery, at the conclusion

of the operation good pulsatile flow could be demonstrated distal to the suture line. The

cavity of the aneurysm was drained through the wound of entrance on the lateral side of

the arm and the incision closed.

Immediately after operation the color of the hand was good and faint radial pulse was

palpable. By the next day the radial pulse had returned to its full volume, and oscillometric readings weeks after operation showed that the pulsations at the wrist were greater

on the affected side than on the normal side. An attempt to make an arteriogram was not

successful, but since it was possible to obliterate the left radial pulse by pressure applied to

the brachial artery just above the elbow, it was concluded that the arterial repair had

probably been successful.

Comment. Transverse repair of the artery was successful in 15 of the 17

cases in which it was attempted. Restoration of the continuity of the vessel

was demonstrable by arteriogram in 10 of these cases and in the other by

the persistence of normal pulses distal to the site of repair. Of the unsuccessful attempts, thrombosis occurred at the suture line in patient, but this

was due in part to faulty technique, i. e., failure to obtain adequate control of

the artery above the fistula. In the second patient (Case 11) scar tissue of the

aneurysmal wall was used to reinforce the suture line. This patient reported

the recurrence of the aneurysm and it may be that the scar tissue gave way,

permitting new aneurysm to form.
ARTERIAL REPAIR 287

SUMMARY

The value of arterial repair in the treatment of aneurysms and arteriovenous fistulas has been questioned since the incidence of gangrene after

ligation of major arteries of the extremities is negligible. While it is true that

gangrene is rare after ligation, the end results are often not favorable.

Remarkably little consideration has been given to the results of permanent

reduction of the blood supply to the tissues, especially the muscles, distal to

the lesion. After ligation the development of collateral circulation will usually

suffice to care for the metabolic requirements of the tissues at rest, but it is

only rarely that symptoms of impaired circulation are not noted.

In this connection certain studies made at the vascular center of DeWitt

General Hospital are of interest. questionnaire was sent to former patients

in whom the popliteal or the femoral artery had been ligated as treatment for

arteriovenous fistula. Nine of the 12 individuals who replied complained of

restriction in their activities. similar questionnaire was sent to those in whom the popliteal or the femoral artery had been repaired. Nine of the 11

who replied had no complaints, and the patients with complaints both stated

they could walk from to blocks before any symptoms appeared.

The oscillometer provided another means of assessing results of operative

procedures. At DeWitt General Hospital comparison of the oscillometric

readings was made between those patients with arteriovenous fistulas treated

by ligation and those treated by arterial repair. In 10 patients treated by

ligation the average oscillometric readings were;

Before operation:

Affected side 2. 72

Normal side 5.

After operation:

Affected side 0. 75

Normal side 4.

In the 12 patients treated by reparative procedures the average oscillometric

values were:

Before operation:

Affected side 2. 77

Normal side 4. 44

After operation;

Affected side 3. 85

Normal side 3. 79

On the basis of this evaluation, all the advantages seem to lie with repair

instead of ligation of the affected artery.

Even conceding that preservation of the continuity of the artery is to be

preferred, the question may still be posed as to the possible risk to the patient.
288 VASCULAR SURGERY IN WORLD WAR II

In the past it has been held that this technique was contraindicated because even

though the arterial repair was successful, there remained the possibility of

recurrence of the fistula or the development of false aneurysm close to the site

of repair. In only patients in this series did the fistula recur. One followed

transvenous suture of the popliteal artery and the other recurrence of an

arterial aneurysm was reported subsequently by the patient.

The dangers of hemorrhage or infection do not appear to be increased by

arterial repair. In only one patient was serious infection encountered.

Thrombosis at the suture line occurred in patients, but the collateral

circulation proved sufficient to prevent gangrene. There was nothing to

suggest propagation of the thrombus in these patients.

The defect in the wall of the vein was sutured in 18 patients. Phlebograms

taken of 12 patients after they had recovered demonstrated the patency of the

vein in patients, but in others it was occluded. Neither thrombophlebitis

nor pulmonary embolism was encountered in any instance.

It was the opinion at this center that transverse suture of the defect in

the arterial wall after excision of the damaged portion was the most satisfactory

method of arterial repair.

VASCULAR REPAIR AT MAYO GENERAL HOSPITAL

Analysis of Data

In the course of World War II more than 300 aneurysms and arteriovenous

fistulas were observed at the vascular center of Mayo General Hospital. The

majority of patients with these lesions were treated by various surgical procedures involving extirpation of the lesion. In 34 patients, including 21 with

arteriovenous fistulas and 13 with arterial aneurysms, some type of reparative

surgery was employed.

Four techniques of repair were used: (1) ligation or transfixion of the fistula,

(2) lateral arteriorrhaphy, (3) end-to-end suture, and (4) vein transplantation.

Anticoagulants were usually employed when lateral suture, end-to-end anastomosis, or vein graft were carried out. Except in those instances in which an

adequate prothrombin level had been obtained before operation by the administration of dicumarol, it was the policy to give 50 mg. of heparin intravenously

as soon as the decision to attempt arterial repair was reached. Heparin was

continued at 4-hour intervals until suitable response had been obtained from

dicumarol, administration of which had been started as soon after operation

as the prothrombin level could be determined. In most patients dicumarol

was continued for 21 days. small amount of fibrin foam was often placed in

the wound. This seemed to give some protection against bleeding from the

operative site without adding any risk of intravascular clotting.
ARTERIAL REPAIR 289

Methods of Repair

Ligation and Transfixion of Fistula

Thirteen patients with arteriovenous fistulas (Table 29) were treated by

ligation and transfixion. The age range in this group was from 19 to 45 years,

11 of the 13 patients were under 36 years of age. The duration of the lesion

at the time operation was performed ranged from to 11 months and was

months or more in 10 patients. The fistula involved the carotid artery and

the jugular vein in instances, the popliteal in 4, the femoral in 5, and the

axillary in 1. The saccular aneurysms present in patients arose from the vein

in instances, from the fistula in 2, and from the artery in 1. In the lastmentioned patient the aneurysmal sac had small neck which could be ligated

and transfixed. Associated injuries included fracture of the femur in instance (Case 10) and peripheral nerve injuries in instances (Cases and 6).

Neurorrhaphy was performed at the same time as the vascular operation in of

these patients and at later date in the other.

Eight patients were treated by sympathectomy before operation to improve

unsatisfactory collateral circulation, and received anticoagulants. In patient

(Case 6) heparin was given at the time of operation and continued until

satisfactory prothrombin level had been obtained from dicumarol. In patients

(Cases and 10) dicumarol was given preoperatively for several days. In all

patients dicumarol was continued for from to weeks. In the fourth patient

(Case 13) single 50-mg. dose of heparin was given at the time of operation.

In 12 of the 13 patients in this group the fistula was ligated and transfixed

at the point of its emergence from the artery, then was buttressed by segment

of the divided vein (Fig. 39). In the remaining patient (Case 13) the fistula

was simply ligated in continuity without disturbing the artery or vein. Case 13

represents the only failure by the ligation and transfixion technique. Recurrence

of the bruit and thrill was observed within 48 hours of operation and second

operation (excision of the fistula and quadruple ligation of the vessels) had to

be performed weeks later. The second operation was successful.

Results were good in the other 12 patients. No thrill or bruit could be

demonstrated over periods of observation ranging from to months. The

affected artery was not demonstrably narrowed or distorted in any instance,

nor was it dilated. The two limbs were of equal warmth and color except in

those patients upon whom sympathectomy had been performed; in those the

affected foot was warmer than the normal foot. All the pulses distal to the site

of anastomosis were full and were considered by number of observers to be

about equal to those in the contralateral extremity. In the patients upon

whom sympathectomy was not performed oscillometric readings were approximately the same on both sides. In the patients upon whom sympathectomy

was performed they were slightly higher on the affected side. The only abnormal

physical findings after operation were limited to edema which was present in

patients; in both it was slight and became progressively less as time passed.
290 VASCULAR SURGERY IN WORLD WAR II

Figure 39. Ligation and transfixion of arteriovenous fistula. Top. The fistula has been ligated

at its origin from the artery. transfixing suture is next placed. Bottom. The vein has

been divided above and below the fistula and the ends have been transfixed. The cuff of vein

will now be plicated in order to reinforce the ligated fistula.

Lateral Arteriorrhaphy

There were patients in which the arterial defect was repaired by lateral

suture; of these, exhibited aneurysms and 3, arteriovenous fistulas. (Table

30.) The age range in this group was from 20 to 29 years. Duration of the

lesion at the time of operation ranged from 2.5 to 6.5 months. The brachial

artery was affected in patient, and the subclavian and the femoral artery in

patients each. There were no associated injuries.

Heparin was given in patients, in (Case 14) for 48 hours and in the

others (Cases 15 and 17) until dicumarol had become effective. In the latter,

dicumarol was continued for 11 days. Sympathectomy was not regarded as

necessary in any patient in this group.
ARTERIAL REPAIR 291

Table 30. Lateral Arteriorrhaphy—Data on Patients with Aneurysms and

Arteriovenous Fistulas

The same basic technique was used on all patients (Fig. 40). The edges of

the rent, after being freshened, were stripped of adventitia and approximated

with interrupted mattress sutures. In the arteriovenous fistulas the cuff

of vein which remained was used to reinforce the closure.

Results in patients were excellent. At the conclusion of the operation

the diameter of the artery, which was in good condition in patients and in fair

condition in 1, was but slightly reduced. The color and warmth of the affected

and nonaffected limbs were the same, as were the pulses. In the patients in which oscillometric studies were made, the oscillations were bilaterally equal

in 1; in the other, moderately reduced on the affected side. In patients the operation was failure. In the first patient (Case 14),

although the artery appeared in good condition, gross infection was present at

operation. The arterial diameter was reduced only slightly at the conclusion

of the procedure and continuity of blood flow was maintained, but on the 13th

day after operation serious hemorrhage occurred through the sutured defect.

Exploration showed no evidence of healing at the line of suture. The affected

segment was therefore excised and the artery ligated. Results of this procedure

were good. In the second patient (Case 18), the artery was in poor condition

at operation and its diameter was reduced more than 50 percent by the surgical

procedure. At this time the question arose whether immediate excision of the

damaged segment might not be the wiser course. No pulse could be felt distally

after operation and within hours it was evident that thrombosis had occurred.

The wound was reopened and the diagnosis verified, though neither central nor

Case

No. Age of patient Type of lesion Location of lesion

Duration of lesion

Preoperative

sympathectomy

Anticoagulant

therapy

Length

of arterial

defect

Postoperative ob- servations

Results

Months Mm. Months

14 27 Saccular aneurysm.

Brachial,

distal 3d.

2.5 4-5 2.0 Excellent until hemorrhage

13th day. Secondary excision and ligation, good

results. Gross infection

present at first operation.

15 25 Saccular aneurysm.

Subclavian,

distal 3d.

3.5 2.5 Excellent. Hematoma evacuated 10th postoperative

day.

16 20 Arteriovenous

fistula.

Subclavian,

distal 3d.

6.0 12 1.5 Excellent.

17 27 Arteriovenous

fistula.

Femoral,

proximal

3d.

6.0 12 1.5 Excellent.

18 29 Arteriovenous

fistula.

Femoral,

middle 3d.

6.5 12 1.0 Poor. No pulse felt distally

after operation. Excision

of thrombosed segment

hours after first operation,

goodresults.
292 VASCULAR SURGERY IN WORLD WAR II

Figure 40. Lateral arteriorrhaphy. A, B. Lateral closure with interrupted everting mattress

sutures. C. Application of the same technique to an arteriovenous fistula. cuff of vein is left attached. After completion of the suture line, the venous cuff is closed with

interrupted sutures.

peripheral propagation of the thrombus had occurred. The thrombosed

segment was excised and recovery was thereafter uneventful.

End-to-End Suture

There were 10 patients in whom the artery was repaired by end-to-end

suture; were instances of aneurysm and of arteriovenous fistula. (Table

31.) In of the fistulas saccular aneurysm was also present. The age range

in this group was from 19 to 35 years and the duration of the lesion at the time

of operation, from to 8.5 months. The brachial artery was involved in

patients and the axillary artery in 2. In the remaining patient double fistula

was present between the femoral vein and the femoral and profunda femoris

arteries. Five patients had injuries of the peripheral nerves; these injuries

required neurolysis in all and neurorrhaphy in 2.

In patient sympathectomy was performed before operation, and in

all anticoagulant therapy was administered. In patient receiving anti-
ARTERIAL REPAIR 293

Table 31. End-to-End Suture—Data on 10 Patients with Arterial Aneurysms

and Arteriovenous Fistulas

coagulant therapy (Case 25) heparin was given at operation and also, by

mistake, 1,500 mg. of dicumarol and 250 mg. of heparin during the course of

the following 20 hours. When the error was discovered, anticoagulant therapy

was discontinued and synthetic vitamin was given at once. No hemorrhagic

difficulties ensued.

Damage to the involved arteries required the excision of segments ranging

from 1.5 to 3.0 cm. in length. End-to-end suture was accomplished by first

placing four evenly spaced mattress sutures which were used as traction

sutures. This technique facilitated the insertion of the everting mattress

sutures which completed the anastomosis (Fig. 41). In lesions of the axillary

and brachial vessels, the length of the available artery was increased by adducting the arm against the body and flexing the forearm upon the arm.

This position was maintained after operation by the use of elastic bandages or

plaster splints. In the patient in whom the femoral artery and the profunda

were involved (Case 28), the divided ends of the femoral artery could not be

approximated, but it was possible, without tension, to approximate the

proximal end of the profunda to the distal stump of the femoral artery (Fig. 42).

Case

No.

Age of patient Type of lesion Location of lesion

Duration of lesion

Preoperative

sympathectomy

Anticoagulant

therapy

Length

of excised

artery

Postoperative

obserservations

Results

Months Mm. Months

19 20 Saccular aneurysm.

Brachial, distal

3d.

5.6 1.5 2.0 Excellent.

20 35 Saccular aneurysm.

Brachial, distal

3d.

7.5 1.5-2.0 2.0 Excellent.

21 27 Saccular aneurysm.

Brachial, proximal 3d.

8.0 1.5-2.0 3.5 Excellent.

22 28 Saccular aneurysm.

Brachial, middle

3d.

8.5 1.5 2.0 Excellent.

23 23 Saccular aneurysm.

Axillary, distal

3d.

5.5 2.0-2.5 2.0 Excellent.

24 19 Saccular aneurysm.

Brachial, middle

3d.

6.0 1.5 2.0 Excellent25 24 Saccular aneurysm.

Brachial, distal

3d.

6.0 2.0 1.0 Segment thrombosed.

Good circulation.

26 21 Saccular aneurysm.

Brachial, distal

3d.

3.0 2.0 5.0 Probably thrombosed

and recanalized. Good

circulation.

27 29 A-V fistula

and saccular aneurysm.

Axillary, distal

3d.

3.0 2.0 4.0 Excellent.

28 29 A-V fistula.. Femoral and profunda arteries,

femoral vein.

3.0 3.0

2.0

2.5 Excellent.

Femoral artery.

Profunda femorisartery.
294 VASCULAR SURGERY IN WORLD WAR II

Figure 41. End-to-end suture. Four mattress sutures are placed through the ends of the

vessels at equidistant points. Traction upon these sutures converts the cylindrical ends of the vessels into square with the intima everted. Closure is completed with additional mattress sutures.

Good results were obtained in of the 10 patients managed by end-to-end

suture, but operation was unsuccessful in the other patients. In patient (Case 25), although good circulation was maintained in the hand, thrombosis of the sutured segment soon became evident. In this patient the aneurysm

was near the distal end of the brachial artery, the sac lying partly in the belly

and tendon of the biceps muscle. The divided ends of the artery could be

sutured after the sac had been excised, but the diameter of the vessel was

small and the distal segment was somewhat scarred as the result of the original

trauma. Additional resection at this end to make more normal tissue available for suture would have been desirable, but this was impractical because

of the proximity of the bifurcation of the vessel. In the other failure (Case 26)

damage to the distal arterial segment was probably even more extensive than

in the case just described. Though the patient continued to have good

radial pulse after operation, the ulnar pulsations were significantly reduced

as were the oscillometric readings. The anastomosis may have remained

patent, but it seemed more reasonable to assume that thrombosis had occurred

and had perhaps been followed by recanalization.

Vein Transplant

There were patients, instances of aneurysm, of arteriovenous fistula,

in whom an arterial defect was repaired by vein transplantation. In of the

fistulas saccular aneurysm was also present. In of the patients the lesion
ARTERIAL REPAIR 295

Figure 42. (Case 28, Table 31.) Postoperative arteriogram taken 10 weeks after resection of fistula between femoral and profunda femoris arteries and femoral vein, with end-to-end

suture of profunda artery proximally to femoral artery distally. Injection of 70 percent

diodrast into the common femoral artery reveals excellent filling of the femoral artery. No

narrowing is evident at the suture line.

was of traumatic origin, in the sixth patient (Case 32) saccular popliteal

aneurysm had followed medionecrosis of the artery. The age range in this

group was from 19 to 36 years and the duration of the lesion at the time of

operation, in the patients in which this information was available, ranged

from to 5.5 months in patients. For the fifth patient it was years. The

330323 0—55 20
296 VASCULAR SURGERY IN WORLD WAR II

Table 32. Vein Transplant—Data on Patients with Arterial Aneurysms and

Arteriovenous Fistulas

Figure J+S. Vein transplantation. The venous segment has been sutured to the distal end of the artery with interrupted mattress sutures. Suture to the proximal end of the artery

has been started.

femoral artery was involved in patients and the brachial and the popliteal

artery in patient each. One patient had an associated fracture of the femur,

and another nerve injury for which neurolysis and neurorrhaphy were

necessary.

All the patients in this group received anticoagulant therapy. In 2,

sympathectomy was carried out.

The venous segment used for repair was excised from any accessible

vein of suitable caliber. The main saphenous vein was used in patients,

and the femoral vein, branch of the femoral vein, and the small saphenous

vein in patient each. The technique employed in end-to-end suture

(that is, the use of mattress sutures as traction sutures before the other sutures

are placed) was used in all patients (Fig. 43). The segment of vein was so

Case

No.

Age of

patient

Type of lesion Location of lesion

Duration of lesion

Preoperative

sympathectomy

Anticoagulant

therapy

Length

of vein

graft

Source of

vein graft

Postoperative

observations

Results

Months Cm. Months

29 26 A-V fistula

and saccular aneurysm.

Femoral, distal

3d.

4.0 2.0 Saphenous. 3.0 Excellent.

30 19 A-V fistula.. Femoral, middle

3d.

5.0 2.0 Branch of

femoral.

3.0 Excellent.

31 26 A-V fistula. Femoral, distal

3d.

4.0 5.0 Saphenous. 3.0 Excellent.

32 35 Saccular

aneurysm.

Popliteal, middle 3d.

Unknown2.0 Small

saphenous.

4.0 Excellent.

33 36 Saccular

aneurysm.

Femoral, proximal 3d.

72.0 2.5 Femoral... 1.5 Excellent.

34 24 Saccular

aneurysm.

Brachial, middle 3d.

5.5 2.5 Saphenous. 1.0 Thrombosis.

Good circulation maintained.
ARTERIAL REPAIR 297

inserted that its proximal end was sutured to the distal end of the artery and

its distal end to the proximal end of the artery. This was done to inhibit

the action of any valves which might be present in the transplanted segment.

Failure resulted in patient (Case 34). Good circulation was maintained but thrombosis occurred. possible explanation for this failure might

be that the suture was technically imperfect because the brachial artery was

unusually small. Excellent results were achieved in the other patients.

Arteriograms revealed patent vessels, and showed no postoperative dilatation

of the venous insert. When the vessels were of approximately the same size,

the relative diameters remained essentially unchanged. When the venous

transplant had been larger than the artery at operation, it was found to have

assumed much the same proportions as the artery.

Results

In general, the results of arterial repair were excellent. Twenty-eight

reparative procedures out of possible 34 were successful. Except for some

edema in of the patients listed in Table 29, symptom which diminished

progressively with the passage of time, the circulatory status appeared normal.

None of the patients had sensitivity of the hand or foot to cold—a fairly common sequela in those in whom aneurysm or fistula was treated by procedure

involving ligation of the artery. Excluding few patients in whom exercise

tolerance could not be judged fairly because of motor paralysis or fracture,

and few who had fatigability of the extremity before operation at time

when blood flow through the affected artery was intact, none had any appreciable decrease in tolerance of exercise. This was in decided contrast to those

in whom surgical treatment had necessitated ligation of major artery. To

illustrate, those with ligated popliteal or femoral arteries could walk only an

average of about seven-tenths of mile before onset of extreme fatigue or

cramps in the calf. 23

In retrospect, of course, it becomes clear that certain of the failures might

perhaps have been avoided if different plan of treatment had been adopted,

though in other instances no alternative method could conceivably have altered

the outcome. In Case 13 (Table 29) the vein should have been divided and

used to reinforce the transfixed fistula, the technique employed in the other 12

patients treated by this method. In Case 14 (Table 30) gross infection was

present and it is not surprising that satisfactory healing did not occur. In

Case 34 (Table 32) no technique other than vein transplantation could have

been used for repair because of the length of the arterial segment which had to

be excised. In this patient the vessel was unusually small and while it is

possible that repair was not technically perfect, it appeared satisfactory at the

time of operation and there was free flow of blood through the venous insert

when the incision was closed. In Cases 18 (Table 30), 25 and 26 (Table 31),

23 Shumacker, H. B., Jr.: Sympathectomy as an adjuvant In the surgery of aneurysm and arteriovenous fistulas.

Surgery 22; 571-596, Oct 1947.
298 VASCULAR SURGERY IN WORLD WAR II

local damage to the artery was sufficient to account for the postoperative thrombosis. In Case 18 lateral suture should probably not have been performed;

it would have been better to excise the damaged segment and to accomplish

repair by end-to-end suture or vein graft. Anticoagulants should also have

been used. In Cases 25 and 26 additional resection of the distal segment was

recognized as desirable, but was not possible because of the close proximity of

the point of bifurcation of the vessel to the severed distal end. In Case 26

there was difference of opinion about the end results. The operating surgeon

believed that thrombosis and subsequent recanalization had occurred, but

several other surgeons who examined the patient differed with him and regarded

the operation as successful.

In addition to the complications just discussed there were few others.

One patient had postoperative hematoma which required exploration of the

wound hours after the original operation (Case 30, Table 32). The vein

graft was found to be functioning well and the bleeding to be coming from

small branch to muscle. This was clamped and ligated. Three other

patients had hematomas develop in the wound. (Case 15, Table 30, and Cases

32 and 33, Table 32.) In instance the hematoma was evacuated by aspiration. In the other instances exploration of the wound revealed diffuse

capillary bleeding. All of these patients were receiving anticoagulant therapy

and in each patient the therapy was stopped and no further difficulty encountered. In patients (Cases 32 and 33, Table 32) mild wound infections

developed, but did not interfere with the success of the vascular repair.

Methods of Evaluating Results Various examinations were used to evaluate the success of the reparative

operation in terms of patency of the repaired artery. That the foot was warm

and of healthy color was not considered sufficient evidence, nor was the

presence of pulsations distal to the repair. The presence of palpable radial

pulse after brachial or axillary repair or of dorsalis pedis pulse after femoral

or popliteal repair was also not sufficient evidence since such pulses may be

present after ligation of main arteries proximally if the collateral circulation is

adequate. The presence of all pulses distal to the site of repair, if they were

equal in volume to the pulses in the contralateral limb, was felt to provide

adequate evidence of successful maintenance of continuity of the artery.

When, for instance, full popliteal, posterior tibial, and dorsalis pedis pulses

were present after repair of the femoral artery, the patency of the latter vessel

could be assumed.

Arteriograms were of great value after operation to determine the patency

of the repaired artery and to furnish evidence of dilatation or other changes

which mightresult from arterialrepair. In addition, criteria of success included

oscillometric results comparable to those in patients in which the patency of

the artery was established by arteriographic examination and in excess of those

observed in proved instances of arterial ligation.
ARTERIAL REPAIR 299

Data concerning oscillometric studies are available in 28 of the 34 patients

in whom reparative surgery was carried out at Mayo General Hospital (Table

33). In 23 of these patients the operation was successful, in the other patients

either thrombosis occurred or ligation had to be done secondarily because of

hemorrhage or recurrence of the fistula. In general, oscillometric readings were

high in those patients in whom the continuity of blood flow through the repaired artery was maintained and low in those in whom the segment was

occluded by thrombosis or the artery was ligated.

Of considerable interest was the observation that oscillations were, in

general, about equal on both sides when the fistula was simply ligated and

transfixed, were only slightly reduced on the affected side when lateral arteriTaBLE 33. OsCILLOMETRIC STUDIES FOLLOWING ARTERIAL REPAIR IN 28 PATIENTS

orrhaphy was performed, but were reduced to somewhat greater degree in

those patients in whom end-to-end suture or vein graft was done. This

observation came as surprise since in all of these patients comparison of the

color, warmth, and pulsations in the normal and in the affected limb were

substantially the same after reparative surgery. The reduction in oscillations

did not seem explicable on basis of local or general vasoconstriction, since

the limbs showed no evidence of vasospasm. Moreover, in some patients in

whom sympathectomy had been performed similar reduction in oscillations

was noted. Arteriograms showed no evidence of constriction at the site of

repair. Since there was little or no evidence of any functional circulatory

impairment, the diminished oscillations were considered of little practical

concern.

Type ofrepair Artery

repaired

Number

of patients

Osclllometric read- ing at ankle or wrist Osclllometric read- ingat calfor forearm Osclllometric read- ing at thigh or arm

Average

reading

Percent

of reading in contralateral

limb

Average

reading

Percent

of reading in contralateral

limb

Average

reading

Percent

ofreading in contralateral

limb

2.3 96 5.1 96 3.5 95

Ligation of fistula-. Popliteal 5.1 75 7.6 95

Lateral arteriorrhaphy Subclavian.. 2.5 83 3.8 70 4.5 88

1.0 37 1.5 41 2.2 44

2.5 83 2.8 51

3.0 60 4. 50 7.0 100

3.1 67 4.0 50 4.0 67

Vein transplantation Popliteal 2.0 67 3.0 43

Total successful cases- 23 2.9 79 4.3 68 4.0 68 Unsuccessful cases* 1.0 17 0.9 16 0.5 18

•These cases included lesion Involving the femoral and involving the brachial artery.
300 VASCULAR SURGERY IN WORLD WAR II

SUMMARY

The ideal method for the surgical treatment of aneurysms and arteriovenous fistulas is extirpation of the lesion and maintenance or restoration of

the continuity of the artery. Though local anatomic factors sometimes preclude the use of reparative methods, the attitude of the surgeon determines,

perhaps more than anything else, the frequency with which these procedures

are applied. high degree of success can be expected; nevertheless, one cannot assume that the results of arterial repair will be uniformly successful.

Since this is the case, it is advisable to do everything possible to make certain

that the collateral circulation is adequate before definitive surgery is attempted.

The chief hazards of surgical repair of arteries are hemorrhage, thrombosis,

and subsequent development of aneurysmal dilatation at the site of repair.

The chief local factors which endanger the success of the repair appear to be

damage to the wall of the artery, infection, or lumen of such small caliber

as to make accurate approximation difficult.

In the present series postoperative hemorrhage occurred only once; the

sutured artery lay in pool of pus and healing did not take place. Thrombosis

occurred times; times following lateral arteriorrhaphy or end-to-end suture

in which local arterial damage was sufficiently extensive to raise doubts in the

mind of the surgeon at the time of the operation that the artery would remain

patent. In the other instance an exceedingly small brachial artery was

repaired with vein transplant.

Extension of thrombus so as to compromise important collateral arteries

has been advanced as contraindicating arterial repair. The data from this

series suggest that such propagation of thrombus is unlikely provided the

collateral circulation is adequate, for extension of thrombus is not apt to

occur if the circulation proximal and distal to the site of repair is kept active

by collateral blood flow. In one patient in whom thrombosis occurred, the

occluded segment was excised and the thrombus sharply limited to the immediate area of repair. Furthermore, the chance of thrombosis occurring, or of

its propagation if it should occur, can be lessened considerably by the use of

anticoagulants.

There was recurrence of an arteriovenous fistula in one patient in this

series—the fistula was simply transfixed and ligated in continuity, procedure

which appears to be unwise. No aneurysms developed at the site of repair

in any instance. Should this unfortunate event take place it appears likely

that it would occur within the first few weeks or months after operation and

not years later when atherosclerotic changes might add an additional hazard

to its extirpation. Under such circumstances it would seem that the original

procedure could still be looked upon as justifiable; such patients should be

able to withstand surgical cure of the aneurysm with no more risk than would

have been entailed had the artery been ligated at the original operation.
ARTERIAL REPAIR 301

It was the opinion at this center that while the patient may have been

subjected to certain additional hazards, these hazards are minimal and of little

practical concern provided the collateral circulation is adequate, no collateral

vessels are sacrificed, and anticoagulants are used. Altogether there seems

every justification for performing reparative or restorative procedures instead

of arterial ligation whenever such methods can be applied. Certainly the

results of successful repair are superior to those of any method which necessitates

sacrificing the continuity of the affected artery.
CHAPTER IX

Arterial Aneurysms and Arteriovenous Fistulas

Successful Suture of the Abdominal

Aorta for Arteriovenous Fistula

Norman E. Freeman, A4. D.

and

Ambrose H. Storck, M. D.

An arteriovenous fistula involving the abdominal aorta is seldom observed

since death usually follows promptly from the massive hemorrhage caused by

the original injury. Even if the patient recovers from the initial loss of blood,

as in the two cases reported by Makins in which the patients survived for

several weeks, the short-circuiting of the circulation immediately places such

strain on the heart that early cardiac failure occurs.

In 1944, Pemberton, Seefeld, and Barker successfully repaired an arteriovenous fistula occurring between the abdominal aorta and the inferior vena

cava. They were unable, in comprehensive review of the literature, to find

any previously reported case in which the patient had survived for sufficiently

long period of time after surgical repair to furnish evidence that the operation

had been successful. The case described in this chapter is apparently the

second to be recorded in which successful repair of the abdominal aorta has

been performed.

CASE REPORT

The patient, 25-year-old infantryman, was wounded on Okinawa 14 May 1945.

bullet from .25-caliber rifle entered the abdomen inches below the ensiform cartilage just

to the right of the midline and passed out through the back at the level of the second lumbar

vertebra. He immediately became paralyzed below the waist. laparotomy was performed the day of injury and large retroperitoneal hematoma found. The abdomen was

closed without drainage. The patient stated that he was told that numerous veins had been

tied off during the operation. Ten days after injury he was transferred to another hospital

where roentgenograms were made. They disclosed several fracture lines in the spinous

process of the second lumbar vertebra radiating through the lamina without displacement or

separation. On the 15th day after injury, laminectomy was performed and the comminuted

fragments of the spine at the first and second lumbar vertebrae, and the lamina of the second

lumbar vertebra, removed. The underlying dura was found to be compressed and lacerated

and three of the nerve roots severed.

Maklns, O. H.: On Gunshot Injuries to the Blood Vessels, Founded on Experience Gained in France During the

Great War, 1914-1918. Bristol, John Wright Sons, Ltd., 1919.

Pemberton, J. deJ.; Seefeld, P. H., and Barker, N. W.: Traumatic arteriovenous fistula involving the abdominal

aorta and the inferior vena cava. Ann. Surg. 123 580-590, Apr 1946.
REPAIR OF ABDOMINAL AORTA 303

After this operation there was considerable return of function in the lower extremities.

On the fifth postoperative day, swelling of the right leg appeared and diagnosis of thrombophlebitis was made. This swelling subsided in few days.

Preoperative Clinical Course. Six weeks after his original injury the patient complained

of some epigastric pain and, on examination, pulsating mass with intense thrill was found

in the upper abdomen. diagnosis of aneurysm of the abdominal aorta was made and he

was evacuated to the Zone of Interior.

When admitted to the debarkation hospital his blood pressure was 150 mm. of mercury

systolic and 60 diastolic. Hemaglobin was 72 percent of normal and urine examinations

showed some infection to be present. Tidal drainage was instituted to correct this condition.

Some dilated veins over the abdominal wall were observed. Physical examination revealed

nothing which would indicate cardiac enlargement. That the heart was of normal size was

confirmed by roentgenogram. chemical examination of the blood revealed it to be essentially normal, and the result of the Kahn test was negative.

The patient was transferred to the vascular center at DeWitt General Hospital August

1945. Examination at this time revealed pulsating mass in the epigastrium which was

more prominent on the right of the midline. The superficial abdominal veins were dilated

(Fig. 44).

continuous loud bruit, which was accentuated during systole, could be heard over the

mass in the abdomen. The pulse rate was 96 beats per minute and the blood pressure 152

mm. of mercury systolic and 96 diastolic. The heart was not enlarged and there was no

Figure 44- Infrared photograph of patient with arteriovenous fistula involving abdominal aorta

and vena cava. Note dilatation of veins of abdomen and thorax.
304 VASCULAR SURGERY IN WORLD WAR II

evidence of dilatation or engorgement of the neck veins. The patient was neither dyspneic

nor orthopneic. Venous pressure measured in the right antecubital vein was cm. of water.

The lungs were clear and the liver edge palpable at the right costal margin.

Neurologic examination revealed residual paraplegia involving principally the motor

components of the posterior tibial and common peroneal nerves on the right side, and some

involvement of the peroneal nerve on the left side. The sensory loss was small and was

confined to small area about the anus and scrotum on the right side.

It was not possible to obliterate the thrill by pressure in the epigastrium or right upper

quadrant. The fact that the heart showed no evidence of marked strain, even months

after the development of the lesion, was interpreted as evidence that there was some interference with the free return of blood from the arterial to the venous side of the circulation.

Since the liver was not enlarged, it was felt that there was no involvement of the portal

venous system. The dilatation of the superficial abdominal veins suggested involvement

of the inferior vena cava. diagnosis was made of arteriovenous fistula probably involving

branch of the abdominal aorta and either the vena cava or some tributary of this vein.

The patient was placed on the paraplegic ward where he was encouraged to increase his

activities as much as was compatible with his residual neurologic lesions. During his stay

the bladder infection was controlled by tidal drainage, his appetite improved, and he regained

some of the weight which he had lost.

On 15 September, months after the initial injury, the patient complained of some

abdominal discomfort and vomited. Examination at this time disclosed the abdominal

mass to be approximately cm. in diameter. Both the pulsation and the thrill were more

apparent than they had been. Gastrointestinal examination with barium meal failed to

reveal evidence of any extrinsic mass producing pressure upon the pylorus or duodenum.

The cardiac consultant noted definite increase in the size of the liver with an increase in the

pulse rate and expressed the opinion that the patient was showing evidence of cardiac strain.

Because of the possibility of cardiac damage and the increase in the size of the mass it was

decided to operate without further delay.

Operation. The operation was carried out with the patient under intratracheal etheroxygen anesthesia. right paramedian incision was made from the xyphoid to just below

the umbilicus. Numerous dilated veins were encountered in the subcutaneous tissues.

When the peritoneum was opened, large pulsating mass was found beneath the gastrohepatic

omentum. puckered scar was present near the border of the liver on the right side and

probably represented the point of entrance of the rifle bullet. The aneurysm, which lay

behind the vena cava, displaced the vena cava forward and so compressed it as to hinder the

ready flow of blood back to the right side of the heart. The veins of the portal system did

not appear to be dilated. The hepatic, common, and cystic ducts were readily visualized

and appeared to be pushed forward by the pulsating mass which occupied the posterior

aspect of the right upper quadrant. The aneurysm was under considerable pressure and at

one point, below and slightly medial to the gallbladder, the thrill of the arteriovenous fistula

was most easily palpable. While compression at this point obliterated the thrill, it also

appeared to produce an increase in the intra-aneurysmal pressure.

The round ligament of the liver and some adhesions were divided. An attempt was

made to visualize the artery entering the aneurysm by dividing the gastrohepatic omentum.

This, however, still did not permit localization of the opening of the artery into the aneurysm.

Only by pressure on the aorta at the hiatus of the diaphragm was it possible both to obliterate

the thrill and to cause the aneurysmal sac to collapse. The aorta was therefore exposed at

this point by dividing some of the fibers of the diaphragm. It was then encircled by fine

rubber catheter fitted to Bethune tourniquet. Attempts to expose the aorta through the

root of the mesentery beneath the transverse colon were unsuccessful because of the dilated

veins in this region.

The peritoneum and transversalis fascia were next incised from within the abdomen

just to the left of the midline. By separating these structures from the underlying muscles
REPAIR OF ABDOMINAL AORTA 305

it was possible to expose the anterior surface of the psoas muscle and the vertebral column.

The spleen, descending colon, pancreas, left kidney, and intestines were reflected to the right

and the abdominal aorta exposed as it lay on the anterior surface of the lumbar vertebrae.

Many large veins were divided and ligated. The tissues about the aorta were thickened

and edematous. The discoloration which was present indicated old hemorrhage. The

abdominal aorta was encircled by segment of rubber tubing just proximal to the origin of

the inferior mesenteric artery. It was then exposed just above the origin of the left renal

artery where it was again encircled by piece of tubing. Compression of the aorta by this

piece of tubing caused the sac to collapse. An additional section of tubing was placed about

the left renal artery. With the proximal and distal aorta and the left renal artery occluded, the inflammatory tissues surrounding the aorta at the site of the fistula were incised and the

aorta was finally cut away from the aneurysm at this location. Figure 45 illustrates the

location of the lesion.

The opening into the aorta measured one-half inch in length. It was closed by transverse running stitch of No. 0000 Deknatel which had been passed through sterile mineral oil.

Bleeding from the sac was only moderate and was readily controlled by digital pressure.

No effort was made to excise the sac. This opening was closed by running stitch of No.

0000 silk. At the conclusion of this procedure, the segments of tubing around the distal

aorta, left renal artery, and proximal aorta were released in that order. Good pulsation,

expansile in character, was apparent in the aorta below the suture line. No bleeding took

place. Two Penrose drains were inserted through stab wound below the left costal margin

into the region of the left lumbar gutter and the abdomen was closed.

During the operation, which lasted almost hours, the patient received continuous

transfusion of 3,000 cc. of whole blood and 500 cc. of physiologic salt solution. When the

abdominal aorta was occluded the blood pressure increased from 118 mm. of mercury systolic

and 70 diastolic to 240 systolic and 100 diastolic. The pulse rate rose from 130 to 160 beats

per minute and the neck veins became greatly distended. When the tourniquet, which had

been in place for hour and 40 minutes was released, the systolic pressure fell to 50 mm. of

mercury. Within 30 minutes, however, it rose to 110 mm. of mercury. The diastolic

pressure at this time was 80 and the pulse rate was 140 beats per minute.

Postoperative Course. Immediately after operation strong femoral pulse was palpable

and within an hour the pulse at the wrist was of good volume and all extremities warm and

dry. The patient was placed in an oxygen tent and continuous intestinal decompression

therapy was instituted by means of suction applied to an indwelling Levin tube. By the

following morning the abdomen was flat and peristalsis present. The patient was conscious

and alert. Because of persistent low blood pressure and rapid, weak pulse, he was given

another transfusion of whole blood. Blood pressure then rose to 160 mm. of mercury systolic

and 90 diastolic. Administration of penicillin and sulfadiazine was begun, but owing to

urinary suppression the sulfadiazine was discontinued after the administration of cm. in

the first 36 hours.

Impaired renal function presented serious complication. During the first 48 hours,

in spite of receiving 3,500 cc. of 5-percent glucose in distilled water and 1,000 cc. of 5-percent

glucose in physiologic salt solution, the patient voided only 200 cc. of urine. Elevation of

the nonprotein nitrogen following operation is shown in Table 34.

For the first week after operation treatment consisted chiefly of continuous oxygen

therapy, decompression of the upper gastrointestinal tract, and the administration of fluids

by vein in amounts just sufficient to balance the losses through the gastrointestinal tract

and kidneys, and by insensible loss of water.

Three days after operation the venous pressure in the right antecubital vein was 12.6

cm. of saline solution. The patient was feeling well, but he had no appetite and his mouth

was sore because of superficial erosions of the mouth and lips. Blood pressure was consistently 170 mm. of mercury systolic and 80 diastolic.
306 VASCULAR SURGERY IN WORLD WAR II

Figure Diagrammatic representation of findings at operation for arteriovenous fistula of abdominal aorta and vena cava.
REPAIR OF ABDOMINAL AORTA 307

Table 34. Chemical Constituents of Blood

Six days after operation, ophthalmologic examination was reported as showing “remarkable generalized narrowing of the retinal arterioles throughout all divisions. In many of the

vessels there are variations in caliber indicative of focal spasm. No signs of sclerosis are

noted, no hemorrhages or edema.” diagnosis of acute retinal angiospasm was made.

Because of his sore mouth and lack of appetite the patient refused to eat. On the 10th

postoperative day, therefore, high caloric feedings were started. In 36 hours the patient

received 1,500 cc. of fluid containing approximately 1,800calories. The feedings were given

by continuous drip through nasal tube. He tolerated this feeding very well and his general

condition improved rapidly. The nonprotein nitrogen of the blood dropped as the volume

of urinary excretion increased. The wound healed without complications.

The day after operation the patient noted that he could not dorsiflex the left foot.

Neurologic examination showed definite increase in the neurologic disturbances noted prior

to operation. In addition to the foot drop on the left side, the area of anesthesia had increased and there was decrease in the bladder tone. For the first months after operation

severe burning pain was experienced in both feet, but this condition suddenly cleared up at

the end of this period with concurrent improvement in motor power.

Evidence of renal damage persisted for several weeks with constantly low specific

gravity of the urine and persistent mild hypertension, and even weeks after operation the

ophthalmologic examination revealed moderate generalized narrowing and increased tortuosity of the retinal vessels. Excretory urograms made weeks after operation revealed

the excretory function of the kidneys to be normal. The final urine concentration test,

made months after operation, showed an ability of the kidneys to concentrate the urine to

1.018. Roentgenograms, made at this time, showed defect in the laminae between the

second and third lumbar vertebrae at the site of the original fracture.

About 2% months after operation the patient was transferred to another general hospital. At this time he had recovered sufficiently from the spinal cord injury to walk with

the aid of one cane.

Eight months after operation it was reported that the patient had shown no evidence of

recurrence of the fistula.

COMMENT

The presence of fistula between the abdominal aorta and vena cava

usually leads to rapid heart failure and death. The absence of this complication in this case can probably be explained by the intervention of large

Date of determination Nonprotein nitrogen Urea nitrogen Chlorides Serum proteins CO2 Combining

power

27 July

Mg. per 100 cc. Mg. per 100 cc. Mg. per 100 cc. Gm. per 100 cc. Vo/.

33.

34.

Operation

111.

116.

116.

120.

107.

70.

63.

14 August 18. 7. 10

27 September

29 September

30 September

522 6. 48 60.

October

October

October

October

80.

91.

541

591

572

568

5. 39

5. 75

6. 48 59.

61.

13 October
308 VASCULAR SURGERY IN WORLD WAR II

aneurysmal sac between the two vessels. The dilatation of the superficial

abdominal veins observed before operation is in keeping with this explanation.

The transient swelling of the right leg noted 10 days after injury (which was

originally diagnosed as thrombophlebitis) was probably the result of interference

with the return flow of blood from the lower extremity.

The increase in the paralysis of the bladder and lower extremities following

operation was not surprising in view of the fact that the abdominal aorta was

completely occluded for 100 minutes. After complete occlusion of the aorta

for period of 40 to 55 minutes, Blalock and Park observed paralysis of the

hind quarters in the dogs used in their experiments. The neural damage evident

after operation might be attributed to the result of impairment of the circulation

to the spinal cord and cauda equina or to the temporary ischemia of the distal

nerves, but the involvement of the nerves to the bladder suggest the former

explanation. The rapid improvement which was observed months after

operation indicated favorable prognosis.

The second postoperative complication was the temporary urinary suppression, associated with hypertension. This complication was probably the result

of the renal ischemia produced by occlusion of the abdominal aorta above the

renal arteries. It was associated with marked vasospastic changes in the eyegrounds and with nitrogen retention. With resumption of renal function at

the end of weeks, the hypertension subsided. The final urine concentration

test, which was done months after operation, showed an ability to concentrate

to 1.018. The excretory urogram was also quite satisfactory, but it is possible

that some permanent damage to the kidneys was sustained. In case reported

by Alexander and Byron in which segment of the thoracic aorta was resected,

hypertension with severe retinal angiospasm, exudates, and hemorrhages proved

serious late complication. In case reported by Pemberton, Seefeld, and

Barker, persistent hypertension with cardiac hypertrophy was also noted.

During the operation considerable difficulty was experienced in locating

the opening of the artery into the aneurysmal sac. Reflection of the duodenum

with exposure of the anterior surfaces of the aorta and vena cava was employed

by Pemberton and his associates as the method of exposure, but the aneurysmal sac in their patient lay to the left of the aorta. Since in this case the sac

appeared to lie between the aorta and the vena cava, similar approach could

not be used. It was only after retroperitoneal exposure of the anterior surface

of the psoas muscle and the lumbar vertebrae by displacement of the abdominal

Blalock, A., and Park, E. A.: Surgical treatment of experimental coarctation (atresia) of the aorta. Ann. Surg.

119: 445-456, Mar 1944.

When this patient was examined year after the operation at the time of his discharge from the Veterans Hospital

at Van Nuys, Calif., he couldwalk with the aid of single cane and could goup and down stairs. There was no recurrence

of the abdominal aneurysm or arteriovenous fistula. Bladder control was incomplete, but he could retain 12 oz. of urine.

Subsequently letter was received from the patient saying that he had returned to work (cabinetmaking) and was able

to hold full-time job.

Alexander, J., and Byron, F. X.: Aortectomy for thoracic aneurysm. J. A. M. A. 126; 1139-1145, 30 Dec 44.

See footnote 2, p. 302.

1bid.
REPAIR OF ABDOMINAL AORTA 309

contents from the left lumbar gutter that the abdominal aorta could readily

be exposed. It was then possible to visualize the entire length of this vessel

from the diaphragm to its bifurcation.

Transvenous suture of the opening between the aorta and vena cava, the

technique known as the Matas-Bickham operation, was used by Pemberton

and his associates. Although it is frequently valuable, it has the disadvantage of not permitting inspection of the entire arterial wall and arterial aneurysms

have been known to develop after its use in cases in which there happened to

be additional weakened points in the arterial wall. Closure of an arteriovenous

fistula leads to marked increase in blood pressure within the artery at the site

of the fistula. If the wall close to the former communication is defective it

may give way and result in the formation of an aneurysm. On the other hand,

complete dissection of the artery from the fistula permits thorough examination

so that other damaged portions of the wall are unlikely to escape notice.

Excision of the damaged portion of the arterial wall with transverse closure of

the defect is the procedure of choice under these circumstances. 10

Matas, R.: Treatment ofarteriovenous aneurisms by intrasaccularmethod ofsuture (endo-aneurismorrhaphy)with

special reference to transvenousroute. Ann. Surg. 71: 403-427, Apr 1920.

Freeman, N. E.: Direct measurement ofblood pressurewithin arterial aneurysms andarteriovenous fistulas. Surgery 21: 646-658, May 1947.

10 Freeman, N. E.: Arterialrepair in the treatment of aneurysms and arteriovenous flstulae; report of 18 successful

restorations. Ann. Surg. 124 888-919, Nov 1946.
CHAPTER

Arterial Aneurysms and Arteriovenous Fistulas

Anticoagulant Therapy in Reparative Surgery

Harris B. Shumacker, Jr., A4. D.

David I. Abramson, M. D.*

and

Herbert H. Lam pert, A4. D.**

Prior to World War II occasional reports appeared in the literature concerning the clinical and experimental use of anticoagulants in arterial surgery.

All, however, were limited to the use of heparin. The anticoagulant dicumarol

was not introduced until after the beginning of the war. While these two

agents were not generally used in the vascular centers at the general hospitals

in the Zone of Interior, they were employed occasionally on special indications

at some of the centers. At Mayo General Hospital where they were used,

study was undertaken to test their efficacy in the prevention of thrombosis

following arterial repair. The patients chosen for this study were those in

whom some type of reparative or restorative procedure had been employed in

an effort to maintain continuity of the artery following surgical obliteration of

peripheral aneurysm or arteriovenous fistula.

CLINICAL MATERIAL AND METHODS

Some type of reparative surgery (transfixion of fistula, lateral arteriorrhaphy, end-to-end suture, or vein transplantation) was carried out in 34

patients in series of 288 aneurysms or arteriovenous fistulas treated at this

installation. Twenty-two of these 34 patients received anticoagulant therapy

for more or less prolonged period of time. An additional patient received

single injection of heparin at the time of operation. Eighteen received combined heparin-dicumarol therapy after operation, received dicumarol before

operation and combined therapy afterward, received only dicumarol which

was given both before and after operation. In these 23 patients there were

instances of postoperative thrombosis.

‘Clinical Associate Professor of Medicine, University of Illinois College of Medicine. Formerly Major, MC, AUS.

“Senior Clinical Physician in Internal Medicine and Cardiology, Mount Sinai Hospital. Formerly Major, MC,

AUS.

(1) Murray, Q. D. W.: Heparin in surgical treatment of blood vessels. Arch. Surg. 40 307-325, Feb 1940.

(2) Murray, Q. D. W.: Heparin in thrombosis and blood vessel surgery. Surg., Oynec. Obst. 72: 340-344, Feb

1941.

Link, K. P.: The anticoagulant from spoiled sweet clover hay. Harvey Lecture Series 39: 162-216, 1943-44.
ANTICOAGULANTS IN REPARATIVE SURGERY 311

Of these 34 patients treated by reparative arterial surgery, 11 did not

receive anticoagulant therapy. In of these patients postoperative thrombosis occurred.

In the majority of patients in this series, heparin was administered on the

operating table as soon as the decision was made to attempt arterial repair and

was continued for period of hours until dicumarol, administration of which

had been begun as soon after operation as the prothrombin time could be determined, had produced satisfactory alteration of the prothrombin level.

Crystalline heparin in aqueous solution was given intravenously in 50-mg.

doses every hours for period of 48 hours. During this time its anticoagulant

effect was measured occasionally, but not at regular intervals, by determining

the clotting time according to the method of Lee and White.

The method of Quick was used for the determination of the prothrombin

level. In general, 300 mg. of dicumarol were given the first day, 200 mg. the

second day, and 100 mg. the third day. Thereafter the dosage for each patient

was determined daily on the basis of the level of his prothrombin time. The

exact quantity required to maintain the prothrombin time at the desired level

varied for the different patients and not infrequently for the same patient during

the course of therapy. Generally daily dose of 100 mg. was necessary, although in some instances smaller amounts were adequate. When patient

was being given heparin and dicumarol concurrently, blood for prothrombin

determinations was drawn just before the administration of dose of heparin

in order to minimize any possible effect of the latter upon the prothrombin

blood level determination. An effort was made to maintain the prothrombin

level in the neighborhood of 20 to 30 percent of normal according to the Quick curve; this is roughly equivalent to “clotting index” of 50. control test

using normal plasma was run with each daily set of determinations.

It was found to be wise precaution to delegate dicumarol therapy to

single member of the staff. Each morning report of the prothrombin determinations of all patients receiving this therapy was submitted to the responsible staff member. On the basis of this information he issued orders regarding

each patient’s dosage of dicumarol for that day.

Eighteen patients in this series of 23 received combined heparin-dicumarol

therapy after operation. In 1, ligation and transfixion of fistula had been

performed, in lateral arteriorrhaphy, in 10 end-to-end suture, and in vein

transplantation. In these patients the administration of heparin was started

during the operation procedure and continued for an average of 48 hours;

dicumarol, which was administered as soon after operation as prothrombin

determination could be obtained, was usually continued for 21 days. In few

patients dicumarol was given for periods ranging from 10 to 16 days; in

patients it was given for even shorter periods of time.

Lee, R. I., and White, P. D.: clinical study of coagulation time of blood. Am. J. M. Sc. 145; 495-503,1913.

Quick, A. J.: Clinical application ofhippuricacid andprothrombin tests. Am. J. Clin. Path. 10; 222-233, Mar 1940.

Quick, A. J.: Natureof bleeding in jaundice. J. A. M. A. 110: 1668-1662, 14 May 38.

330323 0—55 21
312 VASCULAR SURGERY IN WORLD WAR II

In each of these patients there was special reason for discontinuing the

therapy. In the first patient the response was unusually prompt and the

prothrombin level at the end of days abnormally low. In the second patient

lateral suture had been performed in the presence of gross infection. Since

the prognosis for healing was poor and hemorrhage possibility, dicumarol

was discontinued after the third day. In the third patient dicumarol was discontinued on the fourth day because of persistent bleeding from the wound.

In the fourth patient, in which brachial aneurysm was excised and end-to-end

suture accomplished, the usual heparin-dicumarol routine was instituted, but

through error the patient received 300 mg. of dicumarol every hours for

doses, in addition to 50 mg. of heparin every hours for the same number of

doses. When the mistake was discovered anticoagulant therapy was discontinued at once and 60 mg. of synthetic vitamin were administered intravenously. The prothrombin level remained fairly low for several days, but no

hemorrhagic difficulties ensued and the patient’s condition was not alarming

at any time.

In patients in this series of 23, dicumarol was given before operation

and an adequate reduction in prothrombin level had already been attained by

the time of operation. Two of these patients received, in addition, single doses

of heparin during the operation. In all patients dicumarol was continued

for approximately 21 days.

One patient in this series received no anticoagulant treatment other than

single dose of heparin given at the time of operation.

ANALYSIS OF RESULTS

Of the 23 patients receiving anticoagulant therapy 15 recovered with no

complications, in thrombosis developed, and in some later difficulties with

bleeding occurred. It should be emphasized that in spite of the thrombosis,

there was no evidence of propagation of the clot in any of the patients. No

difficulty with hemostasis was experienced at operation in any case in this

series regardless of whether heparin was administered immediately before the

anastomosis was accomplished, or whether the prothrombin time had been altered before the operation through the administration of dicumarol. Fibrin

foam was frequently placed in the wound as safeguard and this precaution

appeared to give some protection against bleeding from the operative site

without adding any risk of intravascular clotting.

Details of the cases in which complication followed the operative procedure

are as follows: In patients receiving anticoagulant therapy, thrombosis developed. In of these patients, end-to-end suture had been performed for

traumatic aneurysm of the distal end of the brachial artery. In both instances

the proximal end of the artery was perfectly normal, but the distal segment

was somewhat scarred. Further resection of that end, in order to have available for suture longer strip of normal artery, was impossible because of the
ANTICOAGULANTS IN REPARATIVE SURGERY 313

proximity of the bifurcation of the artery into its radial and ulnar branches.

Both patients received heparin immediately after operation. The first also

received dicumarol for period of 14 days. The second was the patient mentioned previously who through error was given large amount of dicumarol

during the first 20 hours following operation and following this discovery no

anticoagulants at all. The thrombosis which developed in both patients can

very logically be attributed to the local arterial damage.

The third patient in whom thrombosis developed had had defect in the

brachial artery repaired by vein graft. An adequate prothrombin level had

already been achieved with dicumarol at the time of operation. single dose

of heparin was given during the operative procedure and dicumarol was continued for about 14 days thereafter. While no explanation for the thrombosis

in this patient is apparent, the artery was unusually small and it is not unlikely

that an imperfect suture may have been the cause even though the completed

anastomosis appeared to be satisfactory at the time of operation.

In patients difficulty with bleeding was encountered. In patient

hematoma of moderate size developed in the wound. Lateral suture of the

subclavian artery had been performed and the patient was receiving dicumarol.

The operative site was explored on the 10th day and large clot evacuated.

No bleeding was encountered and the wound was closed; convalescence was

thereafter uneventful. second patient, in whom vein graft to the popliteal

artery had been performed, had small hematoma which was evacuated without difficulty. There was no further bleeding during the 6-week period in

which dicumarol was administered.

third patient developed large hematoma after excision of femoral

arteriovenous fistula repaired by vein transplant. Two hours after the operation brisk bleeding occurred. The wound was explored and small branch

to the muscle found to be the source of the bleeding. This artery was ligated,

the wound closed, and no further difficulty occurred although dicumarol was

continued for several weeks.

In fourth patient slow, steady oozing of bright red blood from the wound

was noted shortly after femoral arteriovenous fistula had been excised and

vein graft performed. Heparin was continued intermittently in spite of the

bleeding until the fourth day after operation when an adequate prothrombin

level was obtained with dicumarol. By this time the blood loss had been

sufficient to result in significantly lowered erythrocyte count. The patient

was given transfusion of whole blood and 50 mg. of synthetic vitamin K.

The wound was thereafter explored, but was closed promptly when only diffuse

capillary bleeding was found. No further bleeding occurred.

It is noteworthy that in none of these patients did thrombosis of the repaired arterial segment take place.

In fifth patient the brachial artery remained patent after lateral suture

in the presence of gross infection. Hemorrhage, however, occurred through
314 VASCULAR SURGERY IN WORLD WAR II

the sutured defect on the 13th postoperative day. Exploration of the wound

revealed that no healing of the suture line had taken place. The segment was

excised and the artery ligated. The results in this patient were good. Since

dicumarol had been discontinued for 10 days before the bleeding took place,

it seems unlikely that this agent was implicated in the bleeding. Hemorrhage

was probably caused by nonhealing consequent to infection.

Analysis of Results in Patients Not

Receiving Anticoagulant Therapy

No control group, as such, existed for the patients who received anticoagulant therapy following arterial repair. Anticoagulants were reserved, as

rule, for those in whom the type of repair was such that the hazard of thrombosis was greater. Since the 11 patients in this series denied this therapy

were those with the simpler types of repair, they cannot be considered proper

controls. Notwithstanding, the results in these patients are considered of

value for comparative purposes.

In of the 11 patients not receiving anticoagulants following arterial

repair, recovery was uncomplicated. In patient thrombosis developed

and in the fistula recurred. In the former, femoral arteriovenous fistula

was resected and the rent in the artery repaired by lateral suture. The success

of the operation seemed questionable when it was performed because there was

obvious injury to the arterial wall in the neighborhood of the fistula and because the vessel was constricted to about one-half its normal diameter by the

suture. Blood flowed freely through the segment, however, and it was decided

to do nothing further. Two hours after operation it was apparent from the

absence of pulsations in the popliteal, the dorsalis pedis, and the posterior

tibial arteries that thrombosis had occurred. When the wound was reexplored

thrombus was found which was sharply limited to the repaired segment of

the artery and was without proximal or distal propagation. The segment was

excised and the artery ligated. In retrospect it would seem that in this instance

the segment should have been excised originally and vein transplantation performed. The use of anticoagulants also would have been wise.

In second patient fistula was ligated and transfixed, but division of the

vein was not performed nor cuff of vein used to buttress the ligated fistula.

This was the only instance in this series in which this technique was used.

Recurrence was prompt and subsequent excision and quadruple ligation of the

vessels were required.

In the remaining patients not treated by anticoagulants there were no

untoward results.

COMMENT

The efficacy of heparin in the prevention of thrombosis in aneurysms

treated by arterial repair had been suggested by experimental and clinical

evidence for some time before World War II. Later it became evident that
ANTICOAGULANTS IN REPARATIVE SURGERY 315

dicumarol was of benefit in reducing the incidence of postoperative venous

thrombosis and pulmonary embolism and, on the basis of experience in other

types of surgery, it seemed likely that it would be equally effective in reducing

the incidence of postoperative thrombosis after arterial repair. The experience

at Mayo General Hospital does not furnish complete proof of its effectiveness, however, since no true control group existed and since most patients in this

series received heparin as well as dicumarol. Untreated cases recorded in the

literature cannot be used for controls because so many other factors are important in evaluating the success of arterial surgery, as, for example, the type

of repair, the proficiency of the surgeon, the presence or absence of infection,

and the degree and extent of the local arterial injury or disease.

It is believed that dicumarol was of benefit in preventing arterial thrombosis in the present series, but that it is not complete safeguard is suggested

by the observation that adequate and prolonged anticoagulation therapy did

not prevent thrombosis in all patients. The conclusion therefore seems warranted that, helpful as anticoagulants may be, their use will not be attended

with success unless (1) local damage to the sutured artery is not great and (2)

the surgical repair is properly executed.

It is of interest, as mentioned previously, that in none of the patients in

whom thrombosis occurred following anticoagulant therapy was there any

evidence of extension of the clot from the repaired segment. However, in the

patient who did not receive anticoagulants following arterial repair and in

whom thrombosis occurred, there was also no evidence of extension of the

clot. An analysis of these cases suggests the extreme importance of the maintenance of good blood flow in the distal segment through adequate collateral

channels and it seems reasonable to assume that anticoagulant therapy will

prove of aid in the important problem of prevention of distal extension of the

clot.

It would seem pertinent to this discussion to mention the results, from the

standpoint of postoperative thrombosis, in the other 254 lesions treated at

this center. In this group the affected artery was ligated and divided and

anticoagulants were not used prophylactically. In two patients postoperative

thrombosis occurred.

In the first patient partial hemiplegia, presumably caused by distal

propagation of thrombus, developed some hours after ligation of the internal

carotid artery for an intracranial carotid aneurysm. This patient recovered.

In the second patient disaster of great moment occurred. The patient

had femoral arteriovenous fistula, just distal to the point at which the profunda

is given off, which necessitated excision and quadruple ligation of the vessels.

Good circulation was maintained in the foot until the sixth postoperative day

when there was sudden intense pain in the calf and the foot. This was followed

by swelling of the leg, coldness and pallor of the foot. The patient stated that

this foot was numb. On examination it was evident that extensive venous
316 VASCULAR SURGERY IN WORLD WAR II

and arterial thrombosis had occurred. In spite of poor response to spinal

analgesia in respect to both color and temperature, sympathectomy was performed as last resort. The warmth and sensation of the foot were significantly improved by this procedure, but the increase in circulation was insufficient to prevent gangrene of the sole of the foot and amputation was subsequently necessary. Anticoagulants were begun shortly after the difficulty was

first noted, but no apparent therapeutic effect resulted.

Although this was the only case in the large experience at the Mayo

General Hospital in which postoperative thrombosis occurred in an extremity

after nonreparative surgery for aneurysm or arteriovenous fistula, it suggests

the thought that the routine use of anticoagulants in the surgery of peripheral

aneurysms and fistulas, whether or not reparative surgery is done, may be

valuable in avoiding the uncommon but disastrous occurrence of postoperative

thrombosis. Such program would undoubtedly result in higher instance

of hematomas and oozing, but these difficulties, experience indicates, would

probably not be serious.

With regard to the choice of anticoagulant agents dicumarol has apparent

advantages over heparin both in cost and in ease of administration. It must

not, however, be used in any institution in which itis not possible and economically feasible to provide facilities for accurate daily determinations of the blood

prothrombin level. Its uncontrolled administration is fraught with great

danger, and under these circumstances heparin can be employed more safely.

The experience at the vascular center of Mayo General Hospital suggests

that it is more desirable to obtain an adequate prothrombin level before operation by means of dicumarol than to begin anticoagulant therapy with heparin

at the time of the surgical procedure. Under this plan, there is no necessity

to use heparin intravenously during the first few days after operation.

CONCLUSIONS

Although the clinical applicability of anticoagulant therapy cannot be

precisely defined from the Mayo General Hospital experience, it is evident

that this method must be used on very strict indications and contraindications.

The experience at this installation suggests that surgery of the peripheral

arteries can be undertaken safely at time when full anticoagulant effect has

already been obtained either from dicumarol or heparin. In such cases, however, it is imperative that adequate hemostasis be achieved before the wound

is closed. Fibrin foam proved helpful in control of capillary bleeding, and other

coagulant sponges would probably be equally useful. In spite of such precautions it must be assumed that the use of anticoagulant agents willresult in

Additional postwar studies on the efficacy of these agents in the prevention of thrombosis were carried out by one of

the authors of this chapter. See Kiesewetter, W. B., and Shumacker, H. B., Jr.: Experimental study of comparative

efficacy of heparin and dicumarol in prevention of arterial and venous thrombosis. Surg., Qynec. Obst. 86 687-702,

Jun 1948. Ed.
ANTICOAGULANTS IN REPARATIVE SURGERY 317

certain increases in the incidence of hematoma and in persistent oozing from

wounds, though the possible dangers of such complications are minimal if they

are recognized promptly and treated properly by withdrawal of anticoagulant

therapy, by surgery, if that is indicated, and by the use of reversing agents

such as synthetic vitamin K.

Although no proof of the effectiveness of anticoagulants was furnished

by this study, the impression was gained that this therapy renders less likely

thrombosis of the repaired segment of an artery.
CHAPTER XI

Arterial Aneurysms and Arteriovenous Fistulas Sympathectomy as an Adjunct

Measure in Operative Treatment

Harris B. Shumacker, Jr., M. D.

Part I. Preoperative Sympathectomy and Sympathectomy Coincidental With Vascular Surgery

Interruption of the sympathetic pathways as preliminary to surgical

extirpation of an aneurysm was introduced in 1934 by Gage and in 1935

by Bird. They were unaware of each other’s activities. Gage used alcohol

injections and Bird ganglionectomy.

Bird, although he was impressed with the apparent improvement of the

collateral circulation achieved by this method, presented his contribution with

definite reservations because he was hopeful that the pavex boot, which had

recently been introduced, might make unnecessary any other effort to foster

development of the collateral circulation. Gage, on the other hand, was

convinced that sympathetic interruption would continue to occupy prominent

place in the surgical management of aneurysms. He and Ochsner subsequently reported additional successful experiences with this procedure.

After 1934 when Gage’s original contribution appeared, number of

other observers reported the use of sympathectomy as an adjunct measure

in the management of aneurysms and recommended that it be performed

either before the vascular operation or as part of the vascular procedure.

Gage, I. M.: Mycotic aneurysm of common iliac artery; sympathetic ganglion block as aid in development of collateral circulation in arterial aneurysm of peripheral arteries; report of case. Am. J. Surg. 24 667-710, Jun 1934.

Bird, C. E.: Sympathectomy as preliminary to the obliteration of popliteal aneurisms; with suggestion as to

sympathetic block in cases of ligature, suture, or thrombosis of large arteries. Surg., Gynec. Obst. 60:926-929, May 1935. (1) Gage, M., and Ochsner, A.: The prevention of ischemic gangrene following surgical operations upon the major

peripheral arteries by chemical section of the cervicodorsal and lumbar sympathetics. Ann. Surg. 112: 938-959, Nov 1940.

(2) Gage, M.; The development of the collateral circulation inperipheral arterial aneurysms by sympathetic block.

Surgery 7: 792-795, May 1940. (1) Veal, J. R.: The value of sympathetic interruption following the surgical repair of peripheral aneurysms. M.

Ann. District of Columbia 9: 227-230, 1940.

(2) Richards, R. L., and Learmonth, J. R.: Lumbar sympathectomy in treatment of popliteal aneurysm. Lancet

1: 383-384, 28 Mar 42.

(3) Pemberton, J. deJ., and Black, B. M.: Surgical treatment of acquired aneurysm and arteriovenous fistula of peripheral vessels. Surg., Gynec. Obst. 77: 462-470, Nov 1943. (4) Kirtley, J. A., Jr.: Arterial injuries in theater of operations. Ann. Surg. 122: 223-234, Aug 1945.

(5) Freeman, N. E.: Secondary hemorrhage arising from gunshot wounds of the peripheral blood vessels. Ann.

Surg. 122: 631-640, Oct 1945. (6) Harbison, S. P.: Experiences with aneurysms in an overseas general hospital. Surg., Gynec. Obst. 81; 128-

137, Aug 1945. (7) Albright, H. L., and Van Hale, L. A.: Traumatic aneurysms; study of 43 cases in an overseas general hospital.

Surgery 20: 452-477, Oct 1946.

(8) Warren, R.: War wounds ofarteries. Arch. Surg. 53: 86-99, Jul 1946.
PRE- AND POSTOPERATIVE SYMPATHECTOMY 319

All the reported cases were successful; the circulation apparently proved

adequate after operations which necessitated ligation of the affected artery.

The universally successful results reported in these contributions created the

impression, perhaps contrary to the intent of the authors, that sympathectomy

provides an almost impregnable defense against ischemic disaster in vascular

lesions treated by ligation of main arteries.

In the vascular centers during World War II the general usefulness of

sympathectomy was confirmed, but at the same time certain limitations were

revealed. At the vascular center of Ashford General Hospital sympathectomy was used only occasionally in the management of aneurysms; at the vascular

centers of both DeWitt and Mayo the experience with sympathectomy was

extensive. At the last-named hospital study was made of sympathectomy

as an adjuvant in the operative treatment of vascular lesions. The purpose of this study was twofold: to determine the merits and limitations of sympathectomy, and to formulate logical plan for its use.

There is ample experimental and clinical evidence to support the view

that sympathectomy is of real help in maintaining an efficient circulation in

various conditions in which the continuity of the blood flow through important

arterial trunks has been interrupted. There are two concepts regarding the

mechanism by which this efficient circulation is achieved:

1. Sympathectomy ensures the fullest use of the existing collateral circulation because it eliminates vasoconstrictor impulses and thus contributes to

the maintenance of near-maximum circulation. This concept is well established.

2. Sympathectomy brings about more rapid growth of new collateral

channels because it reduces peripheral resistance to the blood flow (or perhaps

the new channels are brought about by some other mechanism). This explanation is still hypothetical and will require considerable investigative support before it can be considered factual.

The point of view might readily be defended that sympathectomy should

be performed upon every patient with an aneurysm or fistula if cure might

entail ligation of an important arterial stem. Clinical experience during World

War II demonstrated, however, that large numbers of aneurysms and fistulas

can be extirpated without serious ischemic difficulties provided (1) the data

secured by careful testing of the collateral circulation are used as guide in

the selection of the proper time for operation, and (2) the operation is so

carried out that no collateral blood vessels are needlessly sacrificed. Some

investigators hold that sympathectomy should be used almost uniformly in

the surgical management of aneurysms and fistulas, others take the position

that the procedure should rarely, if ever, be employed. At the vascular center

of Mayo General Hospital practice between these two extremes was followed: Sympathectomy was utilized whenever it might reasonably be expected to

result in benefit to the patient. Undoubtedly it was carried out more often
820 VASCULAR SURGERY IN WORLD WAR II

than was actually necessary, as, for example, to prevent gangrene. In spite

of this possibly excessive use, it may be said that if clear-cut benefit did not

follow in every instance in which it was employed, at least no harmful results

were noted.

CLINICAL MATERIAL AND METHODS

This analysis is based upon 75 sympathectomies (Table 35) performed on

288 patients either before or in the course of operations for aneurysm or arteriovenous fistula at the vascular center of Mayo General Hospital during World

War II. In an additional 13 patients sympathectomies were carried out in

anticipation of operation, but no operative treatment proved necessary because

in all 13 spontaneous cure of the lesion by thrombosis occurred. One other

sympathectomy might properly be added to this group. It was performed on

patient in whom physical findings pointed to diagnosis of aneurysm, but

surgical intervention established the fact that the signs were caused by costoclavicular compression of the subclavian artery (see Chapter IV).

Table 35. Sympathectomy Performed Before or at the Time of Operation for

Aneurysm or Arteriovenous Fistula

There were no deaths and no serious complications in these 302 patients.

Indications. In the 77 patients upon whom sympathectomy was performed

there were chief indications for interruption of the sympathetic pathways

(Tables 36-42):

1. Evidence of poor collateral circulation in patients with lesions of

sufficiently long duration to have produced, under ordinary circumstances,

fairly efficient collateral circulation.

Two hundred eighty-eight aneurysms and fistulas were treatedsurgically at this hospital, 63 lesions were treated in

which surgery had been performed prior to transfer to this hospital, and 13 lesionswere observed in which spontaneous

cure occurred. These 364 lesions occurred in 351 patients (9 patients presenting total of 22 lesions). Unfortunately in thedistribution of patients andlesions, the differentiationbecame obscuredand in this discussionthe designation “patient”

will be used for “patient/lesion” since so few patients presented multiple lesions.

Location of lesion

Arterial aneurysms Arteriovenous fistulas

Number of patients operated upon

Number of patients

treated by sympathectomy

Percent

treated by sympathectomy

Number of patients op- erated upon

Number of patients

treated by sympathectomy

Percent

treated by sympathectomy

Innominate __ 100.

Subclavian 20. 33.

Axillary... 13 46. 12 33.

Brachial 22 18. 11 18.

Femoral 66. 50 16 32.

Popliteal 14 11 78. 41 14 34.

Other 21 4. 86 10.

Total 82 28 34. 206 47 22.
PRE- AND POSTOPERATIVE SYMPATHECTOMY 321

2. The presence of an inadequate collateral circulation in association with

peripheral nerve injuries requiring surgical exploration. The management of

this type of case was problem. Early surgical treatment of peripheral nerve

injuries was desirable because it resulted in better return of function than the

late treatment of such lesions. On the other hand, it was hazardous to explore

the nerve before the aneurysm or fistula had been treated. Every effort was

made therefore to increase the efficiency of the collateral circulation as promptly

as possible, particularly because it was usually feasible to carry out both the

vascular operation and the neurosurgical procedure at the same time.

3. The impossibility of testing the collateral circulation in certain patients

in whom an important arterial trunk appeared to be involved. This indication

was not often valid reason for sympathectomy, but in an occasional patient

the affected artery could not be compressed at the site of the fistula or aneurysm

and accurate preoperative testing of the collateral circulation was impossible.

4. The association of the aneurysm or fistula with an ischemic lesion.

5. Intense local vasospasm in the affected limb, or rather severe generalized

vasospastic disorder.

6. The loss of one or more major arteries by previous injury or operation

in limb in which the cure of an aneurysm or fistula was likely to necessitate

ligation of other important arterial channels.

7. Causalgia in the affected limb which could be relieved temporarily, but

not cured, by sympathetic blocks.

Technique. At this center interruption of vasoconstrictor impulses was

achieved by surgical resection rather than by paravertebral alcohol injection.

Operative sympathectomy was preferred for two reasons (1) surgical interruption has more lasting effect, and (2) neuritic pains sometimes constitute distressing sequelae of alcohol injection. Twenty-four of the 77 sympathectomies

involved dorsal, and 53 lumbar, operations. Lumbar sympathetic ganglionectomy was performed through an anterior extraperitoneal muscle-splitting

incision. These operations were carried out with the aid of spinal analgesia.

Dorsal sympathectomy was accomplished by the preganglionic operation devised by Smithwick. It was carried out with the patient under intratracheal

gas-oxygen-ether anesthesia.

Anatomic Distribution oj Operations. The majority of the 77 sympathectomies were in patients with lesions of the larger peripheral arterial stems. If we

exclude the cases in which spontaneous cure without vascular surgery followed

sympathectomy (Cases 27 and 47), it will be seen that the 75 sympathectomies

represent 26 percent of the 288 patients with aneurysms or arteriovenous

fistulas treated at this center by surgical methods. (Table 35.) One hundred

thirty-six of these patients had lesions of the femoral, popliteal, or axillary

arteries. It was upon this group that most of the sympathectomies were

Smithwick, R. H.; The rationale and technicof sympathectomy for the relief of vascular spasm of the extremities.

New England J. Med. 222: 699-703, Apr 1940.
322 VASCULAR SURGERY IN WORLD WAR II

performed (55 sympathectomies). In the 44 patients with lesions of the subclavian and brachial arteries, sympathectomy was performed only times. In

the remaining 108 patients with lesions of arteries not included in the foregoing

breakdown, only 11 sympathectomies were performed. Moreover, as will be

pointed out shortly, sympathectomy was performed upon number of patients

in the miscellaneous group because preoperative study had erroneously indicated that an important artery near the affected vessel was involved in

the lesion.

Proportionately, sympathectomy was performed more often upon patients

with arterial aneurysms than upon those with arteriovenous fistulas (Table 35).

The discrepancy is more apparent if only those patients with lesions of axillary,

femoral, and popliteal lesions are considered, since it was upon these patients

that sympathectomy was most frequently done. The relative percentages for

axillary, femoral, and popliteal aneurysms were, respectively, 46.2, 66.7, and

78.6, in contrast to percentages for arteriovenous fistulas of 33.3, 32.0, and 34.1.

Although these differences are primarily reflection of the tendency to poorer

collateral circulation in instances of arterial aneurysms, they can also be explained by the fact that associated nerve injuries requiring operative treatment

were twice as common in arterial aneurysms as in arteriovenous fistulas. The

difference cannot be explained by higher incidence of involvement of major

arterial stems in arterial aneurysm than in arteriovenous fistula; 46.3 percent

of the arterial aneurysms operated on in this series involved the subclavian,

axillary, femoral, and popliteal arteries, against 52.9 percent involvement of

these arteries in arteriovenous fistulas. This is not significant difference.

INDICATIONS FOR PREOPERATIVE SYMPATHECTOMY

The results of sympathectomy (Tables 36-42) can best be analyzed if they

are considered in relation to the chief indications for the procedure. It should,

of course, be borne in mind that in number of patients sympathectomy was

decided upon not for single reason but for combination of reasons.

In all of the patients included in this analysis the status of the collateral

circulation was investigated by the repeated use of number of tests and observations (see Chapter II). Chief reliance, however, was placed upon the

reactive hyperemia test devised by Matas.

Poor Collateral Circulation

Poor collateral circulation was the chief indication, or major indication,

for sympathectomy in 38 of the 77 patients upon whom it was performed (Tables

36 and 37). There were, however, other indications in this group. In 16

patients, for instance, associated peripheral nerve lesions required operative

treatment. In number of patients severe pain or pronounced vasospasm

was present and in patient superficial gangrene was the indication.
PRE- AND POSTOPERATIVE SYMPATHECTOMY 323

In all 38 patients in this group, intermittent proximal occlusion of the

involved artery had been practiced without apparent improvement in the collateral circulation, though in only few instances had this method been given

prolonged trial.

Table 36. Sympathectomy Performed Before Operation for Aneurysm or Fistula.

[Indication—Poor Collateral Circulation; Patients in Whom Collateral Circulation Became Satisfactory Following Sympathectomy]

Case

No. Location of lesion

Interval

between

injury and sympathectomy

Interval

between

sympathectomy

and opertlon

Type

of

operation

Comment Results

Cases of Arterial Aneurysms

Months

3.0 Weeks2.0 Also had brachial plexus injury requiring neurolysis.

Also plexus injury requiring neurolysis.

Also median and ulnar palsy; median

neurolysis, ulnar neurorrhaphy.

Also plexus injury requiring neurolysis; collateral circulation did not become satisfactory for mo.

Good; has some cold

sensitivity.

6.5 5.0

5.0 2.0 Excellent.

3.0 10.0 A-E Excellent.

5.5 1.0

Popliteal 2.0 3.0 Very large, subcutaneous rupture,

severe pain, pain less after sympathectomy.

Excellent.

5.0 3.0 Excellent.

5.5 5.0 Excellent.

Cases of Arteriovenous Fistulas

10

Subclavian

Axillary

5.0

3.0

3.0

2.

Also ulnar palsy,requiring neurolysis..

Also plexus injury, neurolysis, radial

neurorrhaphy, hand cold, blue

before sympathectomy; circulation

strikingly improved.

Also plexus Injury, requiring neurolysis.

Excellent.

Excellent.

11 5.0 3.5 Excellent.

12 6.5 2.0 Excellent.

13 6.5 3.0 Also plexus injury, ulnar and radial

neurorrhaphy necessary.

Also ulnarand median palsy requiring

neurolysis, collateral circulation

very poor before, good after sympathectomy.

Excellent.

14 3.0 7.5 Excellent.

15 5.5 1.0 Excellent.

16

oral.

3.0 2.0 Excellent.

17 Femoral 2.5 21.0 Also peroneal palsy, F. C. C. femur

and pain; collateral circulation adequate shortly after sympathectomy;

burning pain disappeared.

Collateral circulation Improved progressively over period of several

weeks after sympathectomy.

Excellent.

18 Femoral 3.0 5.0 E-R Excellent; successful

ee footnote at nd of table.

vein graft to arterial

defect.
324 VASCULAR SURGERY IN WORLD WAR II

Table 36. Sympathectomy Performed Before Operation for Aneurysm or

Fistula Continued

[Indication—Poor Collateral Circulation; Patients in Whom Collateral Circulation Became Satisfactory Following Sympathectomy] ‘—Continued

Table 37. Sympathectomy Performed Before Operation for Aneurysm or Fistula

[Indication—Poor Collateral Circulation; Patients in Whom Collateral Circulation Did Not Become Satisfactory

Following Sympathectomy]

Case

No. Location of lesion

Interval

between

injury and sympathectomy

Interval

between

sympathectomy

and opertlon

Type

of operation

Comment Results

Cases of Arteriovenous Fistulas

19

Months

2.5

Weeks

2.0

20 3.5 1.5 Also pronounced vasospasm. Excellent.

21 3.5 2.0 Also peroneal palsy requiring suture..

Collateral circulationthought adequate

after sympathectomy.

Also peroneal palsy ...........

22 4.0 3.0 Poor, gangrene of distal

third of the foot.

23 Popliteal. 10.0 3.0 Excellent.

24 9.0 4.0 E-R Excellent; continuity

of artery maintained;

ligation of fistula.

Abbreviationsused in this table:

E, Excision.

A-E, Excision with restoration or maintenance of continuity of affected artery.

A, Aneurysmorrhaphy or aneurysmotomy with intrasaccular ligation or transfixing of the artery.

E-R, Aneurysmorrhaphy or similar procedure followed by excision of the sac.

F. C. C., Fracture compound comminuted.

Case

No. Location of lesion

Interval

between

injury and sympathectomy

Interval

between

sympathectomy

and oper- ation

Type

of operation

Comment Results

Cases of Arterial Aneurysms

Months Weeks

25 3.5 9.0 A-E-R Also plexus injuryrequiringneurolysis. Excellent: successful

end-to-end suture.

26 Brachial. 4.0 6.5 A-E Also plexus injuryrequiring neurolysis

and radial neurorrhaphy.

Excellent.

27 Femoral-- 2.0 None Thrombosis occurred after sympathectomy with gradual obliteration

of sac.

Excellent.

28 Popliteal 2.0 8.5 Excellent.

29 Popliteal 4.0 15.0 Excellent.

30 Popliteal Unknown 17.0 E-R Aneurysm due to medionecrosis; circulation in foot poor before, good

after sympathectomy.

Excellent: successful

vein graft.

See footnote at end of table.
PRE- AND POSTOPERATIVE SYMPATHECTOMY 325

Table 37. Sympathectomy Performed Before Operation for Aneurysm or

Fistula Continued

[Indication—Poor Collateral Circulation; Patients in Whom Collateral Circulation Did Not Become Satisfactory Following Sympathectomy] '—Continued

Of this group of 38 patients, sympathectomy was carried out when the

lesion had been present months or more in 18, months but less than

months in 14, and less than months in 5. In patient (Case 30) the

aneurysm was caused by medionecrosis and it was not possible to determine the

time interval. In the patients upon whom sympathectomy was performed

even though the lesion had been present for less than months, circumstances

existed which made it seem advisable to undertake it without further delay.

Two of these patients (Cases and 17) had severe pain. In of them

popliteal aneurysm had ruptured subcutaneously and it was obvious that

further increase in its size might necessitate operation at any moment. The

other had severe causalgia associated with femoral arteriovenous fistula,

Case

No. Location of lesion

Interval

between

injury and sympathectomy

Interval

between

sympathectomy

and oper- tion

Type

of

operation

Comment Results

Cases of Arteriovenous Fistulas

Months Weeks

31 Femoral-.. 3.5 31.0 E-R Collateral circulation improved after Excellent; continuity

sympathectomy but never satis- of artery maintained,

factory. fistula ligated.

32 Femoral.-. ... 7.0 5.0 E-R Collateral circulation improved Excellent; continuity

markedly after sympathectomy; be- of artery maintained,

came questionably adequate. fistula ligated.

33 Femoral 6.0 9.0 E-R Collateral circulation improved Excellent; continuity

slightly but never became adequate. ofartery maintained,

fistula ligated.

34 Popliteal 3.5 10.0 E-R Collateral circulation improved Excellent; continuity

markedly after sympathectomy; ofartery maintained,

never entirely satisfactory. fistula ligated.

35 Popliteal 6.5 10.0 E-R Also peroneal palsy requiring suture; Excellent; continuity

collateral circulation improved but ofartery maintained,

never became satisfactory. fistula ligated.

36 Popliteal 5.0 5.0 E-R Collateral circulation improved Excellent: continuity

but never became completely satis- of artery maintained,

factory. fistula ligated.

37 Popliteal 11.0 3.5 Collateral circulation improved Excellent.

but never became satisfactory.

38 Popliteal 5.0 13.0 E-R Collateral circulation improved Excellent; continuity

slightly but never became satis- of artery maintained,

factory. fistula ligated.

Abbreviationsused in this table;

A-E-R, Aneurysmorrhaphy or similar procedure followedby excision of the sac and by restoration of continuity

of the artery.

A-E, Aneurysmorrhaphyor similar procedure followedby excision of the sac.

A, Aneurysmorrhaphyor aneurysmotomy with intrasaccular ligation or transfixing of the artery.

E-R. Excision with restoration or maintenance ofcontinuity of affected artery.

E, Excision.
326 VASCULAR SURGERY IN WORLD WAR II

saccular aneurysm and peroneal paralysis, in addition to compound comminuted fracture of the femur, intense vasospasm of the foot, an ulcer of the

heel, and superficial gangrene of the toes. His pain had been so severe that

narcotics had been used to the point where there was real danger of addiction.

In both of these patients pain was diminished or relieved shortly after sympathectomy had been performed, and tests thereafter showed the collateral

circulation to be satisfactory.

third patient (Case 19), with popliteal aneurysm of months duration,

had extremely poor collateral circulation and complete peroneal paralysis.

The collateral circulation became adequate soon after sympathectomy and

early treatment of the aneurysm and nerve lesion was possible. The fourth

patient (Case 27) had femoral aneurysm and the fifth (Case 28) popliteal

aneurysm. Both of these lesions had been present for months and in both

patients the collateral circulation was extremely poor. Although the tests

did not show the collateral circulation to be entirely satisfactory in either

patient after sympathectomy, they did show some improvement. Spontaneous

cure occurred in patient, and in the other success followed operative

treatment months after sympathectomy.

Twenty-four of the 38 patients upon whom sympathectomy was performed

because of inadequate circulation showed evidence of satisfactory collateral

circulation subsequent to the operation, and in the majority, tests showed it to

be adequate very shortly after sympathectomy. There was no great difference

in this respect between those patients with arterial aneurysms and those with

arteriovenous fistulas. In of 14 patients with aneurysms and in 16 of 24 with

fistulas, evidence of good collateral circulation became apparent after sympathectomy according to the reactive hyperemia test and other tests used for

this purpose.

In these 24 patients (see Table 36) the vascular operation was not always

performed as soon as tests showed the collateral circulation to be adequate;

some patients were permitted to return home on sick leave between operations.

In some instances the second operation was deferred because of an illness unrelated to the vascular lesion, e. g., malaria or gastroenteritis. In most instances,

however, operation on the vascular lesion was performed shortly after sympathectomy. In of the 24 patients it was done within weeks, in 16 within

weeks or less, and in 18 within weeks or less (the figures are cumulative).

In only instances was operation delayed weeks or longer. In of these

patients (Case 17) tests showed the collateral circulation to be adequate

shortly after sympathectomy, but operation had to be deferred because of

compound fracture of the femur and infected ulcers of the foot. In the other

patients tests showed that the collateral circulation improved slowly and

steadily after sympathectomy.

In all but of the patients listed in Table 36, cure of the aneurysm or

fistula required ligation of the affected artery. In the exceptions (Cases
PRE- AND POSTOPERATIVE SYMPATHECTOMY 327

18 and 24) continuity of the artery was preserved or reestablished by ligation

of the fistula or by bridging the arterial defect with vein graft.

In the statement of results the term excellent in this and in other tables

should be understood to mean that the limb was of normal warmth and color

under ordinary environmental conditions, that there was no significant or disturbing sensitivity to cold, and that there was satisfactory evidence of the return of nerve function. If the patient was not followed long enough for restor- ation of sensation and motor power to become evident, such evidence as progression distally of the point at which Tinel’s sign might be elicited was interpreted to mean satisfactory improvement as compared with that recorded by

patients with nerve injury but in whom no vascular disorder existed. Naturally, there was no regeneration of those nerves in whichapparently irreparable

damage had occurred and on which no reparative procedure could be carried

out. The term excellent should not be understood to imply that no fatigue

was present on exercise. This finding was invariably noted in patients who

had had arteries ligated, especially the femoral or the popliteal.

One patient (Case 1) had some cold sensitivity following an operation in

which it was necessary to ligate the axillary artery, and in another (Case 22)

gangrene of the distal third of the foot occurred after operation.

Case 22. This patient, 35-year-old soldier, had popliteal arteriovenous fistula. No

flush was present during the reactive hyperemia test. Sympathectomy was performed

months after the injury and immediately afterward tests showed definite improvement in

the collateral circulation. The flush appeared promptly after deflation of the constricting

cuff and steadily improved becoming full and complete in minutes; there was no further

improvement upon release of pressure from the popliteal artery. Similar results were

obtained on several occasions.

The fistula was explored weeks after sympathectomy. large communication was

found between the popliteal artery and vein and there was present in addition small saccular aneurysm of the popliteal artery from which emerged large geniculate branch. This

branch had to be ligated in the course of the excision. It seemed probable that during the

preoperative tests the fistula had been occluded without interruption of the blood supply

through this branch and that the information concerning the state of the collateral circulation had therefore been misleading. At the conclusion of the operation both the color and the

warmth of the foot were poor and within few days gangrene was apparent. Amputation

of the distal third of the foot was necessary.

Comment. This case has been described in some detail because it illustrates

number of points: (1) that sympathectomy offers no guarantee against ischemic

disaster; (2) that tests for collateral circulation may sometimes be fallible, and

(3) that it is essential to take every possible precaution in vascular surgery.

In this connection it should be mentioned that one essential precaution was

omitted in the case described above. The drapes used at operation were

applied in such way that the foot was not in view during the procedure;

The author of this chapter, in total military and civilian experience covering 56 femoral and 55 popliteal aneurysms

and arteriovenous fistulas treated by surgical means, observed only other case In which gangrene occurred under these

circumstances. In this case thrombosis developed on the sixth postoperative day, In limb In which the circulation had

previously been excellent.

330323 0—55 22
328 VASCULAR SURGERY IN WORLD WAR II

precaution which should never be omitted in any instance in which doubt exists

as to the adequacy of the collateral circulation. It was unfortunately omitted

in this case because of the false sense of security which prevailed: Up to this time in the hospital experience, ischemic difficulty had never occurred in limb

following sympathectomy, and there had never been an episode to suggest that

the reactive hyperemia test might give misleading information.

In 14 patients (Table 37) the collateral circulation was adjudged inadequate

following sympathectomy. In all, however, there was some improvement over

that shown by preoperative tests. In few the improvement was quite noticeable but in none did the collateral circulation become adequate according to

criteria established. It will be noted that in this group of patients longer

interval elapsed between sympathectomy and operation than in the group in

which sympathectomy produced better results. In only of the 14 patients

(Case 37) was the interval less than weeks, and in patients, almost twothirds of the total number, it was months or longer. In patient in this

group (Case 27) satisfactory spontaneous cure occurred as the result of

thrombosis. In patients continuity of the affected artery was maintained

or restored by ligation of the fistula, by end-to-end suture, or by vein transplant. In only patients was it necessary to ligate the involved artery.

In all 14 patients (Table 37) an excellent end result was obtained. The

limbs were of good color and warmth, there was no sensitivity to cold, and in

those patients with peripheral nerve paralysis, return of nerve function progressed satisfactorily. In those in whom the continuity of the affected artery

was maintained or restored there was, in addition, no fatigue on exercise in

any instance in which it had not been present before operation.

In all of the 13 patients upon whom operation was performed (in

patient [Case 27] spontaneous cure occurred by thrombosis and operation was

unnecessary) color and warmth of the affected foot or hand were observed

during operation over prolonged period of precise occlusion of the involved

artery with rubber-shod clamp. In every patient but the collateral

circulation was observed to be adequate, though repeated preoperative tests

had led to different conclusion. The excellent postoperative results in the

patients in whom the involved artery was ligated proved that the collateral

circulation was efficient. In some of the other patients anatomic conditions

were found at operation which explained the reason for the misleading results

of the tests carried out before operation. In some instances large collateral

vessels were present which would necessarily have been occluded during

digital compression, but which could be preserved at operation.

That the collateral circulation was apparently satisfactory in all but

of the 14 patients in this group (Cases 27 and 31) does not necessarily indicate

that it was made so by sympathectomy. All that can be said is that the

same tests for the collateral circulation made before and after sympathectomy

showed some improvement in all instances following sympathectomy and

notable improvement in few instances but in no instance did they show the
PRE- AND POSTOPERATIVE SYMPATHECTOMY 329

collateral circulation to be entirely adequate according to established criteria. Four types of response to sympathectomy were evident (Tables 36 and 37). (1) In some instances tests showed the collateral circulation to be

adequate immediately after, or shortly after, sympathectomy. (2) In some

instances the tests showed significant improvement soon after sympathectomy,

and this was followed by slow, steady improvement until the collateral circulation became completely satisfactory some weeks later. (3) In some instances

the tests showed some improvement, but never enough improvement so that the

collateral circulation could be adjudged adequate before the vascular operation,

though more precise tests performed with the lesion exposed at operation

demonstrated that the collateral circulation actually was satisfactory. (4)

In one instance tests showed the collateral circulation to be inadequate and

according to all tests, including those made at operation, it remained so.

It may be profitable to illustrate these four types of response with brief

illustrative case reports:

Case 5. 32-year-old soldier who had been injured by shell fragments 15 May 1944

was admitted to Mayo General Hospital September 1944 with large aneurysm in the

region of the right femoral artery. There was no essential difference in the color or temperature of the two feet. The reactive hyperemia test, carried out on several occasions between

the date of admittance and the latter part of October, revealed no flush in the foot over

period of minutes compression of the femoral artery although brilliant flush appeared as

soon as compression was released. Lumbar sympathectomy was performed 31 October. When the reactive hyperemia test was carried out on the third postoperative day, the

flush was almost instantaneous, reaching the toes in seconds and becoming complete and

full in 60 seconds. There was no further improvement upon release of pressure from the

femoral artery. Excision of the femoral aneurysm November, with concomitant ligation

of the femoral vein, produced an excellent result. There was good warmth and color in the

foot at all times.

Case 18. 26-year-old officer who had sustained an injury from shell fragment 16

April 1945was admitted to Mayo General Hospital 29 May with midfemoral arteriovenous

fistula. There was no flush of the foot during the reactive hyperemia test. Sympathectomy

was performed 14 July. When the test was carried out again week later, flush appeared

in some of the toes in 15 seconds and became complete and of good quality in minutes.

much more brilliant flush, however, appeared when pressure was released from the femoral

artery. By 17 August the reactive hyperemia test showed an excellent flush which began

at the toes in 10 seconds and was complete and full in 80 seconds. There was no improvement upon release of pressure from the femoral artery. The fistula and the involved area

of artery and vein were excised 20 August; vein graft was utilized to bridge the arterial

defect. The graft was successful and the patient had excellent circulation in the limb.

Case 29. 20-year-old soldier injured 10 December 1944 was admitted to Mayo

General Hospital March 1945 with fairly large popliteal aneurysm. After admittance

and for the next few weeks, the flush during the reactive hyperemia test was poor and incomplete. Sympathectomy was performed 19 April. Thereafter the results of tests showed

steady improvement. On May flush reached the toes in 30 seconds, improved slowly

during the 2-minute period of observation, and became strikingly better upon release of

pressure from the popliteal artery. By 30 July the flush reached the toes in 10 seconds.

Though it improved considerably during the 2-minute period of observation, it improved

still more upon release of pressure from the popliteal artery. When the aneurysm was
330 VASCULAR SURGERY IN WORLD WAR II

explored August and the popliteal artery occluded with rubber-shod clamp just proximal

to the lesion, the foot was warm and of good color. The sac was opened and the artery

transfixed above and below the defect. After operation the foot was always warm and of

good color.

Case 31. 27-year-old soldier, injured 26 February 1945, was admitted to the Mayo

General Hospital May with signs indicative of femoral arteriovenous fistula. After

admittance and for several weeks thereafter, no flush occurred during the reactive hyperemia

test. Sympathectomy was performed June. It was followed by only slight improvement;

the flush was of poor quality and incomplete. There was no noticeable change during the

following weeks. In the belief that some local factor might be responsible for the poor

results of the reactive hyperemia test and that the collateral circulation might actually be

adequate, as it had proved to be in other cases, the lesion was cautiously explored 25 August.

When rubber-shod clamp was placed upon the artery above and below the fistula, the foot

promptly became extremely pale and cool and did not change its appearance as long as the

clamps were left in place. The wound was therefore closed without an attempt to extirpate

the fistula. The limb was tested repeately during the next few months and finally, 11

January 1946, the vessels were again explored. As at the previous operation, precise

occlusion of the artery produced persistent pallor and coldness in the foot. The fistula was

carefully dissected out and it became evident that it could be transfixed and reinforced by

segment of the divided vein thereby preserving the continuity of the artery. This was

done and the results were excellent.

Collateral Circulation not Determinable

Sympathectomy was performed in 10 patients (Table 38) because it was

impossible to compress the involved artery at the site of the aneurysm or fistula

to test the status of the collateral circulation. In patients the artery could

Table 38. Sympathectomy Peeformed Before Operation for Aneurysm or Fistula

[Indication—Impossibilityof Testing Collateral Circulation]

Interval Interval between between Case Location of injury sympa- Type of Comment Results No. lesion and

sympathectomy

thectomy

and operation

operation

Cases of Arterial Aneurysms

Months Weeks

39 Innominate 9.0 8.0 Triple ligation.At previous exploration hand became completely pallid with innominate occlusion;

partial proximal ligation had failed as

judged by oscillometric readings, etc.

Excellent.

40 Subclavian 4. 2.0 A-E Also plexus injuryrequiring neurolysis Excellent.

41 3.5 7.0 A-E Also plexus injuryrequiring neurolysis; also

cold sensitivity.

Good; cold

sensitivity.

42 Axillary 3.0 2.0 A-E Excellent.

43 Femoral 1.5 2.5 Huge aneurysm, edema, coldness of foot,

pain; circulation improved and pain relieved after sympathectomy.

Excellent.

44 Popliteal 2.0 1.0 Huge infected aneurysm, loss anterior tibial

group muscles, large ulcer; aneurysm ruptured subcutaneously days after sympathectomy forcing operation.

Excellent.

See footnote at end of table.
PRE- AND POSTOPERATIVE SYMPATHECTOMY 331

Table 38. Sympathectomy Performed Before Operation for Aneurysm or Fistula— Continued

[Indication—Impossibility of Testing Collateral Circulation.] •—Continued

not be compressed near the affected portion because the aneurysm was extremely large and the attempted maneuver was accompanied by intolerable

pain. In more, compression of the artery was impossible because the lesion

was located in the mediastinum. In the final 3, all with axillary or subclavian

lesions, the overlying clavicle and heavy musculature made it impossible to

occlude the lesion near the site of the defect. Since, with single exception

(Case 39), there was no way of determining what the results might have been

had sympathectomy not been performed, it was difficult to evaluate the effect

of the procedure. Certain data, however, suggest that it was beneficial.

Thus in the exceptional case just mentioned (Case 39), the patient had lesion

within the mediastinum. During an exploratory operation, complete pallor

of the hand occurred during temporary occlusion of the innominate artery

proximal to the aneurysm. partial proximal ligation was done, but since the

resulting reduction in pulsation in the extremity was so transient (confirmed

by oscillometric readings) it was obvious that the procedure had failed. Sympathectomy was performed, followed by complete proximal and distal ligation.

Results were excellent. The aneurysm ’was cured and there was excellent

circulation in the hand.

Again, in two patients (Cases 41 and 48) some sensitivity to cold was

present after operation. Since it is well established that this condition is

Case

No. Location of lesion

Interval

between

injury

and

sympathectomy

Interval

between

sympathectomy

and oper- ation

Type of operation Comment Results

Cases of Arteriovenous Fistulas

Months Weeks

45 Aorta-innominate-subclavian.5.5 10.0 Exploration. Thought before exploration to involve innominate vessels.

46 8. 2.0

47 Subclavian 4.5 2.0 Exploration. Continuous bruit and thrill disappeared

after sympathectomy; slightsystolic bruit

remained.

Excellent;

thrombosis

of fistula.

48 Brachial 2.0 1.0 Huge A-V saccular aneurysm, pain and

swelling prohibited testing collateral;

severe plexus injury requiring neurolysis

and suture, circulation of hand impaired,

cold sensitivity:rupture days after sympathectomy forced operation.

Good; slight

cold sensitivity.

Abbreviationsused in this table:

A-E, Aneurysmorrhaphyor similar procedure followed by excision of the sac.

A, Aneurysmorrhaphy or aneurysmotomy withintrasaccular ligationor transfixing of the artery.

E, Excision.
332 VASCULAR SURGERY IN WORLD II WAR

either improved or relieved by sympathectomy in instances involving ligation

of the artery, there is every reason to believe that it would have been even

more marked in these patients had sympathectomy not been performed.

Two patients (Cases 43 and 48) who had had severe pain before sympathectomy were more comfortable after the operation.

Four patients (Cases 40, 41, 42, and 48) who had sustained extensive

damage to the brachial plexus experienced some return of nerve function following sympathectomy. In light of the state of the nerves at the time of

exploration, any return of function must be considered remarkable.

In one patient (Case 47) signs of mediastinal subclavian fistula disappeared immediately after sympathectomy as the result of thrombosis. The

possible role of sympathetic denervation in bringing about cure by means of

thrombosis will be discussed later.

Obviously the sympathectomy performed upon one patient was needless

(Case 45), for the vascular lesion was afterwards found to be inoperable.

Vasospasm

The only sure way to prevent vasoconstriction from jeopardizing the circulation after operation is to interrupt the sympathetic innervation. Since in

operative cure requiring ligation of main artery, maintenance of adequate

circulation in limb depends upon full utilization of existing collateral channels,

persistent vasospasm should not be permitted to compromise circulation

through these channels.

Sympathectomy was performed upon patients (Table 39) because of the

primary indication of vasospasm. In all there was evidence of intense persistent vasospasm in the affected limb and additionally, in 3, longstanding

history of pronounced tendency to vasospasm in all the extremities. The

results in these patients, and in number of patients with vasospasm in other

categories, furnish evidence of the benefits to be secured by sympathectomy

performed upon the indication of vasospasm. In all instances the hand or

foot remained warm and the color good after surgical cure of the aneurysm or

fistula. In several patients tests for collateral circulation showed it to be only

fair before sympathectomy and good following the procedure.

Miscellaneous Indications

In patients (Table 40) sympathectomy was carried out chiefly because

of causalgia. In patient (Case 56) prompt and complete relief was experienced. In the other (Case 57), the patient reported “about 90 percent”

relief. As result, it was possible to withdraw rapidly the narcotics to which

he was almost addicted. This patient also had number of other complications, including nerve paralysis, compound comminuted fracture of the femur,

and ulcers and superficial gangrene of the toe and heel. All of these lesions

healed and there was adequate circulation in the extremity.
PRE- AND POSTOPERATIVE SYMPATHECTOMY 333

Table 39. Sympathectomy Performed Before Operation for Aneurysm or Fistula

[Indication—Vasospasm]

Another patient (Case 58) had gangrene and infection of all the toes and

compound comminuted fracture of the femur. The gangrenous toes were

amputated at the time that the sympathectomy was performed. The end results in this patient were excellent. The fistula was cured through surgical

intervention, the fracture healed, the infection cleared, and the patient had

useful limb with excellent circulation.

Three patients (Cases 55, 59, and 60) had peripheral nerve lesions in limbs

in which the circulation was obviously impaired or the collateral circulation

regarded as only questionably adequate. One of these had in addition an

ulcer of the foot. Following sympathectomy, results were good in all three.

In the last patient in the category of miscellaneous indications (Case 61),

three previous attempts by other surgeons had failed to effect cure of an

arteriovenous fistula. Both the ulnar and the radial artery had previously

been ligated and divided. It seemed likely that important collateral vessels

might have to be sacrificed in radical excision of the cirsoid aneurysm which

Case

No. Location of lesion

Interval

between

injury and sympathectomy

Interval

between

sympathectomy

and op- eration

Type of operation Comment Results

Cases of Arterial Aneurysms

49

Months

3.5

Weeks

2.0 Midfoot amputation had been done fortrauma; large ulcer, rapid healing after sympathectomy.

Excellent; healed, case suitable for Syme

amputation.

Cases of Arteriovenous Fistulas

50 7.0 4.5 Long history of vasospasm; collateral circulation only fair before, good after sympathectomy.

51 Femoral Long history Raynaud-like disorder.. .. 3.0 7.0 Excellent.

52 2.5 7.0 Marked vasospasm for years; collateral circulation only fair before sympathectomy.

Affected foot remained cold in ordinary

room terperature, other warm; ulcer of

leg.

Cyanosis and coldness of foot had followed

excision of posterior tibial A-V; two A-V’s

remained to be excised, involving peroneal

and anterior tibial vessels, one excised at

time of sympathectomy, other weeks

later; cyanosis and coldness disappeared

after sympathectomy.

53 3.0 1.0 Excellent.

54 Foot, cirsoid... Unknown 4.0 Good; only difficulty was slow

healing of ulcer

of foot.

Abbreviation used in this table:

E, Excision.
334 VASCULAR SURGERY IN WORLD WAR II

Table 40. Sympathectomy Performed Before Operation for Aneurysm or Fistula

[Indication—Miscellaneous]

involved the ulnar aspect of the forearm. Sympathectomy was performed in

the hope that it would provide protection against ischemic difficulties. Operative cure necessitated excision of the flexor sublimis muscle and of the extensive

vascular channels in and about this muscle. Results were good; circulation

in the hand remained excellent.

Errors of Localization

In patients (Table 41) sympathectomy was performed in error because

an aneurysm or fistula was thought, before operation, to involve arteries

other than those actually affected. Such tests as could be performed indicated

poor collateral circulation in all. In patients (Cases 62, 63, and 64) digital

pressure sufficient to still the aneurysm or fistula invariably occluded the overCase

No. Location of lesion

Interval

between

injury and sympathectomy

Interval

between

sympathectomy

and op- eration

Type of operation Comment Results

Cases of Arterial Aneurysms

55

Months

8.0

Weeks

2.0 Impaired circulation; extensive plexus injury requiring neurolysis and radial

suture.

56 2.0 12.0 Causalgla; reliefafter sympathectomy Excellent.

Cases of Arteriovenous Fistulas

57 1.0 14.0 Causalgia, superficial gangrene of toe and

heel, peroneal palsy, F. C. C. femur; pain

relieved, ulcers healed slowly after sympathectomy.

Gangrene of toes, multiple fractures of metacarpals, compounded and infected F. C. C.

femur; healing after sympathectomy and

amputation of toes; fractures healed, in- fection cleared.

Impaired circulation and complete sciatic

paralysis; nerve suture had been done,

ulcer of foot.

Peroneal paralysis; collateral circulation

only fair before sympathectomy.

Had three previousoperations with ligation

of radial and ulnar arteries and medial

palsy; impossible to foretell what collaterals might have tobe sacrificed in radial

excision.

58 Femoral. 2.0 16.0

59 5.0 2.5 Good; ulcer healed, some cold

sensitivity.

Excellent.

Excellent.

60 2.0 7.0

61 Ulnar, cirsoid.. Unknown 1.0

Abbreviations used in the table:

E, Excision.

F. C. C., Fracture compound comminuted.
PRE- AND POSTOPERATIVE SYMPATHECTOMY 335

Table 41. Sympathectomy Performed Before Operation for Aneurysm or Fistula

[Patients in Whom Mistake in Localization of the Lesion was Made]

lying femoral as well as the involved profunda femoris artery. In all of these

the lesion was, therefore, thought to be in the femoral or common femoral

artery. In each case, however, it was found at operation to be in the profunda

femoris artery.

In two other patients (Cases 65, 66) the fistula was in such close proximity

to the popliteal artery that the bruit and thrill could be eliminated only by digital pressure which compressed the adjacent popliteal artery. In the first

patient the lesion was in the geniculate artery and in the second in the posterior

tibial artery. In sixth patient (Case 67) fistula between the transverse

cervical artery and the internal jugular vein could be occluded only by pressure

which obliterated the brachial pulse. This fistula was thought therefore to

Interval

between

Interval

between

Case

No. Preoperative local- ization of lesion Actual loca- tion of lesion

injury

and

sympathectomy

thectomy

and

operation

Type of operation Comment Results

Cases of Arterial Aneurysms

Months Weeks

62 Profunda 3.0 10.0 Compression which stilled aneurysm

obliterated femoral pulse; thrombosis and shrinkage occurred after

sympathectomybut sac persisted.

Excellent.

Cases of Arteriovenous Fistulas

63 Common femoral.. Profunda 28.0 10.0 Compression which eliminated bruit

and thrill stopped femoral pulse.

Excellent.

64 Profunda 6.0 8.0 Compression which eliminated bruit

and thrill stopped femoral pulse.

Excellent.

65 Popliteal. Geniculate.. 8.0 6.0 Bruit and thrill could not be elim- Excellent.

mated by pressure without loss of

popliteal pulse.

66 Popliteal ..Posterior ti- 5.0 6.0 very high posterior tibial lesion;

bruit and thrill could not be eliminated by pressure without loss of

posterior and anterior tibial pulse.

Excellent.

bial.

67 Subclavian 4.5 3.0 Bruit and thrillcould not be stopped

by pressure without loss of brachial pulse.

Excellent.

cervical.

68 Posterior and anterior tibial.Posterior tibial.3.5 4.0 Bruit and thrill could be stopped

only by pressure, which caused

loss ofanterior and posterior tibial

pulses; had tibial paralysis and

F. C. C. fibula.

Excellent.

'. Abbreviations used in this table:

A, Aneurysmorrhaphyor aneurysmotomy with intrasaccular ligation or transfixing of the artery.

E, Excision.

F. C. C., Fracture compound comminuted.
336 VASCULAR SURGERY IN WORLD WAR II

involve the subclavian vessels. In the remaining patient (Case 68), actually

with an arteriovenous fistula of the posterior tibial artery, it was thought that

the anterior tibial vessels might also be involved since the fistula could be closed

only by compression which occluded the anterior as well as the posterior tibial

artery This patient had an extensive fracture of the fibula and it is likely that

it contributed to the difficulty of accurate digital compression.

In all patients tests showed the collateral circulation to be poor before

sympathectomy and good afterward. It is apparent, in retrospect, that had

correct localization been possible in each of patients, sympathectomy could

safely have been omitted. It is also apparent in retrospect that with possible exception (Case 65), arteriograms might have established the correct site

of the lesion in all 7.

SYMPATHECTOMY PERFORMED AT THE TIME OF THE

VASCULAR OPERATION

In patients (Table 42) sympathectomy was performed at the time that

the operation upon the aneurysm or fistula was done. In patient (Case 77)

the sympathectomy was carried out primarity because the sympathetic chain

was easily exposed in the operative incision through which the iliac artery had

Table 42. Sympathectomy Performed at the Time of Operation for Aneurysm

or Fistula

Cases of Arterial Aneurysms

Case

No. Location of lesion

Interval

between

injury and sympathectomy

Typeof operation Comment Results

Months

69 Popliteal 3.0 Infected aneurysm ruptured subcutaneously,

severe pain.

Excellent.

70 Popliteal. 3.0 Huge aneurysm ruptured subcutaneously,

severe pain; collateral circulation nil by

reactive hyperemia test before sympathectomy, complete flush in 30 seconds after

sympathectomy.

Excellent.

71 Popliteal 6.0 Following excision of aneurysm, foot cold and

blue; circulation still impaired after sympathectomy, but foot warm and pink few

hourslater.

Ischemic palsy developed; recovery.

72 Popliteal 4.0 Large, infected mycotic aneurysm with

sensory and motor loss in foot and much

pain; collateral circulation excellent after

sympathectomy.

Excellent; steady recovery from ischemic palsy.

73 Lateral femoral circumflex.11.0 Profunda had been ligated at time of injury;

aneurysm could be stilled only by pressure

which stopped femoral pulse, collateral

circulation nil by reactive hyperemia test

before sympathectomy, good flush 30 seconds after sympathectomy.

Excellent.

See footnote at end of table.
PRE- AND POSTOPERATIVE SYMPATHECTOMY 337

Table 42. Smypathectomy Performed at the Time of Operation for Aneurysm

or Fistula Continued

Cases of Arteriovenous Fistulas

been isolated as preliminary precaution. The fistula was so high that it was

between the medial circumflex femoral artery and the common femoral vein.

In another instance (Case 73) sympathectomy might also have been omitted

had the fistula been correctly located before the exploration. This patient had

very large aneurysm in the anterior aspect of the thigh which could be stilled

only by pressure which occluded the femoral artery. The profunda had been

ligated in this patient shortly after injury. Tests showed the collateral circulation to be extremely poor before sympathectomy and excellent afterward.

In this case the aneurysm involved only the lateral femoral circumflex artery.

Results were good in of the patients in this group. In patient

(Case 75), though the foot at all times after operation was warm and of

good color, some peroneal sensory loss without motor involvement was added

to the preexisting tibial and saphenous anesthesia. At no time, however,

was there evidence of circulatory impairment and it seems likely that this

complication was the result of pressure from the tourniquet rather than of

postoperative ischemia. In the other patient (Case 71), ischemic paralysis

developed after operation. The circulation was obviously impaired for few

hours after operation, but thereafter the limb rapidly regained normal warmth

and color. In this patient, sympathectomy and the operation upon the vascular

Case

No. Location of lesion

Interval

between

injury and sympathectomy

Type of operation Comment Results

Months

74 Common femoral... 4.5 Collateral circulation poor beforeoperation Excellent.

75 Femoral. 3.0 Huge aneurysm ruptured subcutaneously, severe pain, tibial and saphenous sensory loss;

poor collateral circulation before, good after

sympathectomy.

well colored; some

peroneal sensory

loss, perhaps due

to tourniquet.

76 Hypogastric 5.0 Excellent.

excised weeks after injury; collateral circulation poor before, good after sympathectomy.

77 Medial circumflex

femoral.

13.0 A-V fistula caused by surgical ligation of the

femoral artery at time of injury; bruit and

thrill could be stopped only bypressure high

in femoral area, iliac arteries explored as

precautionary measure, sympathectomy

done only because chain lay exposed during

procedure.

Excellent.

Abbreviationsused in this table;

A, Aneurysmorrhaphyor aneurysmotomy with intrasaccular ligation or transfixing of the artery.

E, Excision.
338 VASCULAR SURGERY IN WORLD WAR II

lesion were performed concomitantly without retesting the collateral circulation

following sympathectomy. This precaution should never be omitted.

That it is sometimes advantageous to perform sympathectomy at the same

time as the vascular operation is obvious from consideration of the patients

in this group in whom severe pain was present. To illustrate, in patient

(Case 70), an extremely large popliteal aneurysm ruptured subcutaneously

and was so painful that the patient writhed in agony. Large doses of morphine

afforded no relief. The reactive hyperemia test was characterized by complete absence of flush. Sympathectomy was performed and complete and

intense flush was present within 30 seconds after release of the constricting

cuff. Aneurysmorrhaphy was therefore done at once. The patient was

entirely comfortable after operation and there was excellent circulation in the

foot.

SPECIAL EFFECTS OF SYMPATHECTOMY

Exercise Tolerance and Cold Sensitivity

Two functional disorders which commonly follow the ligation of an artery

for the cure of an aneurysm or fistula are decrease in exercise tolerance, and

sensitivity of the limb to cold. Since reduction in exercise tolerance is particularly noticeable after ligation of the popliteal, femoral, and common femoral

arteries, consideration of the effect of sympathectomy upon intermittent

claudication or its equivalent is best limited to patients with lesions of these

vessels. In addition, certain other patients should be excluded from any study

of exercise tolerance: (1) those patients who had difficulty walking prior to

sympathectomy because of fractures, amputated digits or parts of limbs, or

motor loss from peripheral nerve injury, (2) those patients who were unable to

walk any distance before operation, and this at time when the continuity of

the blood flow through the affected artery was uninterrupted, and (3) those

patients whose arterial lesions were successfully repaired and continuity of the

blood flow preserved.

Exercise tolerance in the lower extremity was determined by having the

patient walk at normal pace with pedometer, or over measured course,

until he was forced to stop because of fatigue or, occasionally, cramps in the

limb. The distance walked was approximately the same in the two groups.

Patients whose operations had required ligation of the popliteal artery and

upon whom sympathectomy had not been done were forced to stop after they

had walked an average of 0.68 mile, while those who had had sympathectomy

performed could walk 0.73 mile. When ligation of the femoral or the common

femoral artery had been necessary, the distance covered was the same (an

average of 0.73 mile) regardless of whether sympathectomy had or had not

been done.

These data seem to demonstrate that exercise tolerance was almost

precisely the same regardless of whether or not sympathectomy was performed.
PRE- AND POSTOPERATIVE SYMPATHECTOMY 339

The two groups, unfortunately, were not carefully controlled from several

important standpoints. The time interval between operation and final walking

test varied from patient to patient. This is an important factor since some

patients reached their maximum tolerance rapidly, others more slowly. It

proved impossible to analyze the intensity of the exercise pain in some of the patients. Exaggeration was always possibility in those who desired to avoid

duty and be separated from the service. Finally, the two groups were

not entirely comparable because from the various tests and observations it

was evident that the collateral circulation was more efficient in the group in which sympathectomy was considered unnecessary.

More clear-cut information is available concerning the effect of sympathectomy in the prevention of sensitivity of the limb to cold after operation.

Sensitivity to cold of varying degrees was complaint of of 18 patients upon

whom sympathectomy had been done. In these patients the continuity of the

subclavian, axillary, or brachial arteries had been interrupted either through

ligation or reparative procedures which failed. In 31 patients with popliteal

or femoral lesions treated similarly, only complained of sensitivity to cold.

Two of the patients who complained had this sensitivity before operation.

In contrast, cold sensitivity was complaint of 13 of 40 patients upon

whom sympathectomy had not been done. In these patients the continuity of

the subclavian, axillary, or brachial arteries had been interrupted. In 65

patients with popliteal or femoral lesions treated similarly, complained of

sensitivity to cold. Eight of the 18 patients who complained had this sensitivity prior to operation.

Sensitivity to cold was complaint of 14 patients with aneurysms or

arteriovenous fistulas who were received at the Mayo General Hospital after

they had been operated on at other installations (see Part II this chapter).

There were such complaints in 11 patients with lesions of the main arteries

of the upper extremity, and in 30 patients with lesions of the main arteries of

the lower extremities. None of the patients who complained of cold sensitivity

after operation had been treated by sympathectomy. single patient in this

group had had sympathectomy performed at the time of the vascular operation.

He did not complain of sensitivity to cold.

Altogether, of the 50 patients upon whom sympathectomy had been

performed prior to an operation which resulted in interruption of the main

arterial stem to the extremity, complained of sensitivity to cold (12 percent).

In contrast, of 146 patients who had similar operations without sympathectomy,

32 complained of cold sensitivity (21.9 percent).

Infrasaccular Thrombosis

Not uncommonly sympathectomy was followed by noticeable increase in

the mural thrombus within the aneurysmal sac. Sometimes this process was very

extensive. In one patient, for example (Case 62), large pulsating aneurysm
340 VASCULAR SURGERY IN WORLD WAR II

in the thigh became progressively smaller and firmer after sympathectomy and

eventually lost its pulsation entirely. Clinically it appeared that the lesion had

been completely obliterated, but arteriograms revealed the persistence of

sac several centimeters in diameter. At operation the laminated mural thrombus

was found to be many times larger than the remaining aneurysmal cavity.

In other patients cures of this type occurred. The first patient (Case 27)

had pulsating femoral aneurysm about cm. in diameter. Tests of the collateral circulation gave evidence of its complete inadequacy. Sympathectomy

was performed months after injury. After this procedure the aneurysm

became by degrees somewhat firmer and smaller and pulsated less vigorously.

The process was slow during the first few months but finally, months after

sympathectomy, only small, firm, nonexpansile mass remained. Arteriograms

revealed almost complete obliteration of the sac. During the next few weeks

this mass practically disappeared and it was evident that satisfactory cure

had been obtained.

In the second patient (Case 47) there were signs suggestive of an arteriovenous fistula of the proximal portion of the left subclavian vessels. After

sympathectomy the thrill and continuous bruit disappeared and only short

systolic bruit remained. The extra-mediastinal portions of the vessels were

explored in the belief that saccular aneurysm remained. No aneurysm was

found, and there was such dense scarring about the vessels as the mediastinum

was approached that exploration was discontinued on the assumption that the

remaining systolic bruit was probably the result of partial compression of the

artery by scar tissue.

In evaluating the results of sympathectomy in this group it must be borne

in mind that spontaneous cure occurs occasionally without operation in both

arterial aneurysm and arteriovenous fistula (see Chapter XII). It took place

in 11 of the 224 patients in this particular series upon whom sympathectomy

was not done (4.9 percent). On the other hand, cure by thrombosis occurred

in but of the 77 patients upon whom sympathectomy was performed (2.6

percent). It is difficult, therefore, to be certain that thrombosis in these patients

was actually the result of sympathectomy. The decision is particularly difficult

when complete thrombosis occurs gradually and over long period of time, as

happened in patient (Case 27). When it occurs promptly after sympathectomy as in some of the cases recorded in the literature, the march of events

seems to suggest that it has resulted from sympathectomy. The cause-andeffect relationship seems all the more likely because of the incomplete thrombosis

of the sac which is commonly observed after sympathetic denervation.

The question arises whether an increase in mural thrombosis or complete

thrombosis of the sac can be associated with extension of the clot distally. The

course of patient in the author’s experience in civil practice suggests that,

uncommon as the occurrence may be, it can take place.
PRE- AND POSTOPERATIVE SYMPATHECTOMY 341

CASE REPORT

The patient was 49-year-old man with an arteriosclerotic aneurysm of the right

popliteal artery. When he was admitted to the hospital the aneurysm pulsated vigorously

and there was loud systolic bruit. There was also evidence of peripheral arteriosclerosis. On the affected side the dorsalis pedis pulse was present but the posterior tibial, absent.

Both pulses were present in the left foot. The collateral circulation was very poor. Although

these findings were checked the day before sympathectomy was performed, the pulses, unfortunately, were not palpated nor were oscillometric studies made immediately before operation.

The day after sympathectomy the aneurysm was observed to be somewhat firmer and there

was only faint, shock-like sound in place of the systolic bruit previously heard. The

dorsalis pedis pulse had disappeared and oscillometric studies confirmed the impression that

the popliteal artery was occluded distal to the aneurysm. This impression, as well as the

fact of recent increase in the extent of mural thrombus, was verified at operation days

later. Although no proof exists in this case, the evidence suggests that the extension of the

mural thrombus following sympathectomy brought about occlusion of the artery distal to the

aneurysm. An excellent result followed aneurysmorrhaphy.

COMMENT Effects of Sympathectomy

In considering the role of sympathectomy as an adjuvant measure in the

surgical treatment of aneurysms and arteriovenous fistulas, it is important to

keep in mind that in the hands of those familiar with it, this procedure is

associated with minimal risk and very little discomfort. Patients can be

ambulatory the day after either dorsal or lumbar sympathectomy. In the

experience at the Mayo General Hospital there were no deaths and complications were extremely uncommon.

Data derived from the tests given the patients in this series supply convincing evidence that sympathectomy is useful in rendering the collateral

circulation more efficient by eliminating vasoconstriction in the collateral

vessels. This is exemplified by the fact that following sympathectomy the

hand or foot was almost always of excellent warmth and color in patients in

whom cure of the vascular lesion entailed arterial ligation. It is even more

strikingly exemplified by the remarkable improvement in the collateral circulation which so often occurred immediately after sympathectomy was carried

out. These data do not offer convincing proof that sympathectomy actually

increases the collateral circulation by fostering the growth of new collateral

channels. However, data derived from tests made on these patients in whom

the collateral circulation showed only slight improvement immediately after

sympathectomy, but steady significant improvement during the ensuing weeks

and months might suggest that sympathectomy had this effect. Perhaps

more plausible explanation, however, would be simply progressive dilatation of

existing collaterals. In contrast it is noteworthy that in number of patients

upon whom sympathectomy was not performed, tests showed that the circulation had improved during short periods of observation.
342 VASCULAR SURGERY IN WORLD WAR II

The immediate effect of sympathectomy upon the status of the collateral

circulation can be predicted with reasonable accuracy by comparing the

results of the reactive hyperemia test in any given patient under ordinary

environmental conditions with those obtained during reflex vasodilatation with

the patient under anesthesia or, better still, after sympathetic block with

procaine. Such studies are unnecessary as routine measures, however, and one

can proceed with sympathectomy without additional testing in any case in

which the indications are plain. Should the preoperative tests for collateral

circulation show it to be poor and should no distinct improvement follow

sympathectomy, the situation should be considered sufficiently precarious to

warrant the use of all additional measures which might add some safeguard

against ischemic difficulties. These include intermittent occlusion of the artery,

delay in operative treatment, and efforts to preserve the continuity of the

artery at the time of operation.

The Rationale of Sympathectomy

The Mayo General Hospital experience indicates that rational plan for

the use of sympathectomy in aneurysm or arteriovenous fistula can best be

formulated on the basis of the various indications for its use.

Inadequate Collateral Circulation. Sympathectomy seems indicated when

there is evidence of poor collateral circulation provided the lesions are of

sufficient duration to have produced under ordinary circumstances good

collateral circulation, and provided the simpler means of improving the collateral circulation have shown no results during short period of trial. The

literature is full of statements concerning results of intermittent proximal

occlusion of the affected artery on the collateral circulation and in some instances there is clear evidence that such an effect has been achieved. In

many patients, however, it is difficult to see any beneficial results. It would

be significant contribution to the problem of the treatment of aneurysms

and arteriovenous fistulas if controlled experimental and, preferably, clinical

studies should establish beyond question the value and limitations as well as

the criteria for continuing or abandoning such procedures. From the experience at this center it would seem that sympathectomy is indicated if there is

no definite improvement in the collateral circulation following such efforts

as intermittent proximal occlusion of the affected artery carried out over

period of some weeks. It has been established that permanent partial occlusion

of the proximal artery is sometimes helpful in increasing the collateral circulation in instances of arterial aneurysm, but this procedure is not applicable in

instances of arteriovenous fistula.

Since sympathectomy is as simple as partial proximal ligation and probably safer, and since partial proximal ligation may jeopardize the chances of

successfully maintaining or reestablishing the continuity of the involved

artery when the major operation is attempted, sympathectomy seems to be the

wiser procedure in arterial aneurysms in which the collateral circulation does
PRE- AND POSTOPERATIVE SYMPATHECTOMY 343

not appear to be adequate. In the majority of instances in this series in which

sympathectomy was carried out because the results of tests showed the collateral

circulation to be unsatisfactory, improvement was noted fairly promptly.

Even in the instances in which the tests did not show the circulation to be

entirely adequate following sympathectomy, the procedure at least assured the

surgeon that vasoconstriction had been eliminated.

Associated Peripheral Nerve Lesions. When the aneurysm or arteriovenous

fistula is associated with peripheral nerve lesion which requires operative

treatment, precarious collateral circulation seems clear-cut indication for

sympathectomy. It is imperative that the nerve lesion be treated as promptly

as possible and it is entirely too hazardous to attempt nerve repair before

operative cure of the aneurysm or fistula has been achieved. Any effort to

improve the collateral circulation and permit early operative treatment both

of the arterial and the nerve lesion is therefore worthwhile.

Sympathectomy would seem to be indicated particularly when the combined vascular-nerve lesion is associated with obvious evidence of impaired

circulation in the extremity regardless of whether or not the collateral circulation appears to be adequate. In such cases it must be assumed that operative

cure of the vascular lesion may require ligation of the artery and further reduction in the circulation of the limb. Furthermore, an adequate vascular

supply fosters nerve regeneration exactly as impairment of the circulation may

produce ischemic nerve injury. The data in this series are insufficient for

quantitative comparison of nerve regeneration in patients with unimpaired

circulation and those with impaired circulation upon whom sympathectomy

was done. The impression seems warranted, however, that nerve regeneration

was comparable in the two groups. The data do offer conclusive proof that

sympathectomy may be of great benefit in instances of ischemic nerve injury

with impaired circulation resulting from arterial ligation, division, or thrombosis.

Collateral Circulation Undeterminable. When the anatomic location of the

aneurysm or fistula is such that digital occlusion of the artery is not possible,

sympathectomy seems advisable if the artery affected is one in which ligation

is sometimes followed by ischemic difficulties. When the artery cannot be

compressed precisely at the site of the defect, proximal or distal compression

may reveal some information concerning the state of the collateral circulation.

It must be borne in mind, however, that tests of this kind may supply erroneous

information either because collateral channels which can be preserved during

the operativeprocedure are occluded, or because the reverse is true and channels

which may have to be sacrificed have not been occluded.

Ischemic Lesions. When ischemic lesions are present distal to an aneurysm

or fistula, sympathectomy is indicated since cure of the vascular lesion may

entail ligation of the artery thereby still further reducing the circulation. Even

if the blood flow through the artery can be preserved, increase in the circulation

would be highly desirable since the ischemic lesion supplies unequivocal evidence

of insufficiency.
344 VASCULAR SURGERY IN WORLD WAR II

Vasospasm. If the main artery to limb must be ligated for the cure of

vascular lesion, the surgeon cannot afford to take the chance of having the

remaining circulation jeopardized by vasospasm in the collateral vessels.

Vasospasm, of course, is not present in every limb in which main arterial stem

is ligated. Indeed, the vascular tone after ligation may be high, low, or normal.

In some patients the limb actually exhibits evidence of vasodilatation and increased stability of skin temperature under varying environmental circumstances; these findings suggest the effect of periarterial sympathetic interruption consequent to ligation and division of the artery. Whenever there is

evidence of pronounced vasospasm it appears unwise to run the risk of its

occurrence after operation. Such problem might be handled in two ways:

(1) Proceed with the operation and then if alarming vasospasm ensues attempt

to control it by sympathetic blocks or, if necessary, by sympathectomy.

(2) Perform sympathectomy either before the vascular operation or at the

same time, even though tests for collateral circulation show it to be good.

This is the safer method and one to be recommended in instances in which

intense vasospasm is already present.

Miscellaneous Indications. Sympathectomy may be required in the occasional patient in whom one or more of the main arteries to limb have already

been occluded by previous injury or operation and in whom cure of an aneurysm

or fistula may require ligation of other arteries essential to nutrition and proper

function. Similarly, an occasional patient will be encountered in whom an

aneurysm or fistula is associated with severe causalgia which can be temporarily

relieved, though not cured, by sympathetic blocks.

Unnecessary Sympathectomy. Sympathectomy should not be performed

unless there is some specific indication for its use, and even if the indications

listed are strictly adhered to as basis for the employment of the operation it

will undoubtedly be performed in certain instances in which it might safely

have been omitted. These instances occur chiefly when, during operation, it

is found possible to maintain the continuity of blood flow through the affected

artery by some reparative procedure. Since, however, the feasibility of such

procedures cannot be foreseen, and since one cannot always be sure that the

repair will be successful, itis wise to make certain that the collateral circulation

is adequate before an attempt is made to extirpate an aneurysm or fistula.

In practice, adherence to this policy will mean the performance of an occasional

unnecessary sympathectomy.

Sympathectomy is sometimes done needlessly because of improper localization of the aneurysm or fistula. Fortunately, this seldom happens. Difficulties are most often encountered in lesions located high in the profunda femoris

artery in which digital pressure sufficient to still an aneurysm or abolish the

bruit and thrill of fistula is likely to compress the overlying femoral artery.

In such cases arteriograms will ordinarily establish the correct location of the

lesion.
PRE- AND POSTOPERATIVE SYMPATHECTOMY 345

Even though preliminary sympathectomy is not performed, numerous

patients will recover from operative cure of an aneurysm or fistula with no signs

of gangrene or ischemic paralysis. When, however, such serious complications

appear to offer definite threat, it seems wise to take every precaution to avoid

them, even at the risk of performing an unnecessary operation. One cannot afford to gamble with the viability of an arm or leg. Indeed, as the reported

series of cases illustrates, such disasters may occur even if sympathectomy is

performed. It should be emphasized that sympathectomy offers no guarantee

that some ischemic difficulty may not occur after ligation of an important

artery: Sympathectomy must therefore be looked upon as an aid in, but not as

sure preventive of, ischemic troubles. Furthermore, the utmost care in

testing the collateral circulation and in avoiding injury to collateral vessels

at the time of operation must be exercised or sympathectomy will be associated

at times with disastrous results.

Exercise Fatigue and Cold Sensitivity. Fatigue on exercise and sensitivity

to cold are two symptoms which commonly occur in limbs following the operative cure of aneurysm or arteriovenous fistula even though circulation to

the limb is otherwise adequate. As already pointed out, although no definite

conclusions can be formulated in regard to exercise fatigue, the results in the

series of patients observed at the Mayo General Hospital give the impression

that sympathectomy seldom has any marked beneficial effect upon exercise

tolerance. The results of sympathectomy are more clear-cut in respect to cold

sensitivity. Though this complication sometimes occurs following arterial

ligation in patients upon whom sympathectomy has been performed it occurs

far more frequently in those upon whom sympathectomy has not been

carried out.

Intrasaccular Thrombosis. As Gage noted in his original publication,

intrasaccular thrombosis frequently occurs following sympathetic denervation

in instances of arteriovenous fistulas. DeBakey recorded case of carotidcavernous sinus fistula in which cure by thrombosis occurred after sympathectomy, and Colsen and Giddy 10 noted progressive thrombosis of the aneurysmal

sac within few days after they had performed lumbar sympathectomy in

preparation for exploration of popliteal aneurysm. In the latter case an

apparently satisfactory cure was obtained without operative treatment. In

this series of patients extension of the mural thrombus within the sac was often

noted following sympathectomy and in two instances apparent cure by thrombosis followed interruption of the sympathetic pathways. Since spontaneous

cure by thrombosis occurs occasionally without sympathectomy it is impossible

to state that cause-and-effect relationship exists when cure by thrombosis

See footnote 1, p. 318.

Martin, J. D., Jr., and Mabon, R. F.: Pulsating exophthalmos; review of all reported cases. J. A. M. A. 121:

330-335, 30 Jan 43. (Discussion by Ochsner.)

i° Colsen, K., and Giddy, P.: Popliteal aneurysm cured by lumbar ganglionectomy. South African M. J. 18: 242,

22 Jul 44.
346 VASCULAR SURGERY IN WORLD WAR II

follows the operation, although there is evidence which suggests that this is

true.

Sympathectomy Combined with Operation on the Vascular Lesion. Sympathectomy and the vascular operation need not be performed as separate

procedures. They can undoubtedly be combined more often than was done in

the present series of cases. Unless there is evidence of an unquestionably

adequate collateral circulation before operation, the procedure at operation

should be (1) to perform sympathectomy, (2) to test the collateral circulation,

and (3) to proceed with, or abandon, the contemplated operative attack upon

the vascular lesion according to the results of these tests.

Part II. Postoperative Sympathectomy

The usefulness of sympathectomy in increasing the efficiency of the collateral circulation, in providing maximal or near-maximal circulation in an

injured limb, in favorably influencing existing ischemic difficulties, and in

alleviating such associated conditions as causalgia, made it reasonable to

suppose that it might also be of benefit in correcting certain circulatory conditions which sometimes follow the surgical treatment of aneurysms and fistulas.

Similarly, experience with sympathectomy in other disorders in which blood

flow through an important artery had been interrupted by disease, injury, or

operation suggested that this procedure would be of value in correcting these

conditions.

At the vascular center of Mayo General Hospital certain generalizations

concerning circulatory disorders following surgical treatment of aneurysms and

fistulas were confirmed: Circulatory disorders can be lessened if tests for the

efficiency of the collateral circulation are used as guide in the selection of the

proper time for operation and if operative techniques are employed which in

no way injure the collateral blood supply. In addition, these disorders can

practically be eliminated if the continuity of the blood flow through the involved

artery can be maintained or restored by some reparative procedure. Nonetheless, circulatory disorders occur occasionally in spite of all efforts to avoid

them, and this chapter is report of study made at this center on the value

of postoperative sympathectomy in correcting such disorders.

CLINICAL MATERIAL 11

In addition to the 75 sympathectomies performed upon 288 patients either

before or during the course of operation for aneurysms and arteriovenous

fistulas, and the performed upon 13 patients in whom cure by thrombosis

occurred and surgical intervention proved unnecessary, 19 sympathectomies

were performed after operation in the 213 patients in whom preoperative

sympathectomy had not been performed. (Table 43.)

11 See footnote 5, p. 320.
PRE- AND POSTOPERATIVE SYMPATHECTOMY 347

Table 43. Incidence of Sympathectomy in Patients with Arterial Aneurysms

and Arteriovenous Fistulas

Sixty-two patients were admitted to the Mayo General Hospital after operation elsewhere for aneurysms and arteriovenous fistulas (Table 43), 43 of which

had been performed overseas. Upon 19 of the 62 patients sympathectomy

had been performed, before and 18 after vascular surgery. In addition

there was one other admittance of patient, in whom spontaneous cure of the

vascular lesion had occurred (Case 82, Table 44), and upon whom sympathectomy was performed after neurosurgery.

The clinical material thus amounted to 116 patients; in 76 sympathectomy was carried out before or in the course of vascular surgery, in 37 after

vascular surgery, and in the vascular operation was not necessary because

spontaneous cure by thrombosis occurred (Table 43),

Although the proportion of sympathectomies was essentially the same in

the patients operated on at Mayo General Hospital (32.6 percent) and in those

operated on elsewhere (31.7 percent), breakdown of the figures discloses

significant differences (Table 43). Sympathectomy was carried out before

or at the time of the vascular operation in 26.0 percent of the patients of

Category of patient Total

lesions

Sympathectomies performed

Total Preoperative Postoperative

Number Percent Number Percent Number Percent

Operated upon at Mayo General Hospital:

Aneurysm

Arteriovenous fistula

Total

Operated upon elsewhere:

Aneurysm...

Arteriovenous fistula

82

206

36

58

43.9

28.2

28

47

34.1

22.8 11

14.8

6.9

288 94 32.6 75 26.0 19 8.9

29

34

12 41.4

23.5

3.4 11 39.3

23.5

Total

With Nonsurgical Cures (Thrombosis):

Aneurysm

63 20 31.7 1.6 19 30.6

12.5

20.0

12.5

Arteriovenous fistula.. ... 20.0

Total 13 15.4 15.4

Combined Series:

Aneurysm

Arteriovenous fistula

Total.

119

245

49

67

41.2

27.3

30

48

25.2

19.6

19

19

21.3

9.6

364 116 31.9 78 21.4 38 13.3

In this group are included the sympathectomies performed at the time of operation. Percent of lesions not involving preoperative sympathectomy.

Anadditional patient was sent to this center. Neurosurgery was required, and at time of operation it was discovered that spontaneous cure of an aneurysm by thrombosis had occurred. Following neurosurgery sympathectomy was performed. This patient is included in the category of those treated elsewhere.
348 VASCULAR SURGERY IN WORLD WAR II

Mayo General Hospital, but in only 1.6 percent of the patients operated on

elsewhere. The incidence of postoperative sympathectomy at Mayo General

Hospital in the 213 patients upon whom sympathectomy had not earlier been

performed was 8.9 percent, against 30.6 percent in the patients operated on

elsewhere. In both groups the indication for sympathectomy was proportionately more often aneurysm than arteriovenous fistula (Table 43).

The 38 postoperative sympathectomies were performed upon 19 patients

with aneurysms and 19 with arteriovenous fistulas. The upper extremities

were involved in 17 patients and the lower in 21. In patients (Cases 105,

106, and 107, Table 47) sympathetic interruption was achieved by means of

alcohol injection. In the remainder it was brought about by surgical excision

of the sympathetic pathways. Ganglionectomy was used when the lower

extremities were involved, the approach being through an anterior extraperitoneal incision. The Smithwick type of preganglionic operation was

done when the upper extremities were affected.

There were no deaths in the 38 patients and no serious complications

resulted.

INDICATIONS FOR POSTOPERATIVE SYMPATHECTOMY

The chief indications for postoperative sympathectomy in these 38 patients were (1) distressing sensitivity of the limb to cold, (2) associated severe

peripheral nerve damage in limbs in which the circulation was definitely

impaired, (3) persistent edema, (4) ischemic nerve paralysis, (5) causalgia

relieved temporarily but not cured by sympathetic blocks, (6) obviously

impending gangrene, and (7) evidence of sympathetic overactivity, with or

without poor collateral circulation, in limb in which another arteriovenous

fistula required excision. The data concerning the 38 patients are summarized

in Tables 44 through 47, grouped according to the primary indication for

sympathectomy. In many instances, however, there were several circumstances which influenced the decision to perform sympathectomy.

Cold Sensitivity. The largest number of postoperative sympathectomies,

17, was performed because of sensitivity of the affected limb to cold (Table

44). Nine patients in this group had arterial aneurysms and 8, arteriovenous

fistulas. In the upper extremity was involved and in the lower extremity.

In patient (Case 82, Table 44) cure of the aneurysm by spontaneous thrombosis had occurred; in the others excision of the lesion had been necessary.

The duration of the lesion at the time of the vascular operation ranged from

to months and averaged about months in the group operated upon

overseas; the range was from 2.5 to 11 months and averaged about 5% months

in those operated upon at Mayo.

All of the patients in this group had annoying coldness of the affected hand

or foot upon exposure to cold and most of them had cyanosis, mild in some

instances and severe in others. Some patients described the sensation as
PRE- AND POSTOPERATIVE SYMPATHECTOMY 349

aching, others as burning or tingling. Most of them had some degree of numbness of the fingers or toes and nearly all of them complained of stiffness of the

digits. When paresis was present it was aggravated during exposure to cold,

and pain, paresthesia, or hypesthesia also tended to become more intense.

The affected hand or foot was generally warm and of good color in warm

environment. One patient (Case 91, Table 44), for example, always had

warm, well-colored foot under ordinary circumstances and showed no evidence

of circulatory insufficiency except for the usual fatigue on exercise which was

Table 44. Sympathectomy Performed After Operation for Aneurysm and Arterio- venous Fistula

Cases of Arterial Aneurysms

[Indication—Cold Sensitivity]

Interval Interval between

Case

No.

Location of lesion between

injury and operation

operation

and sympathectomy

Type of operation Comment Results

Months Months

78 Axillary 5.0 1.5 Also severe plexus injury, circulation

impaired.

Relief, circulation

improved; nerve

return satisfactory except for

radial; tendon

transplant.

79 Brachial 6.0 0.5 Also mild causalgia, median palsy,

circulation impaired.

Relief, circulation

improved, causalgia largely relieved; nerve return satisfactory.

80 Brachial. 7.5 0.5 Cold sensitivity before and after

operation, ulnar palsy.

Relief, nerve return satisfactory.

81 Brachial 7.0 1.0 Much improved,

satisfactory

nerve return.

82 Brachial. Spontaneous

cure

1.5

Excision

thrombosedartery

6.0

6.0 Relief, excellent return of nerve,

function.

Thrombosed

artery.

83 External il- 11.0.. 1.0 Also frostbite, marked C. S. with pain

and hypesthesia.

C. S. persisted

though considerably lessened,

burning persisted.

iac.

84 Femoral .. 1.0 6. Relief.

85 Femoral 1.0 ..

5.0 Relief.

86 Popliteal 1.0 6.5 Relief, pain lessened.

See footnotes at end of table.
350 VASCULAR SURGERY IN WORLD WAR II

Table 44. Sympathectomy Performed After Operation for Aneurysm and

Arteriovenous Fistula Continued

Cases of Arteriovenous Fistulas

[Indication-i—Cold Sensitivity] ’—Continued

problem with all such patients. He lived in Minnesota, however, and on

exposure to cold his foot became icy cold and numb, and ached severely. Since

there was no improvement in this condition over period of months, he decided

to have sympathectomy performed. Complete relief followed sympathetic

ganglionectomy.

It was the practice to test each patient’s ability to withstand exposure to

cold. If only mild manifestations of sensitivity were present, sympathectomy

was withheld. It was occasionally withheld even when more pronounced, but

this was because the patient planned to live in warm climate and it was felt

that the condition would cause little discomfort or disability. However, if the

patient planned to live in cold climate, symptoms of the same degree, were

considered an indication for sympathectomy. The situation was always carefully explained to the patient and he was allowed to compare the reaction of

the limb to cold environment under ordinary circumstances and following

sympathetic block produced by procaine. After this experience, he was offered

the opportunity to elect operation. An occasional patient felt that his work,

avocations, and general interests would make prolonged exposure to outside

cold unnecessary. The great majority, however, chose to have sympathectomy performed. The advice of fellow patients who had obtained relief from similar

complaints undoubtedly influenced the choice of many.

Case

No. Location of lesion

Interval

between

injury and operation

Interval

between

operation

and sympathectomy

Type of operation Comment Results

Months Months

87 4.0 5.0 Extreme C. S., fatigability.. Relief.

88 4.0 2.0 Marked C. S., fatigability Relief.

89 3.0 2.0

90 2.0 2.0 Marked C. S., vasospasm, pain aggravated by cold exposure, ulnar palsy:

fistula discovered during neurosurgical exploration.

Relief, pain re

lieved.

91 Femoral 2.5 3.0 Relief.

92 Femoral 2.0 4.0 Relief.

93 Femoral.. .. 1.0 3. Relief.

94 Femoral 1.0. 5.0 Partial sciaticparalysis, pain in foot... Relief, pain less

ened.

Abbreviationsused in this table:

E, Excision.

C. S., Cold sensitivity.

Operation performed overseas.
PRE- AND POSTOPERATIVE SYMPATHECTOMY 351

Eight of the 17 patients in this group had, in addition to cold sensitivity,

associated peripheral nerve lesions. few showed evidence of sympathetic

overactivity under ordinary environmental conditions, and in instance the

vasospasm was rather pronounced. In several patients there was obvious

evidence of impaired circulation. One patient had mild causalgia. One had

fairly severe frostbite of both feet which resulted from exposure at the time of

injury. The injury produced an aneurysm of one external iliac which was

treated by excision of the lesion and division of the affected artery. The frostbite continued to cause cold sensitivity in this patient, but the discomfort was

much more severe in the limb in which the artery had been divided.

Results of sympathectomy in this group of patients with associated peripheral nerve lesions were excellent. All except obtained full relief, and

these experienced definite if not complete relief. The patient who suffered

from causalgia gained considerable relief of pain; pain was also relieved in all

other instances in which it had been present except in the patient with frostbite

who continued to have mild burning in the foot. Nerve regeneration in these

patients was as satisfactory as could be expected in the light of the trauma

which had been sustained.

Peripheral Nerve Damage. Sympathectomy was performed after operation

in patients (Table 45) who, in addition to severe nerve damage, showed

evidence of reduced blood flow. One patient had markedly impaired circulation, had extreme hyperesthesia of the hand, and had some sensitivity

to cold in the affected part.

In almost every instance sympathectomy had been considered before

operation but had been deferred because of evidence of excellent collateral

circulation and in the hope that the damage to the nerve might prove to be

caused in large part by pressure of the aneurysm or otherwise to be less severe

than had been anticipated. In all five patients the neurologic condition observed at operation was worse than had been expected.

The results of sympathectomy in all of these patients were extremely

gratifying. Signs of nerve regeneration indicated progress as satisfactory as

might have been hoped for, considering the extent of the initial damage. The

circulation in each of the limbs was visibly improved and sensitivity to cold

relieved or reduced.

Persistent Edema. In patients (Table 46) the indication for postoperative sympathectomy was persistent edema. The edema in these patients

ranged from moderate to massive. All had failed to improve under such conservative measures as rest, elevation of the limb, elastic support, and gradually

increasing periods of exercise. Sympathetic blocks had resulted in only transient improvement or had produced no effect at all other than temporary warmth

and dryness of the foot. All the patients complained of coolness of the affected foot or hyperhidrosis, all had cyanosis, had nerve paralysis, and had

indolent ulcers. Two had been operated on overseas when the vascular lesions

were, respectively, of weeks and months duration. In the upon whom
352 VASCULAR SURGERY IN WORLD WAR II

Table 45. Sympathectomy Performed After Operation for Aneurysm and

Arteriovenous Fistula

[Indication—Reduced Blood Supply and SevereNerve Damage]

the operation was carried out at Mayo General Hospital the lesions were of 2,

3, and months duration.

Results were excellent in patients, moderately good in 1, and fair in

another. In addition to the good effect which sympathectomy had upon the

edema, warmth and normal color prevailed in all the limbs treated, and

satisfactory return of nerve function took place.

Miscellaneous Indications. Sympathectomy was performed upon 11

patients for miscellaneous indications (Table 47). Six of these patients had

arterial aneurysms and 5, arteriovenous fistulas.

Ischemic paralysis was the primary indication for sympathectomy in

patients (Cases 105, 111, and 112). In of these (Cases 111 and 112) neurologic difficultyfollowed operations for the cure of femoral arteriovenous fistulas.

InterInter- val beval be- tween Type

of operation

Case

No. Location of lesion tween

injury

operationand Comment Results

and op- sympaeration thectomy

Cases ofArterial Aneurysms

Months Months

95 Subclavian 2.5 0.5 Severe plexus damage, no surgical repair

possible; causalgia relieved after opertion.

Circulation much improved; good nerve return except for posterior

cord; comfortable.

96 Axillary 2.5 1.0 Extensive plexus damage, circulation impaired, much sensitivity of hand.

Hypersensitivity of hand

relieved, someimmediate

nerve return, subsequent

satisfactory progress.

97 Brachial 1.0 1.5 Had neurolysis ofulnar and suturemedian

nerve, some C. S.

C. S. relieved, satisfactory

nerve return, circulation

improved.

Cases of Arteriovenous Fistulas

98 Axillary. ... 6.5 0.5 Had neurolysis of brachial plexus and

ulnar neurorrhaphy.

Circulation excellent; good

nerve return.

99 Axillary. ... 5.0 1.0 Had neurolysis of plexus and suture of

posterior cord, also some C. S.

Circulation better; slight

C. S. remained, nerve

return satisfactory.

Abbreviationsused in this table:

A, Aneurysmorrhaphyor aneurysmotomy with intrasaccular ligation or transfixing of the artery.

E, Excision.

C. S., Cold sensitivity.

Operation performed overseas.
PRE- AND POSTOPERATIVE SYMPATHECTOMY 353

The clinical records accompanying the patients contained no data concerning

the state of the collateral circulation before operation. One patient (Case 111)

had an extensor paralysis of two toes, anesthesia of the foot, and stocking hypesthesia almost up to the knee. Sympathectomy was performed and improvement observed almost immediately. He continued to improve during the

ensuing weeks. When last observed motor power had returned to his toes,

hypesthesia had disappeared from his leg, and his foot, although still hypesthetic, was no longer anesthetic. The other patient (Case 112) had stocking

anesthesia with complete sciatic paralysis after operation. Return offunction

inthe tibial nerve had beenprompt afterrepair of the vascular lesion, but when he

was admitted to the Mayo General Hospital he had complete peroneal motor loss

and almost complete sensory loss. The neurologic condition seemed stationary.

Sympathectomy was performed and within few days return of peroneal functionwas noted. He improved steadily thereafter and completerecovery ensued.

Table 48. Sympathectomy Performed After Operation for Aneurysm and

Arteriovenous Fistula

[Indication—Edema]

Case

No. Location of lesion

Interval between

injury

and op- eration

Interval be- tween

operation and

sympathectomy

Type

of operation

Comment Results

Cases of Arterial Aneurysms

Months Months

100 Popliteal 0.5 2.5 Marked edema; cyanosis of foot, ulcers of Markedimprovement,edeleg, peroneal palsy, tibial palsy, ques- ma minimal, ulcers

tionably due to postoperative ischemia. healed.

Cases of Arteriovenous Fistulas

101 Popliteal 3.0 0.5 Saccular aneurysm as well as A-V fistula; Marked improvement,foot

subcutaneous rupture caused peroneal warmer, edema much

palsy; after operation fairly marked less—subsequently disedema, foot cool. appeared, good nerve return.

102 Popliteal 6.0 1.0 Marked edema, foot cool_ Edemalessened, footwarm.

103 Posterior tib- 2.0 1.0 Moderate edema, some coolness, cyanosis, Edema almost completely

ial. and hyperhidrosis; temporary relief and disappeared, foot warm

reduction in edema from sympathetic and well colored.

blocks but no lasting effect.

104 Posterior tib- 2.0 6.0 Persistent edema, some cyanosis of foot Edema considerably lessial. ened.

Abbreviations used in this table:

A, Aneurysmorrhaphy or aneurysmotomy with intrasaccular ligation or transfixing of artery.

E, Excision.

Operation performed overseas.
354 VASCULAR SURGERY IN WORLD WAR II

Table 47. Sympathectomy Performed After Operation for Aneurysm and

Arteriovenous Fistula

[Miscellaneous Indications]

Case

No. Location of lesion

Interval be- tween injury and operation

Interval

between

operation

and sym- pathectomy

Type of operation Comment Results

Cases of Arterial Aneurysms

105 Brachial

Months

1.5

Months

3.0... Completeparalysis upperextremity

after injury, after several months

gauntlet typeanesthesia, etc., suggested residual paralysis was

largely ischemic; hand cold, cyanotic.

Obviously impending gangrene of

hand, especially of thumb, with

marked ischemic paralysis following operation; also had traumatic plexus injury treated by

alcohol injection.

Foot extremely cold and pale after

operation.

Causalgia, severe C. S., severe plexus

injury including irreparable damage to musculocutaneous nerve.

Causalgia and peroneal paralysis followedoperation.

Moderate causalgia temporarily re- lievedby sympathetic block; tibial

palsy, definite hypochondriasis.

Marked improvement began after

sympathectomy;

steady, significant

but incomplete return of function.

Gangrene limited to

thumb which was

amputated; slow,

steady, but incomplete recovery from

ischemic and traumatic paralysis.

Excellent, good color

and warmth.

Causalgia relieved;

coldsensitivitylessened, nerve return

satisfactory.

Causalgia greatly relieved.

106 Axillary ...

2.5--_ Same day

One day..

12.0

107 Femoral 3.0

108 Brachial .. 1.0-..

109 Popliteal

Profunda fe0.5.. 1.0 ..110 2.0--. week

moris. slight, subsequent

complete relief

with exercise and

encouragement.

Cases of Arteriovenous Fistulas

in Femoral.. .. 2.0. 3.0 Stocking hypesthesia up to just below knee, foot largely anesthetic;

extensor paralysis toes and 2,

ischemicpalsy followingoperation.

Boot anesthesia and complete tibial

and peroneal paralysis followed

operation, regained tibial function

promptly; on admittance peroneal

motor loss complete, sensory almost complete.

Some C. S., poor collateral circulation; second (hypogastric) A-V

fistularemained to be excised.

Noanesthesia, hypes

thesia only of foot,

regained extension

of toes; improvement began few

days after sympathectomy.

Improvement began

within few days,

complete recovery.

Excellent, good circulation following

excision of hypergastric fistula; no

C. S.

112 Femoral- 3.5.

saccular

ligation.

113 External iliac. 1.5 3.5

See footnotes at end of table.
PRE- AND POSTOPERATIVE SYMPATHECTOMY 355

Table 47. Sympathectomy Performed After Operation for Aneurysm and

Arteriovenous Fistula Continued

[Miscellaneous Indications] '—Continued

The third patient with ischemic paralysis (Case 105) had paralysis of the

upper extremity after injury. When examined at the Mayo General Hospital,

months after excision of brachial aneurysm and 4.5 months after injury, the

gauntlet type of anesthesia and other findings made it evident that his residual

paralysis was largely ischemic in character. The hand was cold and cyanotic

and he complained of aching upon exposure to cold. Improvement was noted

shortly after sympathectomy. The anesthesia receded steadily and months

later sensation in the extremity was normal except for hypesthesia of the dorsum of the hand and anesthesia of the palmar surface of the fingers. The hand

was warmer and of good color and withstood exposure to cold fairly well.

Return of motor function, although considerable, was still incomplete.

Two patients in the miscellaneous group (Cases 113 and 114) had multiple

arteriovenous fistulas. In one (Case 113) there was some sensitivity to cold

and evidence of extremely poor collateral circulation following excision of an

external iliac fistula. The operation had been performed overseas. When

the patient was admitted to Mayo General Hospital second fistula remained

to be excised. At operation this was found to involve the neighboring hypogastric vessels. Sympathectomy was performed and immediately afterward

tests of the collateral circulation showed it to be adequate. This fistula was

therefore excised. Thereafter, circulation in this limb was excellent. The

second patient (Case 114) had congenital cirsoid aneurysm of the foot with

Case

No. Location of lesion

Interval be- tween injury and operation

Interval

between

operation

and sym- pathectomy

Type of operation Comment Results

Cases of Arteriovenous Fistulas Continued

114

Months Months

3. Hyperhidrosis and cyanosis followed

excision posterior tibial A-V;

peroneal and anterior tibial A-V

fistulas remained to be excised.

115

foot.

Femoral 8.5 week

warm, dry, and

well colored after

remaining fistulas

were excised.

Some improvement

with descent of

cold level; gangrene

of toes and sole of

foot occurred, however.

6th postoperative day when arterial and venous thrombosisoccurred

with coldness, numbness, and

paresis of foot.

Abbreviationsused in this table:

E, Excision.

A, Aneurysmorrhaphyor aneurysmotomy with intrasaccularligation or transfixing of the artery.

C. S., Cold sensitivity.

Operation performed overseas.
356 VASCULAR SURGERY IN WORLD WAR II

distinct individual fistulas of the anterior and posterior tibial and peroneal

vessels. Excision of the posterior tibial fistula was followed by extreme hyperhidrosis and cyanosis of the foot which persisted for several months. Sympathectomy was performed and thereafter the foot remained warm and dry.

The remaining fistulas were resected without difficulty.

Sympathetic interruption was carried out in patients (Cases 106 and 115)

because of obviously impending gangrene. One of these patients (Case 106)

had been operated upon overseas nearly months after an injury which had

produced partial paralysis of the brachial plexus. An aneurysm of the axillary

artery was encountered unexpectedly at operation and excised. After operation the hand became cold and cyanotic, and the thumb, in particular, seemed

devoid of circulation. Alcohol injection of the dorsal sympathetics was accomplished successfully, but gangrene of the thumb occurred and required

amputation. Fairly good circulation was restored in the remainder of the hand.

In this patient definite ischemic paralysis had been superimposed on the preexisting damage to the brachial plexus. Steady improvement in nerve function

occurred, but recovery was incomplete. The second patient (Case 115), who at

first had had good warmth and color in the foot after excision of femoral arteriovenous fistula, on the sixth postoperative day suddenly complained of pain and

swelling in the foot and leg with coldness, numbness, and paresis of the foot.

It was apparent that extensive arterial and venous thrombosis had occurred.

Although spinal analgesia produced little improvement in the circulation,

sympathectomy was performed because the situation was desperate. The cold

level became lower and circulation improved but the improvement was insufficient to prevent gangrene of the toes and sole of the foot, and amputation

was required.

In another patient (Case 107) sympathectomy was performed the day

after aneurysmorrhaphy because the foot became alarmingly cold and pale.

In this patient the foot regained good warmth and color promptly.

Sympathectomy was carried out in patients (Cases 108, 109, and 110)

because of causalgia. All had suffered peripheral nerve damage and had

severe sensitivity to cold. In each, temporary relief followed series of sympathetic blocks, but lasting effect was not achieved. After sympathectomy

causalgia was promptly and completely relieved in patient and greatly relieved

in another. The third patient continued to complain of pain after operation.

He had, in addition, other complaints which suggested hypochondriasis.

Under reassurance and exercise the pain of which he complained finally disappeared.

COMMENT

If patients who have circulatory difficulties following the operative

cure of peripheral aneurysms or arteriovenous fistulas are to be provided with

the best possible limbs, and if the desire is not merely to avoid such gross

ischemic disasters as gangrene, repeated investigation of the circulatory status
PRE- AND POSTOPERATIVE SYMPATHECTOMY 357

of the affected limbs is necessary. Just the casual observation of patients on

ward will not reveal the true circulatory status of their injured extremities.

It is important to test these affected limbs in order to ascertain whether exercise

can be tolerated without crippling pain, to make certain that no distressing

symptoms ensue when they are exposed to cold, to see that persistent edema or

ischemic paralysis is not present, and to make sure that return of nerve function

in instances of associated peripheral nerve injury is not being compromised

by inadequate circulation. The experience at this center during World War II

shows that in certain instances the performance of sympathectomy will correct

these circulatory difficulties.

Special Effects of Sympathectomy

Exercise Tolerance. As was noted in the discussion of preoperative sympathectomy, fatigue on exercise occurs in striking fashion in the lower extremity after ligation of the iliac, femoral, or popliteal artery and in less

notable degree in the upper extremity after ligation of the subclavian, axillary,

or brachial artery. Exercise tolerance of the lower extremities was determined

in the patients upon whom sympathectomy had been performed postoperatively,

by measuring the number of yards they could walk at normal pace before

they were compelled to stop because of fatigue, or, less commonly, because of

cramps in the calf. Exercise tolerance of the upper extremity was measured by having the patient squeeze once every second rubber bulb which was

connected to 5-gallon bottle with mercury manometer. The number of

squeezing movements which the patients could perform before fatigue prevented further effort was recorded, as was the height of the manometer at the

end of the test.

Statistically significant comparisons were not possible because these studies

were carried out both before and after sympathectomy on only small number

of patients. Many patients were not tested because of associated fractures

or motor paralysis. Results of the test showed, however, that patients upon

whom sympathectomy had been performed after ligation of the femoral or

popliteal artery experienced fatigue or cramps after walking an average of

0.82 mile; approximately the same distance walked by patients with similar

lesions treated by ligation but without sympathectomy (see Part I). Many

patients showed no or only slight improvement in exercise tolerance after

sympathectomy. On the other hand, striking increase in exercise tolerance

was occasionally observed. One patient (Case 84, Table 44), who was admitted 4.5 months after excision of femoral aneurysm, could walk no more

than half mile because of aching and fatigue in the calf. Within weeks

after sympathectomy had been performed on the indication of sensitivity of

the foot to cold, he could walk miles before experiencing fatigue in the calf.

Improvement of such degree was, however, exceptional.

Cold Sensitivity. Next to diminished ability to exercise the limb without

fatigue, the commonest postoperative circulatory difficulty is cold sensitivity.
358 VASCULAR SURGERY IN WORLD WAR II

If, as has already been pointed out, itis of mild degree, or if it occurs in patients

who live in warm climates, it is not likely to cause real discomfort or disability.

When it exists in rather severe degree or is present in patients whose place of

residence and type of work require exposure to low temperatures, the symptoms

are distressing and often disabling.

As the patients in this series show, sympathectomy which was performed

on this indication yielded excellent results. Sympathetic blocks with procaine

followed by exposure to cold served as excellent guides as to what might be

expected of sympathectomy.

Persistent Edema. Persistent edema of significant degree is unusual after

operation for aneurysms or arteriovenous fistulas. If it occurs it should be

treated by rest, elevation of the limb, elastic support, and graduated activity

with the limb dependent for sufficiently long period of time. If these measures prove ineffectual after fair trial, sympathetic blocks or sympathectomy

may be of real value.

It was noted that if they caused transient though not permanent diminution in swelling, sympathectomy was likely to be very helpful, but even if no

effect upon the edema was noted after the blocks, sympathectomy was occasionally effective. Certainly sympathectomy was of real value in every instance when it was performed on this indication in this series—even if the

prospects indicated by sympathetic block had been poor.

Ischemic Difficulties. When ischemic difficulties are present, the efficacy

of sympathectomy depends upon the capacity of the collateral circulation to

improve through the elimination of persistent or intermittent vasoconstriction

and the maintenance of state of vasodilatation. As with other disorders in

which the arterial blood flow has been interrupted, this capacity varies in

different individuals.

In the Mayo General Hospital experience, sympathectomy was strikingly

successful in ischemic nerve paralysis. The results in the two patients in whom

gangrene was imminent were less striking. Nonetheless, the procedure should

be given consideration in such patients even if the limb shows only slight improvement with sympathetic block or spinal analgesia. In occasional instances

of impending or spreading gangrene caused by occlusion of arteries from other

causes, sympathectomy has produced striking benefits even after poor response

to preliminary tests.

The experience at this center also suggested that sympathectomy was

indicated in patients in whom severe nerve damage was associated with obviously impaired circulation. The evidence of good return of nerve function

in these patients would seem to justify the procedure. Unfortunately, there

were available no carefully controlled clinical studies comparing nerve regeneration in patients in whom sympathetic interruption had been carried out with

those in whom it had not been carried out. Furthermore, sympathetic procaine

block did not invariably furnish reliable information concerning the results to

be expected following sympathectomy.
PRE- AND POSTOPERATIVE SYMPATHECTOMY 359

It was noted at this center that if the nerve paralysis had not produced

sensory loss in the entire hand or foot, improvement in the circulation produced

by sympathetic procaine block could be readily demonstrated by skin temperature changes in the normally innervated digits. If, on the other hand,

normal sensation and intact sympathetic innervation had been lost in all parts

of the hand or foot, ordinarily no rise in skin temperature could be demonstrated

during the block. That sympathectomy may actually increase the circulation

in these patients was suggested by number of phenomena, namely, the decreased tendency to dependent cyanosis which was sometimes noted after operation, diminution in sensitivity to cold, an occasional increase in circulation as

demonstrated by the oscillometer and, in particular, the striking improvement

in nerve function which so often followed if part of the neurologic damage was

ischemic in character. Sympathectomy naturally did not alter the tonus of

blood vessels if there was anesthesia of portions of the skin and consequently

local sympathetic denervation. It was equally apparent, however, that blood

flow in the limb was increased by the elimination of vasoconstriction from the

vessels of the limb as whole.

Factors Influencing the Development of Postoperative Circulatory Difficulties

comparison of the patients operated on overseas and those treated at

the Mayo General Hospital reveals certain profitable data concerning factors

influencing the occurrence of postoperative difficulties for which sympathectomy

is required. If only those patients are considered in whom the main arteries

to the extremities were involved (innominate, subclavian, axillary, brachial,

external iliac, common femoral, and popliteal arteries), 17 of 42 patients in

the overseas group were treated by sympathectomy (40.5 percent) against 17

of 182 patients in the Mayo General Hospital group (9.3 percent). If those

patients upon whom sympathectomy was carried out before or at the time of

operation are eliminated, likewise those in whom the continuity of blood flow

through the affected artery was successfully maintained, the figures for the

overseas group become 17 of 41 cases (41.5 percent) and for the Mayo General

Hospital group 17 of 108 cases (15.7 percent). Sympathectomy was performed

upon patient in each group for the additional reason that second arteriovenous fistula required excision.

In general, the time interval between injury and operation for the vascular

lesion was shorter in the overseas group than in the Mayo General Hospital

group. In the former it ranged from few days to 4.5 months and averaged

about 1K months. In only about 17 percent of the patients was the interval

months or longer. In the Mayo General Hospital group, exclusive of

patient with lesion of 13 years duration, the interval ranged from weeks

to 15 months and averaged about months. In about 85 percent of those in

this group the interval was months or longer.

Unfortunately, the overseas group and the Mayo General Hospital group

are not entirely comparable. Early operation was apparently forced by com330323 0—55 24
360 VASCULAR SURGERY IN WORLD WAR II

plicating circumstances in somewhat higher percentage of the patients operated on overseas than in those treated at the Mayo General Hospital. There

were also other differences. Often patients in the overseas group were operated

upon by number of surgeons whose experience in vascular surgery was limited; whereas those in the Mayo General Hospital group were treated by

few surgeons who were specialists in the field of vascular disorders. Careful

testing of the collateral circulation before operation was routine at the Mayo

General Hospital. If the clinical case records are taken at their face value and

if the replies of patients to questioning can be accepted, these tests were carried

out only rarely in patients operated upon overseas. The two groups are

therefore not comparable because of these extremely important factors. Nevertheless, it may be concluded from the data available that postoperative circulatory disorders follow more frequently operations performed upon aneurysms

and fistulas ofrelatively short duration. This hypothesis can probably be expressed more accurately by stating that the incidence of postoperative difficulties is less when an adequate collateral circulation is established before surgery

is undertaken. It must be emphasized that although the collateral circulation

tends to be better when the lesion has been in existence long time, especially

in patients with arteriovenous fistulas, there are frequent exceptions to the

rule, and careful testing is mandatory.
CHAPTER XII

Arterial Aneurysms and Arteriovenous Fistulas

Spontaneous Cures

Harris B. Shumacker, Jr. M. D.

For many years spontaneous cures of both arterial aneurysms and arteriovenous fistulas have been recorded in the medical literature. These accounts have appeared chiefly in the form of isolated case reports or as single examples

in small series of cases. By 1907, according to Matas, Boinet was able to

collect 60 such cures in aortic aneurysms alone. Spontaneous cures of arteriovenous fistulas have been reported less frequently than cures of arterial aneurysms. The cures of aneurysms have included both saccular and fusiform

types and the lesions have occurred in practically all arteries. The duration

of the lesion before cure occurred has varied from few months to many years.

Because of the character of the reports in the literature, it is almost impossible to determine anything concerning the frequency with which spontaneous cures occur. Winslow found only instance of spontaneous cure in 86

aneurysms of the internal carotid artery and none in 19 arteriovenous fistulas,

while Callander mentioned only instance of cure among the 447 arteriovenous fistulas which he analyzed. few other cases are described in which

the lesion disappeared after treatment by compression.

The literature thus supplies little information concerning the frequency of

spontaneous cures of arterial aneurysm and arteriovenous fistulas, the adequacy and permanency of these cures, and the therapeutic means by which

they can be encouraged to take place.

Among the 119 aneurysms and 245 arteriovenous fistulas observed at the

vascular center of Mayo General Hospital, there were spontaneous cures of

arterial aneurysms and of arteriovenous fistulas. Two additional aneurysms

became solidly clotted but had to be excised because of associated nerve lesions,

and additional arteriovenous fistulas underwent spontaneous cure by thrombosis of the affected vein, but persistence of associated saccular aneurysms

made surgery necessary in each of these cases. With 11 exceptions, of which

were of congenital origin, these 364 lesions were traumatic.

Matas, R.; Surgery of the vascular system. In Keen, William W., and DaCosta, John C.: Surgery: Its Principles

and Practice. Philadelphia, W. B. Saunders Co., 1909, vol 5, pp. 17-350.

Winslow, N.: Extracranial aneurysm of the Internal carotid artery; history and analysis of the cases registeredup to

August 1, 1925. Arch. Surg. 13 689-729, Nov 1926.

Callander, L.: Study of arteriovenous fistula with an analysis of 447 cases. Johns Hopkins Hosp. Rep. 19: 347-362,

1921.
362 VASCULAR SURGERY IN WORLD WAR II

It was possible to determine from notes made at the time of operation and

from examination of excised specimens, the types of fistulas and the presence

or absence of associated saccular aneurysms in 195 arteriovenous fistulas observed at Mayo General Hospital during the course of World War II. In 78,

40 percent, no aneurysm was present; there was only direct communication

between artery and vein. In the other 117, 60 percent, one or more aneurysms

were present, and these varied in size from mass cm. in diameter to an ovoid

mass about 22 cm. long and 15 cm. in diameter.

SPONTANEOUS CURES OF ANEURYSMS

Analysis of Data

Of the 119 aneurysms observed at the vascular center of Mayo General Hospital in the course of World War II spontaneous clinical cure occurred in

10 instances. In of these (6.7 percent of the total number) the end results

were satisfactory without local treatment in that the mass disappeared. In

the other 2, the thrombosed sac persisted and required surgical treatment because ofassociated nerve lesions, in of these because of pressure of the thrombosed mass on the nerve rather than because of trauma to the nerve per se.

In of the 10, the aneurysms arose from relatively small arteries as, for example,

the posterior tibial and the ulnar. In the remaining, larger arteries such as

the carotid, brachial, femoral, popliteal, and axillary were involved.

In the 10 patients in whom thrombosis occurred, the process began from

1.5 to 4.5 months following injury and was complete in from to 15 months.

These time intervals are to be compared with approximately 3.5 months, the

average duration of the lesion at the time of operation in the 109 aneurysms

in the series treated by surgical measures.

In of the 10 patients the thrombosis seemed to occur rather suddenly

and to be complete immediately. In the other 4, it was gradual and progressive process. In general, marked contraction of the clotted sac took

place, and in the patients in whom cure was entirely satisfactory the mass

either disappeared completely or became insignificant in size. One patient

(Case 5) had had sympathectomy performed on the indication of poor collateral

circulation prior to the time the thrombotic process began, and in another

patient (Case 2) traumatic sympathetic denervation had resulted from the

same injury which produced the vascular lesion.

Brief abstracts of the 10 cases in which aneurysms cured spontaneously

are presented herewith:

Case 1. 27-year-old soldier received multiple penetrating wounds from fragments of

an exploding shell. Thereafter there were present signs and symptoms of an aneurysm of

the left common carotid artery including paralysis of the left vocal cord, vigorous pulsation

of palpable mass, systolic bruit, and the subjective sensation of short, swishing sound

heard synchronously with each heart beat. In hospital overseas an exploratory operation

was carried out month after injury but no attempt was made to correct the vascular lesion.
SPONTANEOUS CURES OF ANEURYSMS AND FISTULAS 363

Some months later, while the patient was being evacuated by sea to the Zone of

Interior, he observed that the swishing note had disappeared and that the mass was pulsating

less forcefully. When examined few weeks later in the vascular center of Mayo General Hospital firm pulsating mass about cm. in diameter was palpable in the region of the left

common carotid artery. Proximal compression of the artery temporarily stilled the pulsation

of the mass. Four months later (8 months after injury) examination revealed practically

the same findings. At the end of another months the mass was no longer palpable and

there was no evidence of the thrill, bruit, or abnormal pulsation previously present. The

left common carotid artery pulsated normally proximally and distally to the site of the original

mass. It was concluded that the aneurysm had cured spontaneously and that the lumen

of the artery had been preserved.

The first improvement was observed during the time the patient was at sea, but he had

not been seasick and dehydration could not be regarded as initiating the chain of events

leading to cure (see Case 18).

Case 2. 25-year-old soldier was injured by shell fragment weeks before he was

seen at this vascular center in the Zone of Interior. He had pulsating mass about 3.5 by

cm. in the left side of the neck (Figs. 46A and B). The mass was compressible and was

associated with loud systolic bruit. It ceased to pulsate when the left common carotid

artery was occluded proximally. There was also evidence of left cervical sympathetic and

of left recurrent laryngeal paralysis.

Figure J+6. (Case 2.) and B. Aneurysm of left carotid artery weeks after injury.

Five months later after apparent spontaneous cure of lesion. Note normal contour of the

neck. (See p. 362.) It is unfortunate that no postoperative photograph was made in

precisely the same position as one or the other of the preoperative photographs. The presence

of normal skin creases, however, and the clear anterior margin of the sternomastoid muscle,

show reasonably well the absence of any visible mass.

The soldier was granted furlough and after his return an examination revealed that

the mass was smaller, firmer, and pulsated less vigorously. In addition, the bruit had

disappeared. At this time months had elapsed since the date of injury. The mass continued to decrease rapidly in size and weeks later it was only firm, nonexpansible nodule

about 1.5 by 0.7 cm. in size adherent to the carotid artery. Two months later (7Yi months

after injury), examination revealed the same findings. (Fig. 46C.) No signs of aneurysm

were present and the carotid artery pulsated normally proximally and distally.

Case 3. 30-year-old soldier was wounded by machinegun fire. small arterial

aneurysm of the midportion of the brachial artery developed, also paralysis of the right

median nerve. The aneurysm measured about by 1.5 centimeters. Examination revealed

expansile pulsation of the mass and systolic bruit.
364 VASCULAR SURGERY IN WORLD WAR II

Six weeks after injury the mass became firmer and ceased to expand with pulsation.

The changes were associated with definite local pain and tenderness. The mass continued

to decrease in size and after several months had elapsed was no longer even palpable. The

hand, however, showed evidence of persistent vasospasm and was sensitive to cold.

Seven months after injury, during operative neurolysis of the median nerve, it was

possible to inspect the brachial vessels. Both the artery and the vein were thrombosed and

were excised. study of the specimen revealed defect in the arterial wall which represented the former mouth of the aneurysm. No sac could be found. Return of median

nerve function was satisfactory but sensitivity to cold continued and dorsal sympathectomy

was therefore carried out. The results were excellent.

Case 4- 23-year-old soldier was injured by the explosion of land mine. He sustained fractures of the right radius and ulna and of the left femur, laceration of the mesentery

of the ileum for which laparotomy was performed, and an injury to the right common femoral

artery. When examined at the vascular center of Mayo General Hospital weeks later,

pulsating mass about cm. in diameter was found in the right groin over the junction of the

external iliac and common femoral arteries. systolic thrill and bruit were present.

Direct pressure over the mass or over the distal portion of the external iliac artery stilled

the aneurysm.

Three months later the mass was smaller and firmer. It still expanded with pulsation

and the bruit was still present but the thrill had disappeared. Examination year after the

injury showed that the original pulsating mass had been replaced by one that was small and

indurated. This mass completely disappeared months later. There was no other evidence

of the presence of an aneurysm at either of these examinations.

Case 5. 24-year-old soldier was injured by shell fragment. When examined

months later compressible dumbbell-shaped mass cm. in diameter was present over the

upper portion of the left femoral artery. Expansile pulsation was palpable and systolic

bruit heard. Both pulsation and bruit were abolished by compression of the common

femoral artery. Tests revealed the collateral circulation to be inadequate and left lumbar

sympathectomy was performed. The circulation was improved after this procedure but

was still regarded as inadequate.

Two months later, while the patient was on furlough, the mass became firm and ceased

to pulsate. Examination on his return few weeks later showed that the 6-cm. pulsating

mass had been replaced by hard, nonexpansile mass cm. in diameter and without any

associated thrill or bruit. The mass continued to decrease in size and months after the

original injury an arteriogram revealed sac only about 0.5 cm. in diameter. At the end of

another month the mass was still smaller; only tiny, firm nodule was palpable. Oscillometric readings showed that the circulation was normal in the thigh, calf, and ankle on the

affected side. Appropriate tests showed that the patency of the artery had been maintained.

Case 6. 26-year-old soldier was injured in the right popliteal area by shell fragment.

Soon afterward pulsating mass developed in this area associated with systolic bruit.

About weeks after injury the mass became smaller and firmer and ceased to pulsate. At

the end of another weeks it had disappeared entirely as had the bruit. The popliteal

artery and its anterior and posterior tibial branches all pulsated normally.

Case 7. 32-year-old soldier was injured by shell fragment. Soon afterward

pulsating expansile mass appeared on the posteromedial aspect of the leg just above the

internal malleolus. diagnosis of posterior tibial aneurysm was made. Two months

after injury the pulsating mass became firm and did not pulsate. Examination revealed

solid mass about 1.5 cm. in diameter. No bruit or thrill was present. No posterior tibial

pulse could be palpated distal to the mass. Examination months later showed little change

in the mass, but at the end of another months it was neither visible nor palpable. The

posterior tibial pulse distal to the site of injury was still absent.
SPONTANEOUS CURES OF ANEURYSMS AND FISTULAS 365

Case 8. 26-year-old soldier received multiple penetrating wounds from shell fragments. small pulsating mass, associated with loud systolic murmur, developed in the

middle third of the right calf. It was diagnosed as posterior tibial aneurysm. During the

third month after injury, while the patient was on furlough, the mass ceased to pulsate and

became firm and indurated. Examination revealed neither thrill nor bruit. The induration gradually subsided. An arteriogram months after injury revealed normal-appearing

arterial tree. There was no suggestion of aneurysmal dilatation at the site of injury but in

the roentgenogram the site of the injury was marked by the presence of small shell fragment.

Case 9. 23-year-old soldier was wounded in the right axilla by shell fragments.

At the time of wounding there was considerable bleeding. No numbness or paralysis was noted. pulsating mass soon developed in the axilla and systolic bruit became audible.

Six weeks after injury some loss of sensation was noted in the digits and week later the

extensor power of the wrist and forearm was lost and all movements of the hand became

weak. These neurologic changes persisted.

When the patient was examined at this vascular center some months later he stated

that pulsation in the mass had recently ceased. Examination showed solidly thrombosed

aneurysm in the right axilla (Fig. 47). The brachial, radial, and ulnar pulses were absent.

Complete radial and partial ulnar and median paralysis was present, and the sequence of

events left no doubt that nerve damage had resulted from pressure from the axillary

aneurysm.

Figure J+7 (Case 9.) Right axillary aneurysm months after injury.
366 VASCULAR SURGERY IN WORLD WAR II

An exploratory operation was performed and an axillary aneurysm was found which

measured between and cm. in diameter. The axillary artery was thrombosed distal

to the lesion. The median, ulnar, and radial nerves lay in grooves in the wall of the aneurysmal sac (Fig. 48). The median nerve showed only little damage and the ulnar nerve was

only moderately thinned, but the radial nerve was thinned out to fine thread for distance

of 3.5 cm.; strong faradic stimulation in this area yielded no response. The aneurysm was

excised after which the damaged portion of the radial nerve was resected and the ends sutured.

The postoperative course was smooth.

When the excised aneurysm was opened it was found to be completely filled with thrombus, most of the clot was old and well organized. Near the mouth of the sac, however, was

small portion which was fresher and less well organized.

Case 10. 20-year-old soldier sustained wound from rifle bullet in his left hand.

An ulnar aneurysm developed in the hypothenar space and there was some damage to the

digital nerves. By the end of the third month after injury the aneurysm was completely

thrombosed, but over the next weeks it did not decrease in size and there was no improveFigure J+8. (Case 9.) Drawing of conditions found at operation. Note relationship of nerves

to lesion.
SPONTANEOUS CURES OF ANEURYSMS AND FISTULAS 367

ment in the neurologic condition. Operation was therefore performed. The aneurysm, which

was 1.5 cm. in diameter, was solidly clotted and the artery distal to it, thrombosed. The

sac was evacuated and the injured nerves sutured. Recovery was uncomplicated.

SPONTANEOUS CURES OF ARTERIOVENOUS FISTULAS

Analysis of Data

Of the 245 arteriovenous fistulas observed at this vascular center during

World War II, apparently spontaneous clinical cure occurred in instances.

In (2 percent of the total number) the end results were satisfactory without

further local treatment. saccular aneurysm was known to be associated

with the fistula in of the 5. In the other 3, while the fistula was closed by

spontaneous thrombosis of the vein, an associated saccular aneurysm persisted

and operation was necessary. In all but or the artery involved was large

vessel such as the carotid, brachial, subclavian, or femoral.

In the patients in whom the end result of spontaneous cure was entirely

satisfactory, the process of obliteration began 1.5 and 5.5 months after onset

of the lesion. In of these patients the process began within months or less.

In all the process occurred rather suddenly, leading one to infer that closure

of the fistula was achieved by thrombosis rather than by scarring and fibrosis

which is more gradual process. In the remaining patient in this group the

process occurred gradually, beginning within months after injury and completed within the next 1.5 months.

In only instances was the presumption concerning the method of cure

established: In instance (Case 11) by the presence of palpable, thrombosed

saccular aneurysm, and in the other (Case 12) by clinical observation of thrombosis of the vein, confirmed by later inspection of the involved vessels at

operation. In the patients in whom operation was necessary because of

persistance of an associated aneurysm, the process of obliteration began,

respectively 1.5, 3.9, and months after injury. The time intervals in this

group and in the preceding group of patients in whom completely successful

spontaneous cure occurred should be compared with months, the average

interval between injury and operation in the 237 arteriovenous fistulas treated

by surgical excision.

Another point of interest is the proportion of patients in whom cure

occurred as the result of thrombosis. This is in contrast to the general experience that experimentally produced arteriovenous fistulas often close, when they

do so spontaneously, by gradual scarring and contraction of the communication

rather than by thrombosis.

One of the patients who had completely satisfactory spontaneous cure,

and of the who required further surgery, had undergone sympathectomy

before the fistula became obliterated. In of these patients (Case 18) thrombosis of the vein was obviously associated with dehydration and shock.

Brief abstracts of the cases in which spontaneous cures of arteriovenous

fistulas occurred are presented herewith:
368 VASCULAR SURGERY IN WORLD WAI il

Case 11. 34-year-old soldier received multiple penetrating wounds from land mine

explosion. He developed arteriovenous fistulas, involving the right common carotid

artery and internal jugular vein, the right femoral artery and vein. The femoral fistula

was excised about month after injury. Two months later the buzzing sensation, which

had been present in the right side of the neck since the arteriovenous fistula had developed,

suddenly ceased. Examination revealed that the previously continuous thrill had disappeared while of the continuous bruit formerly present only slight systolic component now

remained. rubbery, nonexpansile mass had replaced the original carotid aneurysm. The

carotid artery pulsated normally both proximally and distally to the lesion. Within another

month the systolic bruit disappeared, and the mass became progressively smaller so that

by months after injury it was barely palpable.

Case 12. 22-year-old soldier sustained shell-fragment injury. brachial arteriovenous fistula associated with small saccular aneurysm developed, also partial median

paralysis. He was admitted to this vascular center months after injury. continuous

thrill and bruit were present, and compression of the fistula resulted in bradycardia. Seven

weeks after injury thrombosis of the dilated brachial vein became evident and signs of the

arteriovenous fistula disappeared. Since steady improvement was apparent in median

nerve function, operation was deferred. After the lapse of about /i months there was

complete recovery of motor function, but anesthesia of the median nerve distribution persisted. neurolysis was carried out. At this time the brachial artery and vein were

inspected and were found completely thrombosed, adherent to each other. tiny, solid

mass was all that remained of the original saccular aneurysm.

Case 13. In 26-year-old soldier an arteriovenous fistula of the femoral vessels developed in the midportion of the thigh following wound from rifle bullet. Two months

after injury the continuous bruit and thrill which had been present since the fistula developed

became much less prominent. month later the thrill was barely palpable and the bruit,

though still continuous, was very faint. Pulsations were good in the popliteal, dorsalis

pedis, and posterior tibial arteries. Within the next weeks all signs of the fistula disappeared and they did not reappear during an additional month of observation. Whether the

lesion in this patient involved the femoral vessels or some of the smaller branches was not

definitely established.

Case 14 25-year-old soldier was injured by shell fragment. One month later

clear-cut signs of an arteriovenous fistula in the left thigh below the inguinal region were

present. These persisted for months, then disappeared. When the patient was examined

months after injury no abnormal pulsation was present, no thrill could be palpated, and

no bruit heard.

The notes were not sufficiently complete to permit accurate localization of the fistula,

but the findings suggested that it involved branches of the profunda femoris vessels. The

continuous bruit and thrill noted by several competent observers before the patient was seen

i.n this vascular center left no doubt that an arteriovenous fistula had actually been present.

Case 15. 24-year-old soldier received penetrating shell-fragment wound of the

left chest wall. There was transient paralysis of the left upper extremity and some numbness which did not subside for several weeks. Soon after injury signs suggestive of subclavian arteriovenous fistula appeared. When he was examined about months after

injury, strong and continuous thrill was palpable just above the inner third of the clavicle.

An extremely loud and continuous bruit was transmitted into the mediastinum, up into the

neck, and down the arm to the midforearm. The subclavian vessels could not be occluded

by digital pressure nor could the thrill and bruit be eliminated. Minimal hyperesthesia

was present in the ulnar distribution. diagnosis of subclavian arteriovenous fistula was

made.
SPONTANEOUS CURES OF ANEURYSMS AND FISTULAS 369

Because of rather striking vasoconstriction in the left upper extremity and the inability to occlude the subclavian artery for testing the collateral circulation, dorsal sympathectomy was performed about 4% months after injury. Some days later the thrill

previously felt over the lesion disappeared and the continuous bruit was replaced by loud,

short, systolic bruit. The subclavian vessels were explored shortly afterward in the belief

that though the fistula had been obliterated saccular aneurysm remained. The vessels

were traced proximally to the point at which they emerged from the mediastinum. There

was considerable scarring in this area but no aneurysm could be palpated. Since the remaining bruit could be explained by compression of the artery by scar tissue, exploration

was discontinued. The short systolic bruit persisted, but became less intense, during the

6-week period of observation after operation.

There was unmistakable evidence in this case of the presence of an arteriovenous

fistula, and it seems likely that it involved the first portion of the subclavian vessels.

Case 16. 24-year-old soldier was injured by fragments from bazooka shell. Because of gas gangrene right midthigh amputation was necessary. large left femoral

aneurysm developed. Three months after injury, examination revealed very large pulsating mass in the left thigh, associated with loud systolic bruit. The aneurysm could

be stilled by proximal compression of the femoral artery. Testing showed the collateral

circulation to be entirely inadequate. Left lumbar sympathectomy was performed and the

circulation became satisfactory; aneurysmorrhaphy was carried out thereafter. The sac

was huge and in addition to large free cavity contained 2.5 liters of partially organized

thrombus. The midportions of the femoral artery and vein each opened separately into

the sac through large rents. In this area the femoral vein was completely occluded by

well-organized thrombus.

When this patient was first examined at the vascular center only an arterial aneurysm

was present. The previous records also contained no description of findings diagnostic of

an arteriovenous fistula. The findings at operation, however, left no doubt that the original

lesion was an arteriovenous fistula and that the artery and vein had communicated via the

large sac described. Thrombosis of the vein had converted the fistula into an arterial

aneurysm.

Case 17. 22-year-old soldier was struck in the left shoulder by missile of unknown

type. Immediately partial ulnar and radial paralysis developed. Two weeks later small

pulsating mass was noted in the upper portion of the left arm. Four days later the mass

began to increase rapidly in size and the radial pulse disappeared. Ulnar and radial paralysis then became complete and partial median paralysis developed. Causalgia which had

appeared soon after the injury became much worse.

When the patient was examined at this vascular center weeks after injury, tense

pulsating mass was found in the left upper arm and shoulder area associated with continuous thrill and bruit. Sympathetic block produced transient relief of pain, and sympathectomy was performed. This produced permanent relief from most of the £>ain. Four days

after operation the aneurysm again began to increase in size and simultaneously the continuous bruit and thrill disappeared; only short systolic bruit remained.

When exploration was carried out the following day, the brachial artery and vein were

found to communicate independently with large, poorly organized sac. The vein was

completely occluded by thrombus recently formed.

Case 18. 33-year-old soldier was injured by machinegun bullet. Partial paralysis

of the right ulnar and median nerves resulted. brachial arteriovenous fistula and

small saccular aneurysm also developed. Three months after injury, since the collateral

circulation appeared to be extremely poor, dorsal sympathectomy was performed. The

collateral circulation showed gradual improvement and at the end of weeks it was thought

to be adequate for surgery.
370 VASCULAR SURGERY IN WORLD WAR II

At this time, before the operation could be performed, the patient had severe attack

of food poisoning with so much vomiting and diarrhea that profound degree of circulatory

collapse resulted. The epidemic was widespread and available fluids for intravenous use

became depleted so rapidly that they were reserved for those in the severest states of dehydration and shock. This patient therefore did not receive adequate parenteral fluid

until he was badly dehydrated and in such state of collapse that his pulse was imperceptible.

He recovered rapidly, however, after appropriate therapy.

The day after this episode it was observed that the continuous thrill and bruit previously

associated with the brachial arteriovenous fistula had disappeared. The brachial pulse

distal to the lesion was good. At exploration few days later the brachial artery and vein

were found to have communicated through independent openings into saccular aneurysm

about cm. in diameter. The artery still opened freely into this sac but the vein had become

thrombosed. The ulnar and median nerves were adherent to and stretched over the aneurysm. They were freed from the aneurysm and it was excised. Recovery was uneventful.

COMMENT

Incomplete notes unfortunately do not permit statistical statements

concerning either the presence or the extent of intrasaccular thrombosis in the

arterial aneurysms and arteriovenous fistulas observed at Mayo General

Hospital. Certain general statements may, however, be made: Extensive

intrasaccular thrombosis was the rule in large aneurysms with small mouths,

and generally no thrombus was present in small aneurysms with relatively

large openings into the parent artery. In some instances the thrombus was

well organized and, ordinarily, the older the lesion the more complete was the

process of organization. In some instances (Fig. 49) there was both wellorganized thrombus adherent to the wall of the sac, and poorly organized red

thrombus only loosely attached. In other instances only poorly organized

clot was present (Fig. 50). The size and extent of the thrombus varied widely.

Several femoral aneurysms contained from to 2.5 liters of recent and old clot.

The progressive deposition of thrombus within the sac was often apparent

clinically from the decrease in pulsation of the sac, palpable increase in its

firmness, and sometimes by diminution in the thrill and bruit. Indeed, in

one patient, large aneurysm of the profunda femoris became so firm and so

completely lost its pulsatile character and its bruit that, until arteriography

revealed persistent large cavity, it was thought to have undergone spontaneous cure.

It is matter of considerable interest that in of the 10 aneurysms in

which spontaneous cures occurred, the continuity of the parent artery was

preserved. In this connection, Ballance and Edmunds cited Scarpa, who wrote;

It is certain and incontrovertible fact in practical surgery that complete and radical cure of an aneurysm cannot be obtained in whatever part of the body this tumor is situated unless the ulcerated, lacerated, or wounded artery from which the aneurysm is

derived is by the assistance of nature, or of nature combined with art, obliterated and

converted into perfectly solid ligamentous substance, for certain space above and

below the place of the ulceration, laceration, or wound.

Ballance, C. A., and Edmunds, W.: Treatise on the Ligation of the Great Arteries in Continuity with Observations on the Nature, Progress and Treatment of Aneurysms. London, Macmillan and Co., 1891.
SPONTANEOUS CURES OF ANEURYSMS AND FISTULAS 371

Figure 49. Traumatic aneurysm excised 11 years after Us origin. A. Intact specimen

B. Transected specimen showing well-organized thrombus. Some poorly organized red

thrombus can be seen along the margin of the cavity and between the organized thrombus

and the sac wall in that area where the old thrombus is not fixed to the wall. The sac in

this view is smaller because it has been fixed and shrunken in formalin solution.

This “truth/’ according to Ballance and Edmunds, writing in 1891, had

never been disproved; they had been unable to find the record of single cure

which had occurred in any other way. The experience of the vascular center

of Mayo General Hospital, however, indicates that apparently complete

cures may occur with preservation of the artery.

In discussing the possible factors involved in the spontaneous cure of

arterial aneurysms, Matas wrote as follows:

The conditions which provoke or favor this occurrence may be classified under three

heads: (1) Those which favor clotting in the sac by retardation or arrest of the current

through it; (2) those which increase the coagulability of the blood; (3) those which provoke coagulation through changes in or about the walls of the sac (Stimson). All these

may be briefly summarized as follows: Spontaneous recovery takes place by (1) gradual

deposit of fibrin from the blood in laminated manner on the walls of the sac, so that the

See footnote 1, p. 361.
372 VASCULAR SURGERY IN WORLD WAR II

aneurysm is completely consolidated and subsequently, by condensation and shrinking,

becomes converted into small, nodular mass of fibrous tissue. The artery, under such

circumstances, may remain pervious or become converted into fibrous cord as far as

the first collateral branch above and below the seat of the aneurysm. Such favorable termination may be brought about by retardation of the blood-current induced by (a)

the lowering of the heart’s action; (b) the pressure of the aneurysm upon the artery above

its opening into the sac; (c) partial blocking of the mouth of the sac with piece of detached coagulum; (d) the impaction of piece of clot in the artery below the mouth of

the sac; (e) the pressure of another aneurysm or tumor upon the artery above the sac

or on the sac itself; (f) the aneurysm rupturing and the effused blood compressing the

artery leading to the aneurysm. (2) By filling of the sac with recent ordinary coagulum as

distinguished from the deposit of old-standing laminated fibrin. The coagulation of the

blood in the sac may be brought about by: (a) the complete blocking of the mouth of the

sac by piece of detached clot; or (b) the complete plugging of the artery above and below

the aneurysm. The clot may thus become organized and transformed into fibrous cord.

(3) The inflammation and sloughing of the sac and the plugging of the artery above and

below the clot.

Figure 50. Poorly organized thrombus from large brachial aneurysm of months duration.

Insert shows artery which has been removed from area of rectangular defect in the clot.

The lesion in this case was an arteriovenous fistula; the artery and the vein communicated

via large sac into which each opened independently.
SPONTANEOUS CURES AND ANEURYSMS AND FISTULAS 373

With single exception, no factors were evident in these cases which could

be singled out as possibly having contributed to the spontaneous cure either

of arterial aneurysms or of arteriovenous fistulas. In this exceptional case

(Case 18) fistula was obliterated by thrombosis of the vein during period

of extreme dehydration and circulatory collapse due to fluid loss from diarrhea

and vomiting. In some the process occurred while the patients were confined

to bed; in none was there coincident history of local trauma.

As already mentioned, in patient in whom an arterial aneurysm underwent spontaneous cure, sympathectomy had been performed before the process of thrombosis began, while in another patient traumatic sympathetic

denervation had occurred. Sympathectomy had also been performed upon

patient with an arteriovenous fistula in whom an entirely satisfactory

spontaneous cure occurred, and upon other patients in whom saccular

aneurysm persisted.

Altogether, therefore, spontaneous cure occurred in of 77 patients in

whom sympathetic denervation had been produced by operation or trauma,

and in 12 of 274 patients (presenting total of 287 lesions) in whom sympathetic

function of the part was intact. Clinically satisfactory spontaneous cures

requiring no further treatment occurred in patients submitted to sympathetic denervation, in with traumatic sympathetic denervation, and in 10

with intact sympathetic function. In patient only did the process leading

to the spontaneous cure become evident soon enough after sympathectomy

for causal relationship to be considered possibility.

In nearly all 18 instances of spontaneous cure the fistula or aneurysm

had been temporarily stilled by digital compression once or several times,

but the cure could hardly be said to have resulted from treatment by compression if only because compression had been employed in most of the patients in whom the lesion persisted until it was treated surgically.

Several cases are described in the literature in which aneurysms and

arteriovenous fistulas disappeared after deliberate prolonged compression.

Lyle, for instance, collected number of cases in which aneurysms of the palmar arches were deliberately treated by this method. It hardly seems desirable mode of treatment. For one thing, one could not be certain that thrombosis

would be limited to the desired area, indeed it is quite possible that it might

involve an uncontrolled extent of the affected artery and even of its collateral

channels. The use of internal wiring to promote the development of thick

mural thrombosis in patients with inoperable aneurysm is often, of course,

palliative measure of great usefulness, but it was not employed in any instance

in this series.

Lyle, H. H. M.: Aneurism of the palmar arches; with report of an aneurism of the deep arch cured by excision.

Ann. Surg. 80: 347-362, Sep 1924.
374 VASCULAR SURGERY IN WORLD WAR II

number of observers, notably Reid, have suggested that the possibility

of spontaneous cure of an arteriovenous fistula might constitute valid

reason to delay surgical intervention for some months. If signs are observed

which suggest the possible progressive spontaneous obliteration of either an

aneurysm or an arteriovenous fistula, it would naturally be wise to follow

this advice. The experience at the vascular center of Mayo General Hospital

indicates, however, that the incidence of such satisfactory cures of arteriovenous fistulas, at least during the first few months after injury, is so low

(2 percent), as to make this possibility factor of little or no significance in

deciding upon the proper time for surgical attack. The incidence of satisfactory

spontaneous cures of arterial aneurysms was somewhat higher (6.7 percent),

but again the occurrence seems so unlikely that the possibility is not very

important consideration in the selection of the proper time for the operative

treatment of aneurysms.

Reid, M. R.; Abnormal arteriovenous communications, acquired and congenital: treatment of abnormal arteriovenous communications. Arch. Surg. 11: 237-253, Aug 1925.
CHAPTER XIII

Peripheral Vascular Disturbances

Thromboangiitis Obliterans, Arteriosclerosis,

and Arterial Thrombosis and Embolism

Norman E. Freeman, A4. D.

THROMBOANGIITIS OBLITERANS

Thromboangiitis obliterans affected small proportion of the patients

admitted to the vascular centers established in the Zone of Interior hospitals

during World War II. Thromboangiitis as encountered in the Army did not

differ materially from the disease as observed in civilian practice except that

it was usually observed in earlier stages; very few instances of longstanding

involvement were seen.

Analysis of Data

Of the 3,778 patients with vascular conditions observed at the vascular

centers during World War II, 274 had thromboangiitis obliterans; percentagewise an incidence of 7.3 percent. All reported cases occurred in males. Of the

274 patients observed in the vascular centers detailed information was available

for analysis on only 152 patients. In these 152 patients the great majority

(122 patients) were in the age group between 26 and 40 years. The relatively

low incidence (30 patients) under 26 years of age can probably be explained

by the fact that the disease, although present in other soldiers in that age group,

had not advanced sufficiently to produce symptoms.

As originally described (see Chapter II), the disease occurred in disproportionately large numbers among Jews. Information as to race was recorded in

only 150 of the 152 in this series but in the 150 the distribution was as follows:

Negroes, 111 Caucasians, and 32 Caucasians of the Jewish faith.

Symptomatology and Clinical Course

As mentioned previously, very few cases of longstanding involvement were

seen in the vascular centers. The range in group of 53 patients observed at

Ashford General Hospital may be considered as typical. In this group the

duration of symptoms ranged from month to 13 years, but averaged only about

22 months.

The distribution of symptoms presented at the time of the patients’

admittance to the vascular centers was approximately the same as reported

in other statistical surveys. Intermittent claudication, which Homans has

Homans, J.: Circulatory deficiency in the extremities in relation to medico-legalproblems; arterioscleroticdeficiency

(including diabetes): thromboangiitis obliterans, or Bueger’s disease. Ann. Int. Med. 18 518-534, Apr 1943.

330323 0—55 25
376 VASCULAR SURGERY IN WORLD WAR II

termed “the one characteristic early evidence of the disorder,” was the most

frequent complaint and was observed in 67 percent of the 152 patients in this

series. It was usually associated with pain in the foot and leg. Sixty percent

of the patients complained of some form of pain in the extremities and 20

percent of some disturbance of sensation, chiefly numbness on walking.

Temperature differences, either subjective or objective, were observed in 45

percent of the patients and migratory phlebitis in slighly less than third.

Ulceration was already present in 20 percent of the patients when they were

first seen, though gangrene was unusual and was observed in only 4.4 percent

of the patients. Nine patients had vasomotor disturbances characteristic of

Raynaud’s phenomenon.

Although the clinical manifestations of thromboangiitis obliterans were

usually most noticeable in single extremity, the disease is systemic vascular

disorder and careful examination frequently revealed that the blood vessels

of other extremities were also affected. In almost two-thirds (65 percent)

of the 152 patients, or more extremities were involved, and in 13 patients all

limbs were affected.

Despite the widespread character of the involvement, visceral manifestations were unusual. In patients attacks of precordial pain suggested the

presence of disease of the coronary arteries. In patient, who had suffered

from thromboangiitis obliterans of the peripheral arteries for many years,

quadriplegia and other neurologic manifestations developed while he was under

observation. His clinical course indicated that the cerebral vessels had also

become involved.

Diagnostic Procedures

In addition to complete history and physical examination with particular

attention paid to clinical evidence of vascular disturbances, certain special

procedures were employed to establish the diagnosis of thromboangiitis obliterans. These were particularly necessary and of particular importance in

few patients who had been under examination and treatment on variety of

diagnoses in several installations before the correct diagnosis was made in one

of the vascular centers.

The special procedures used to aid in the diagnosis of thromboangiitis

obliterans included the accurate measurement of skin temperatures, oscillometric recordings of the peripheral arteries, arteriography, and biopsy studies.

Constant temperature rooms were available at all of the vascular centers and

were used to study the effect of varied degrees of coldness and warmth upon

the skin temperatures of patients with thromboangiitis obliterans. In addition, skin temperature measurement and oscillometric readings were made

before and after release of vasomotor tone by reflex vasodilatation, paravertebral injection of procaine, spinal analgesia, and peripheral nerve block. These

procedures proved especially valuable in disclosing early involvement of small

vessels as well as in the selection of appropriate patients for sympathectomy
THROMBOANGIITIS OBLITERANS, ARTERIOSCLEROSIS 377

and were used in all patients indicated. Arteriograms (thorotrast was the

contrast medium used) were made in patients in whom arterial involvement

was suspected but not confirmed by other diagnostic procedures. Peripheral

pulses were normally present in each of the 4, but arteriography demonstrated

that the circulation was maintained by means of collaterals. In otherpatients

the diagnosis was substantiated by biopsy of the affected vessels.

Therapy

Various forms of nonoperative and operative treatment were employed

in the management of patients with thromboangiitis obliterans at the vascular

centers in the Zone of Interior during World War II. It was generally agreed,

however, that no type of treatment was effective unless the patient stopped

smoking.

Nonoperative Treatment. Ever since Erb first called attention to the

close relationship between smoking and endarteritis, this aspect of the problem

of thromboangiitis obliterans has been the subject of numerous clinical and

scientific observations. Silbert, in an experience which covered 1,400 patients,

observed no instance of the disease in patient who had never used tobacco.

Furthermore, he observed no instance of progression in 100 patients with the

disease who gave up smoking completely and who were followed for over 10

years. He concluded, therefore, that thromboangiitis obliterans was caused

by smoking in individuals constitutionally sensitive to tobacco. Horton, on

the other hand, found thromboangiitis obliterans present in 68 of 948 nonsmokers. His position was that while there was no question that smoking had

decidedly bad influence upon the course of the disease, it did not necessarily

follow that smoking was cause.

Whatever may be the etiologic relationship between tobacco and thromboangiitis obliterans, it is generally agreed that abstinence from smoking is

mandatory part of therapy. Allen regarded it as “largely useless” to treat

patients who continue to use tobacco and Homans said of the patient, “Above

all, if he will not abandon tobacco smoking, his disease will almost necessarily

persist and indeed will probably be aggravated.”

It is known that only of the 274 patients with thromboangiitis obliterans

observed at the vascular centers did not smoke. Information about their

subsequent habits, after they had been warned to discontinue smoking, was

obtained for 93 of these patients. Seventy-seven had stopped smoking entirety,

and persistence of the symptoms was observed in only patients in this group.

Among the 16 who had continued to smoke, progression of the vascular obliteration was observed in during the period covered by this investigation.

Erb, W.: Ueber Dysbasia angiosclerotica, intermittierendes Hinken. Munchen. med. Wchnschr. 61: 905-908,1904.

Silbert, S.: Etiology of thromboangiitis obliterans. J. A. M. A. 129: 5-9, Sep 45.

Horton, B. TV Outlook in thrombo-angiitis obliterans. J. A. M. A. Ill: 2184-2189, 10 Dec 38.

Allen, E. V.: Thrombo-angiitis obliterans. Bull. New York Acad. Med. 18: 165-189, Mar 1942. See footnote 1, p. 375.
378 VASCULAR SURGERY IN WORLD WAR II

The opinion of the officers who directed the study and treatment of the

patients with thromboangiitis in the vascular centers might well be summarized.

Capt. J. W. Kahn in writing of the experience at Ashford General Hospital

reported that while smoking is not the cause of thromboangiitis obliterans, it

is very aggravating factor. Unless the patient stops smoking completely,

no form of treatment, including sympathectomy, is of benefit. Recurrent

migratory phlebitis has disappeared with the cessation of the tobacco habit

alone. Wounds and gangrenous areas have cleared rapidly and pain has

considerably improved when the patient stopped smoking. Following sympathectomy patients who still smoked complained of pain, but the pain was

quickly relieved thereafter when the patient abstained. Gangrenous areas

were slow in healing and demarcating when the use of tobacco was continued

after sympathectomy, but gratifying results were noted when the smoking

was stopped.

Maj. David I. Abramson in writing of the experience at Mayo General

Hospital stated that it was felt at this center that no medication would be of

any value if the patient did not abstain from smoking. When the diagnosis

of thromboangiitis obliterans was made, the nature of the disease was thoroughly

discussed with the patient, and the dangers of continuing to smoke were

graphically illustrated by showing him the extremities of patients in an advanced stage of the disease. Most of the patients when informed of the

relationship of smoking to the progress of the disease stated that they would

abstain completely. However, in number of instances it was subsequently

brought to our attention that they had been unable to abide by their pledge.

At the vascular center of DeWitt General Hospital the inability of some

men to abstain from the use of tobacco was recognized as problem and was

so studied. Silbert called attention to the extraordinary fact that some

men will not stop smoking even when repeatedly warned that failure to do so

will result in the loss of their extremities.” Many of the patients seen at this

center had previously passed through several medical installations. When the

diagnosis of vascular disease was first suspected, most of them had been told by

the medical officer that they “should stop smoking” or “should cut down on

smoking,” but the importance of complete and permanent abstinence from

tobacco had never been stressed to them. In many instances the story was the

same: The patient resolved to stop smoking and did stop temporarily, but

resumed the habit. With each successive resolution and failure the process

of stopping became more difficult.

Rather than adopt defeatist attitude toward the problem, policy was

developed at the vascular center of DeWitt General Hospital in which each patient was permitted to decide the matter for himself. This plan was based

on Homans’ suggestion that “the individual should know that he will never

Silbert, S.: Treatment of thrombo-anglitis obliterans. Hebrew M. J. 1: 156-149, 1942.

Homans, John: Circulatory Diseases of the Extremities. New York, The Macmillan Company, 1939.
THROMBOANGIITIS OBLITERANS, ARTERIOSCLEROSIS 379

smoke again.” To accomplish this result each patient with thromboangiitis

obliterans was instructed to continue smoking until he had realized two things:

(1) that the diagnosis of thromboangiitis was irrefutable, and (2) that after

considering the matter thoroughly and completely he had come to know he

would never smoke again.

The patient must have no doubt about the validity of the diagnosis, and

he must be convinced in his own mind that abstinence is the only solution to his

problem. Time is required for the patient to arrive at this state of mind, but

it was the experience at DeWitt that as soon as it was accomplished the soldier

quickly adapted himself to the inevitable. Investigation showed also that the

first time the patient stopped smoking was the one time he was most likely to

succeed.

The patients were helped by being segregated into nonsmoking ward

where they were given special privileges. During the early period of total

abstinence it was found helpful to use group suggestion, occupational therapy,

and sedation. Much, of course, depended upon the personal relationship

between patient and medical officer.

Under the aggressive policy outlined, the proportion of patients who

succeeded in stopping smoking was greatly increased. In 39 successive cases

there were only failures. Horton has estimated that of those who do stop

smoking 50 percent relapse, and it is realized that many of the patients who

succeeded in stopping while at the vascular center may have returned to the

habit after separation from the service and were doomed.

Provided the patient had stopped smoking, typhoid vaccine gave excellent

results. Therationale of the use of typhoid vaccine is primarily the production

of maximal vasodilatation as the result of the febrile reaction. The vaccine was

administered intravenously and the dose was individualized in each patient so

as to produce febrile reaction up to 102° F. without causing chill.

The injection of tissue extracts improved the ability to walk in about half

of the patients. Various pancreatic tissue extracts, including padutin and

depropanex, were used by the intramuscular route. While intermittent

claudication was relieved in many of the patients by the use of these extracts,

other features of the disease were not affected.

Only indifferent results were secured by the use of Buerger’s postural

exercises and physiotherapy, including intermittent suction and pressure, and

intermittent venous occlusion, though they were employed in numerous cases.

Operative Treatment. Sympathectomy was performed for involvement of

extremity in 33 of the 152 patients in this series, and for extremities in 18.

In patients extremities were affected and sympathectomy was performed.

The indications as well as the results, which were generally good, are discussed

in detail in the section on sympathectomy in Chapter XVI.

See footnote 4, p. 377.
380 VASCULAR SURGERY IN WORLD WAR II

In 12 patients treatment consisted in repeated blocking of the lumbar

sympathetic ganglia with procaine. Crushing of the peripheral nerves for the

relief of intractable pain was employed in only patients.

Disposition

In only of the 274 patients in this series was major amputation of an

extremity necessity. However, only 24 recovered sufficiently to continue in

the service; returned to general duty and 21 to limited duty. The remainder

were separated from the service by retirement or by Certificate of Disability

Discharge.

COMMENT

It has been noted that thromboangiitis obliterans was observed in the

vascular centers in World War II chiefly in the early stages of the disease.

This may be explained by the fact that men suffering from clear-cut disorders

of the peripheral circulation were rejected at the original physical examination; Jahsman and coworkers 10 reported on the recognition of the disease in young

draftees. It therefore seems probable that in most instances the disease

developed during the time the patient was in the service. No evidence was

obtained, however, that military service aggravated preexisting disorder.

The fact that in 274 patients only had to have major amputations of

extremities, casts hopeful light upon the therapy of thromboangiitis. The

success can largely be attributed to the awareness by medical officers of the

problem of vascular disorders which made early recognition possible, and the

existence of specialized vascular centers staffed by experts and equipped to

provide any therapeutic measures prescribed.

ARTERIOSCLEROSIS

Arteriosclerosis of the peripheral vessels sufficient to produce symptoms of

vascular disturbances was reported in 55 patients from the vascular centers

in the Zone of Interior. The number is small but the incidence, in view of

the age distribution of the personnel in the Army, is surprising. Although

many observers believe that when arteriosclerosis is invoked as cause of

circulatory disorder the diagnosis should be looked upon with doubt if made

upon individuals under 60 years of age, there was in the present series but

patient beyond that limit. The majority of patients fell into the age group

40 to 55 years. The youngest patient in the series was 30 and the average age

was 45 years.

In more than half of the patients both lower extremities were affected.

One lower extremity was involved in patients and the upper extremities in 8.

Intermittent claudication was present in 27 patients when they were first

seen. Twenty complained of pain and 11 of abnormal coldness of the extremi10 Jahsman, W. E.; Durham, R. H., and Dallis, N. P.: Recognition of incipient thromboangiitis obliterans in young

draftees. Ann. Int. Med. 18: 164-176, Feb 1943.
THROMBOANGIITIS OBLITERANS, ARTERIOSCLEROSIS 381

ties. number presented evidence of systemic vascular disorders. Ten had

cardiac disease, hypertension, diabetes, and nephritis.

Diagnostic Procedures

Skin temperature determinations and oscillometric readings were useful in

establishing the diagnosis of arterial insufficiency. Measurements of skin

temperature after reflex vasodilatation or blockage of the vasoconstrictor

impulses were made in patients.

Special attention was paid to evidences of calcification as revealed by

roentgenograms of the extremities. Calcification was observed in all the cases

reported from the vascular center of Ashford General Hospital and in two-thirds

of the patients reported from the other centers.

In this connection it was observed at Ashford that the incidence of calcification of the peripheral blood vessels in males between the ages of 30 and 40

years of age was remarkable. Capt. J. W. Kahn of this center reported on 10

patients in this age group who were sent to this hospital between March 1944

and September 1945 for vascular study because roentgenograms revealed

calcification of peripheral blood vessels. Roentgenograms had been made for

reasons other than vascular disease or vascular complaints and calcification

was discovered accidentally. None of the patients in this group had any

subjective signs of vascular incapacity nor, upon intensive vascular study,

could they be found to have any objective signs of either organic or vasomotor

disease. Oscillometric readings, skin temperature readings, and vasomotor

tests were well within normal limits. None of the roentgenograms in this group

revealed the spotty, mottled type of calcification; all showed smooth uniform

shadows gradually fading into normal vessels proximally.

According to Captain Kahn, these findings are in keeping with the research

of Huyler who studied calcification in large series of patients for number of

insurance companies. The result of this research had revealed that those with

the smooth type of calcification were relatively symptom-free as compared with

those with the mottled type.

While none of the roentgenograms of the 10 patients revealed the spotty,

mottled type, number of the patients with firm, palpable, noncompressible,

cord-like peripheral arteries failed to reveal any evidence of calcification.

These patients, however, had other stigmata of generalized arteriosclerosis;

the age group was higher and their symptoms were referable to cardiovascularrenal degenerative disease. The possibility of generalized atheromatous disease, without visible calcification, suggested to Captain Kahn form of medial

sclerosis of the Monckeberg type.

It is well known that calcification in arteries can be shown by roentgenogram in only 35 to 40 percent of the patients with sclerotic disease. There is

no question that relatively young patients presenting such findings will exhibit

evidence of this disease at an earlier age than those in whom no evidence of

calcification is found.
382 VASCULAR SURGERY IN WORLD WAR II

Therapy and Disposition

Lumbar sympathectomy was performed in of the 55 patients, with satisfactory results in all. Other forms of treatment such as intramuscular injections of depropanex, intermittent venous occlusion, and physiotherapy were

employed in small number of patients. No major amputations were necessary, and only minor amputation was performed.

Five patients were returned to limited duty. The remainder were separated from the service.

ARTERIAL THROMBOSIS AND EMBOLISM

There were 18 cases of spontaneous arterial thrombosis of unknown

etiology reported from the vascular centers. Case histories are not available

to permit analysis.

There were instances of embolism of the peripheral arteries reported

from the vascular centers. Case histories are available for only patients.

In of the 3, femoral embolism was followed by gangrene of the leg and amputation was necessary. The third patient had been successfully treated in an

overseas hospital by embolectomy of the popliteal artery. When he was examined at one of the vascular centers, the pulses were found to be normal.
CHAPTER XIV

Peripheral Vascular Disturbances—Vasospastic

Disorders—Raynaud’s Syndrome and

Raynaud-Like Disorders

Harris B. Shumacker, Jr., /A. D.

and

David I. Abramson, /A. D.

GENERAL CONSIDERATIONS

The vasospastic disorders are group of peripheral disturbances in which

the arterial circulation is impaired either intermittently and spasmodically or

more or less continuously as result of the tonic contractions of blood vessels.

This group of diseases is differentiated from the obliterative arterial diseases

by the general absence in the walls of the arteries of pathologic changes which

would lead to narrowing or occlusion of the lumen. If, however, the vasospastic state is long continued, alterations of this kind may follow in certain

of these conditions as, for example, Raynaud’s syndrome, in which intimal

thickening and thrombosis of the arteries may be observed late in the course

of the disease. Furthermore, it is well known that vasospastic phenomena

are frequently part of the clinical picture of obliterative vascular diseases.

Normally all components of the peripheral vascular system, including the

main arteries and their branches, the arterioles, the capillaries, the arteriovenous anastomoses, and the veins, are under the control of the vasomotor

center in the medulla which maintains its effect through innervation of these

vessels by the sympathetic nerves. The vasomotor center and other portions

of the sympathetic nervous system are influenced, in turn, by hormonal action,

by various physiologic body functions, by the emotions, and by such external

stimuli as warmth, cold, and noxious agents. All these factors play part in

regulating the caliber of the vessels. Normally the impulses traveling over

sympathetic nerves are constrictor in action and maintain the blood vessels in

state of tonic contraction or tonus. Tonus is particularly evident in the

arterioles and therefore plays most important role in the regulation of blood

flow and in the maintenance of peripheral resistance. The arteriovenous

shunts, which are located chiefly in the digits and which are also richly innervated by sympathetic vasoconstrictor nerves, are important in the regulation

of the temperature of the extremities, in the conservation and dissipation of

body heat, and in the local vascular response to cold environment. Tonus

of blood vessels and variability in blood flow are much more evident in the
384 VASCULAR SURGERY IN WORLD WAR II

distal than in the proximal portions of the extremities or in the trunk. This

phenomenon explains the predilection of the vasospastic disorders for the hands

and feet.

The degree of tonus varies widely from individual to individual. Normally

some persons tend to have low vascular tonus. Their hands and feet are warm

and dry and maintain relatively stabile temperature under different environmental and emotional conditions. Others have high vasomotor tonus.

Their hands and feet are cold and moist and cool rapidly upon exposure to

cold; they may cool and sweat profusely under emotion.

It is sometimes difficult to differentiate between the normal subject with

high vascular tonus and the subject with mild but true vasospastic disorder.

For all practical purposes, the same findings and the same reactions to cold

environment and to emotion may be present in both. Persons with high

vascular tonus obviously have more complaints in cold than in warm climates.

Furthermore, in one person state of high vascular tonus and responsive

vasomotor system may cause no distress or inconvenience while the same

symptoms in another person may constitute an annoying and perhaps disabling affliction. Numerous factors are responsible for these variations including climate, occupation, and personality makeup. Hyperhidrosis may be of

no consequence in certain occupations but may be incapacitating to chemist,

an engineer, or others who must work with delicate weight balances. It was

frequently observed in the course of World War II that tendency to high

vascular tonus which had caused no apparent inconvenience in civilian life

sometimes led to annoying symptoms under the stress of military regimen

RAYNAUD'S DISEASE WITH DIGITAL SYNCOPE

In 1862 Raynaud described the syndrome which now bears his name

and which may be defined as symmetrical vasospastic disorder characterized

by phasic color changes in the digits which may lead to ulceration or gangrene

in the absence of obliterative changes in the larger arteries. Since this syndrome was first described, wide divergence of opinion has arisen over what

really constitutes Raynaud’s disease. Some have tended to group loosely

together wide variety of circulatory disorders in which the common factor is

an abnormal responsiveness to cold. Others have attempted to limit the term

Raynaud’s disease to progressive disorder which is not preceded bj local

injury or disease, which appears in early adult life or early middle age, which

occurs chiefly in women, and which is characterized by symmetrical digital

syncope or cyanosis upon exposure to cold or upon emotional excitation. Still

others are of the opinion that triphasic color reaction is an essential component of Raynaud’s disease, the reaction consisting of blanching during the

attack followed first by cyanosis, and then by rubor prior to restitution of

normal color during the recovery period.

Raynaud, M.: De 1’asphyxie locale et de la gangrene symfitrique des extrfimltfe. Paris, Rignoux, 1862.
RAYNAUD’S SYNDROME AND RAYNAUD-LIKE DISORDERS 385

Although it has been recognized since Raynaud’s original publication that

the primary color change in the digits during the attack may be either pallor or

cyanosis, and although the clinical course is identical regardless of the type of

the colorreaction, the data analyzed in this section of this chapter were obtained

only from those patients in whom digital syncope occurred. This limitation is

necessary because in of the vascular centers in theZone ofInterior diagnosis

of Raynaud’s disease was made only in those patients in whom digital syncope

was present during attacks. It was therefore impossible to determine from the

data submitted by this center (Ashford General Hospital) which patients had

true Raynaud’s disease and which had acrocyanosis or some other vasospastic

syndrome. study of the data on Raynaud’s disease as reported from the

other vascular centers (Mayo General Hospital and DeWitt General Hospital)

reveals that most patients affected with this difficulty had pallor during the

attacks. For this reason exclusion of those patients in wdiom cyanotic

reaction was characteristic, actually omits from the analysis only small proportion of the patients observed.

In view of the confusion wdiich has arisen concerning the initial color changes

in Raynaud’s disease, and since the typical response to cold may occur in variety of conditions, it has been suggested that the term Raynaud’s disease might

logically be replaced by the term Raynaud’s phenomenon or Raynaud’s syndrome. The rationale of the suggestion has been .generally granted but the

change in nomenclature has not been generally adopted. If and when it is,

the term Raynaud’s disease could be reserved for those patients with the syndrome in whom no definite etiology can be discovered and in whom intermittent

episodes of digital syncope or cyanosis have been present for relatively long

period of time (not less than years) without the appearance of signs of occlusive

arterial disease.

Classification

Patients with so-called Raynaud’s disease have been grouped in several

different categories;

1. Patients with hereditary cold fingers. This is mild condition which

occurs in young persons and is characterized by blanching, cyanosis, or

numbness of few fingers on exposure to cold. Some authorities consider it

mild form of Raynaud’s disease. The difficulty is seldom progressive and may

become less severe or may disappear altogether with the passage of time.

2. Patients with pneumatic hammer disease. This disease, which is

manifested by attacks indistinguishable from those of Raynaud’s disease,

results from prolonged use of vibrating tools.

3. Patients with previous experience offrostbite. It has been questioned

whether this disorder or the type of vasospastic disorder known as pneumatic

hammer disease should be segregated from Raynaud’s disease of unknown

etiology since they are otherwise similar.
386 VASCULAR SURGERY IN WORLD WAR II

4. Patients with scleroderma and sclerodactylia associated with Raynaud’s

phenomenon. Opinions differ as to whether these diseases deserve separate

classification since they may be considered as cutaneous alterations which are

part of advanced Raynaud’s disease itself.

Patients with acrocyanosis must be distinguished from those with true

Raynaud’s syndrome. In the former condition the hands or feet generally

tend to be cool, blue, and wet except in an environment which causes extreme

vasodilatation. Patients with this condition also have periods of marked

responsiveness to cold and often to emotional stimuli. At such times there is

an increase in cyanosis and coldness, though the color changes are not limited

to these episodes.

Associated Disease

As has already been mentioned Raynaud’s phenomenon occurs not infrequently in association with obliterative arterial disease and other conditions

in which there is organic obstruction of the arterial blood flow such as thromboangiitis obliterans, arteriosclerosis, and arteritis of either specific or unknown

etiology. It may also occur in association with cervical rib, in the scalenus

anticus syndrome, and in patients in whom the vessels have been compressed

by crutches or by tumors. Before diagnosis of Raynaud’s syndrome is made,

therefore, it is necessary to make certain that these and other organic obliterative or occlusive disorders and conditions are not present.

Clinical Material

One hundred eighty-four patients with Raynaud’s disease with digital

syncope were observed at the vascular centers in the Zone of Interior during

the course of World War II. Ninety-seven patients were admitted to the

Ashford General Hospital, 57 to the Mayo General Hospital, and 30 to the

DeWitt General Hospital. Data were available for analysis on all such patients

treated at the vascular centers of Mayr> and DeWitt General Hospitals and

on 40 of those handled at Ashford General Hospital, giving grand total of

127 patients.

In all of these, digital syncope was observed by the attending medical

officer, had been seen previously and described accurately in other medical

installations, or had occurred so regularly and in so clear-cut fashion that its

presence could readily be established by interrogation of the patient.

In addition to the patients with clear-cut Raynaud’s disease with digital syncope and those with related vasospastic

disorders but without digital syncope who are discussed in this chapter as distinct groups, large number of patients

were observed at the vascular centers who presented ill-deflned vasospastic conditions. These patients formed heterogeneous groupand detailedanalysis of thecases would bewithout profit. In most instances evidences of increased vascular

tone and sympathetic overactivity were present under ordinary circumstances. In some instances only limb was

involved, but in few all were affected.

It is likely that in some of these patients the difficulty represented little more than normally high vasomotor tonus to which attention was directed either by the stress of Army life or by the motivation of possible release from the service

because of these complaints. Both of these theories are strengthened by the numerous and varied symptoms presented

by the patients which could not beadequately explained upon organic or physiologic grounds. Ed.
RAYNAUD’S SYNDROME AND RAYNAUD-LIKE DISORDERS 387

Of the 127 patients were Negroes and 122, Caucasians. One hundred

eleven (87.4 percent) were males; 16 were females. Among Army personnel the

annual admission rate for Raynaud’s syndrome during World War II was five

times as great among females as among males; the annual admission rate for

females was .10 per 1,000 mean strength and .02 per 1,000 males.

The age range in this series was from 21 to 51 years; the average age

31.4 years. In two-thirds of the patients the disorder was of years duration

or less; in the remainder it varied from to 24 years.

In few patients the first attack appeared during cool weather but in the

great majority it occurred during cold weather. In 46 of the 97 patients concerning whom such data were available, the onset occurred in the United States.

In 21 it began in England, and in 15 others in France, Germany, Belgium, or

Holland. In the remaining 15 it was first observed in Alaska, Australia, Iceland,

Iran, Italy, and North Africa. In only of 57 patients from the Mayo General

Hospital questioned on this point did the symptoms arise either during or

immediately before conditions of combat.

Attacks were initiated in all instances by exposure to cold. The critical

temperature, however, varied widely. Some patients experienced blanching of

the fingers in slightly cool weather, but in most instances the phenomenon was

observed only during severe cold. Only 14 of the 97 patients for whom such

data were available gave history of the precipitation of attacks by emotional

excitement or stress and in 10 of the 14 some neuropsychiatric disorder or

emotional instability was found. In other patients who were found to have

psychiatric disabilities emotion played no role in producing the color changes

in the fingers.

Etiology

Frostbite antedated the first appearance of the Raynaud phenomenon in

16 patients in most of whom the exact time relationship was not known. In

of patients questioned on this point at Mayo General Hospital, frostbite

preceded by number of years the onset of Raynaud’s phenomenon, while in

the other patients, attacks of digital syncope appeared immediately after

frostbite had been sustained and became progressively more severe with the

passage of time. Two of the 57 patients with Raynaud’s syndrome at the

Mayo General Hospital had used vibrating tools for some years prior to the

onset of Raynaud’s disorder.

Clinical Manifestations

Twenty of the 57 patients studied at the Mayo General Hospital showed

all the features which have been regarded as classical in Raynaud’s phenomenon.

(Figs. 51A, B, C, and D.) The involved digits, immediately upon exposure

to cold, would turn dead white and the patient would experience in them the

sensation of intense coldness, numbness, and stiffness. clear-cut line of

demarcation was generally present between the portion of the digit showing
388 VASCULAR SURGERY IN WORLD WAR II

the pallor and that retaining normal color. After variable interval following

return to warm environment, the digits would become cyanotic; cyanosis

was followed by period of rubor which was succeeded, in turn, by return to

normal color. During the late stages of the attack most patients complained

of tingling, throbbing, and burning sensations or other paresthesias.

The triphasic color reaction was not present in the other 37 patients

observed at Mayo General Hospital. In 16 patients cyanosis followed the

pallor and was succeeded by return to normal color, the phase of rubor being

omitted. Eleven patients experienced rubor immediately after syncope, the

phase of noticeable cyanosis being omitted. In the remaining 10 patients digital

syncope was followed directly by return of normal color. In all instances, however, the initial response was either pallor or cyanosis, with pallor much

more frequent. It was the general experience that digital syncope could be

more regularly elicited by exposure to cold environment or by taking cold

shower than by immersion of the limb in ice water.

The syncope affected varying numbers of digits and varying portions of

digits. In some patients only the tips of the fingers or toes were affected. In others the changes occurred in the distal phalanx, the distal and middle phalanges, or the entire digit. In some patients only single digit became blanched

while in others all were affected. In number of patients blanching occurred

initially in only limb with involvement of the contralateral extremity occurring

later. In number of patients with symmetrical involvement the phenomenon

was observed first in or digits in single extremity and later itwas noted to

spread progressively to other portions of the hand or foot and eventually to

the contralateral limb.

Of 47 patients about whom these data were recorded at the Mayo General

Hospital, 27 had involvement of the second, third, fourth, and fifth digits of

both hands or both feet, while some of this group also had involvement of the

thumb and great toe. Unfortunately, recorded data were not always specific

on the latter point. In patients, or digits were symmetrically involved

and in another the symmetrical response was observed in single digit. Fourteen patients had asymmetrical distribution of the syncope; of this number,

exhibited syncope of or several digits in only limb.

The upper extremity was more commonly affected than the lower. In the

aggregate of 127 patients analyzed, both hands were affected in 69 (54.3 percent), one hand or the other in (5.5 percent), both hands and feet in 45 patients

(35.4 percent), one hand and one or both feet in patients (2.4 percent), both

feet in patients (1.6 percent), and foot in patient (0.8 percent).

Blanching and symptoms did not necessarily coincide. number of

patients had experienced numbness, coldness, stiffness, and paresthesias in

the involved limbs and digits years before the onset of the attacks of digital

syncope. In others, although the symptoms were usually worse on the side

exhibiting pallor, exposure to cold frequently elicited similar complaints in
Figure 51. Typical digital syncope in patient with Raynaud's disease on exposure to cold.

A. Dorsal surface of fingers. B. Palmar aspect. Marked loss of the subcutaneous pulp

of the fingertips occurred in this patient within few weeks after the onset of symptoms.

C. Dorsal aspect of hands after bilateral sympathectomy. D. Appearance of fingers

(palmar view) after bilateral sympathectomy. The subcutaneous pulp of the fingertips

regained its normal appearance shortly after operation.

RAYNAUD’S SYNDROME AND RAYNAUD-LIKE DISORDERS 389

the contralateral limb in which color changes were not present. It was quite

possible for these symptoms to be incapacitating in the absence of color changes.

Two patients in whom sympathectomy was performed because of the frequent

occurrence of blanching associated with symptoms in an upper extremity,

expressed the desire after they were separated from the service to have the

same procedure carried out on the other extremity in which syncope had

never occurred but in which marked symptoms were being experienced.

In the interval between attacks many patients were completely asymptomatic and circulation was normal. About half of the patients seen at the

Mayo General Hospital, however, had at all times some evidence of excessive

sympathetic activity, manifested either as cool, moist, and slightly cyanotic

hands and feet or in the form of coolness and excessive sweating. Still others,

although their limbs were normal in warmth and color, experienced moderate

hyperhidrosis. As rule, symptoms experienced between acute attacks were

mild.

Trophic changes occurred in 20 of the 127 patients (15.7 percent). In most

instances they were slight and consisted of little more than slight distortion of

the nails or slight thickening of the skin. In few patients in this group,

however, the skin covering the fingertips seemed actually to be separated

from the deeper tissues. Pressure applied in this area produced temporary

dimpling; after release of pressure the skin ballooned out again. In instances

scleroderma or sclerodactylia was present. One patient (Fig. 52A) had small

areas of bilateral gangrene of the fingertips.

Figure 52. A. Patient with longstanding Raynaud’s disease showing bilateral superficial

gangrene offingertips. B. Complete healing of ulcerative areas shortly after bilateral dorsal

sympathectomy.

In an occasional patient trophic changes occurred very early in the disease, in instance there was well marked loss of subcutaneous pulp within

few weeks of the onset of symptoms. Livedo reticularis, which is actually

not trophic change, was observed in of the 57 patients treated at the Mayo

General Hospital (Figs. 53A and B).
390 VASCULAR SURGERY IN WORLD WAR II

Circulatory Tests

Examination of the peripheral circulation in warm environment consistently revealed no abnormalities in any of the patients in this group. Except for the occasional absence of the dorsalis pedis pulse on one or both sides,

all the pulses in the extremities were readily palpable. No signs of arteriosclerosis were noted. Various simple procedures for the determination of the

state of the circulation such as the plantar pallor test, the venous filling time,

oscillometric recordings of arterial pulsations, and the production of local

vasodilatation by means of body heat or paravertebral sympathetic block with

procaine, all indicated that no organic vascular disease existed in these cases.

Therapy

The majority of the patients in this series were separated from the service without active treatment. Prior to their separation their vascular status

was discussed with them and they were advised to stop smoking, to attempt

to control their emotions, if the emotional factor was believed to be important

in precipitating the color changes, and to live in warm environment if possible. If it was not, they were told to attempt to avoid exposure to cold and

were given advice on how to dress during the winter. If the number or severity

of the attacks was distressing or incapacitating, or if nutritional disturbances

existed, sympathetic ganglionectomy was performed.

One hundred sympathectomies were performed upon 46 of the 127 patients. Spread of the denervation was as follows: In patients all extremities, in patients extremities, in 31 patients extremities, and in patients

extremity.

At Mayo General Hospital 21 sympathectomies were performed upon

patients. Since both of us were able to follow the patients closely during

their period of hospitalization the results of the experience at Mayo are presented herewith:

With one possible exception the immediate therapeutic effects were

excellent in all patients (Figs. 51-53). In the single exception all extremities

were denervated in stages. Although after each operation the patient felt

sufficiently relieved to desire the next stage, at the completion of the procedure

he was in doubt about the total benefit he had received. He no longer had

attacks of digital syncope and had relatively stabile circulation in the extremities, but experienced tingling sensations in cold weather. He also suffered

from annoying, and at times incapacitating, hyperhidrosis of the trunk in

warm weather. Another patient who had had all extremities denervated

also suffered from excessive sweating of the trunk in hot weather or with exercise, but to him the relief of vasospasm far outweighed this annoyance.

All of the remaining patients had warm, dry, well-colored extremities which

tended to cool slowly upon exposure to cold. They ceased to have attacks of

syncope. Those who had lost pulp in the tips of the fingers had striking
Figure 53. A. Marked livido reticularis of lower extremities in patient with Raynaud’s syndrome. B. Appearance of feet following bilateral lumbar sympathectomy. Note improvement in livido reticularis.

RAYNAUD’S SYNDROME AND RAYNAUD-LIKE DISORDERS 391

restoration to normal following operation (Fig. 5lB). The areas of gangrene

present in single patient healed promptly and the marked livedo reticularis

noted in another patient (Fig. 53A) cleared to considerable extent after

operation (Fig. 53B).

OTHER VASOSPASTIC DISORDERS

In addition to the patients with Raynaud’s disease observed at the vascular

centers in the Zone ofInterior, 135 other patients treated at these centers suffered

from vasospastic disorder characterized by abnormal responsiveness to

cold but not by clear-cut digital syncope. The findings varied in respect to the

type of reaction to cold, the severity of the symptoms, and the vasomotor tonus

under ordinary environmental conditions. Some patients fell into the category

of true acrocyanosis. few presented syndrome similar to Raynaud’s disease

except for the absence of digital syncope. Others had history of attacks in

which they thought blanching had occurred but the color change, judging from

the patients’ descriptions, was either not definite-or took place infrequently.

Clinical Material

One hundred seven of the 135 patients in this group were observed at the

Ashford General Hospital, 22 at the Mayo General Hospital and at the DeWitt

General Hospital. Data for analysis were available in 55 cases. Fifty-two of

the 55 patients were males and females. Two were Negroes. The age range

was from 19 to 45 years, the average about 30 years. In almost three-fourths

of the patients the disorder was of years duration or less. In the remaining

patients it had been present for periods ranging from to 38 years. In 10 of the

22 patients observed at the Mayo General Hospital the vasospastic difficulty

began in the Zone of Interior. In patients it began in England, and in in

France or North Africa. In the other patients the place of onset was not

recorded.

Etiology

In of the 55 patients there was history of antecedent frostbite but in

only of these was information available concerning the exact interval between

the thermal injury and the first note of an abnormal response to cold. This

patient reported that progressively severer sensitivity to cold had developed

shortly after mild frostbite which had been sustained years earlier. Scleroderma had been present in both hands for about months before he had entered

the hospital. Two patients had used vibrating tools before the development of

the disorder. Infected ulcers of the fingertips were present in of these patients.

Therapy

For most of the patients in this group no active treatment was instituted.

According to the severity of their disorder they were returned to duty or sepa330323 0-55-26
392 VASCULAR SURGERY IN WORLD WAR II

rated from service, with the advice to abstain from smoking and to avoid if

possible exposure to cold. If the condition was advanced, move to warm

climate was suggested.

Twelve sympathectomies were performed upon patients. Spread of

denervation was as follows: In patient all extremities, in patient both

upper extremities, in patients both lower extremities, and in patients upper

extremity.

Immediate results were good in all. The extremities became warm, dry,

and well colored and were no longer abnormally sensitive to cold. There was

dramatic improvement in the condition of the patient who had lost subcutaneous pulp from the fingertips, and in the patient with scleroderma there was

lessening in the degree of involvement as well as relief of symptoms.

COMMENT

The term Raynaud’s syndrome should be reserved for cases in which transient digital syncope or cyanosis occurs upon exposure to cold or upon emotional

excitation. By commonly accepted definition those patients with cold sensitivity but without significant color changes upon exposure to cold should be

considered to present not Raynaud’s syndrome but rather Raynaud-like disorders. Those with persistent cyanosis and coldness who do not manifest

transient alteration in color of the digits should be placed in the category

ordinarily diagnosed as acrocyanosis.

One of the criteria generally accepted as necessary for the diagnosis of

Raynaud’s disease is bilateral and symmetrical involvement of the extremities.

In approximately percent of the patients with clear-cut digital syncope in this

series, however, only one extremity was involved. The explanation may be

that many of these patients, because they were in the service, were seen earlier

than they would have been seen in civilian life, and it is possible that the

earlier the patient is observed, the more frequently will the disease be noted in

one limb alone.

In approximately two-thirds of the patients at Mayo General Hospital

the classical triphasic colorreaction was not present. This brings up the question

of whether the triphasic color response is necessary for the diagnosis. It was

the consensus at the vascular centers that the diagnosis ofRaynaud’s disease can

reasonably be entertained in the presence of vascular attacks of digital syncope

or cyanosis elicited by exposure to cold or emotion, whether or not the triphasic

color reaction is observed, provided no etiologic factor can be established for the

condition and if signs of obliterative vascular disease are absent. Furthermore,

it does not appear to be necessary for either cyanosis or pallor to be replaced

by rubor as preliminary step to the return of normal color when the extremity

is exposed to warm environment. Although segregation of patients according

to the presence or absence of digital syncope is purely artificial classification,

it has been employed in this analysis, as has been explained, because the
RAYNAUD’S SYNDROME AND RAYNAUD-LIKE DISORDERS 393

diagnosis of Raynaud’s disease was made upon this basis at one of the centers.

To be sure, the dead white character of the change is so striking that it affords

one means of definitely differentiating patients with true Raynaud’s phenomenon from others with cold sensitivity alone. Furthermore, it was noted, in

comparing the patients showing digital syncope with those falling into the

same category but without this response, that the vasospastic difficulty was

generally more severe in the former group. Nutritional disturbances were also

more frequently present in this group, although in at least cases typical trophic changes were also noted in the group of related cases without digital

syncope.

Another interesting point of differentiation is the observation that in

patients with digital pallor the hands were frequently affected alone, or, if all

four extremities were involved, more severely than the feet. In the other

group without digital pallor, approximately third of the patients showed

changes in the feet alone. In this group the entire hand or foot was likely to

be affected, while in patients with digital syncope the change in color was

usually limited to the digits.

The present series confirms what is generally known concerning the treatment of Raynaud’s phenomenon and similar syndromes. If the difficulty is

severe, if nutritional disturbances are present, if the process cannot be controlled

by suitable climatic conditions, sympathectomy offers the best means of relief.

This analysis furnishes support for the general experience concerning the

excellence of this procedure. If the severity of the symptoms does not make

it imperative, sympathectomy of all four extremities is to be avoided because

of the discomfort which may result in warm weather from hyperhidrosis of

the trunk.

Examination of the available data from the Army vascular centers reveals

that 87.4 percent of the 127 patients having Raynaud’s disease with digital

syncope, and 94.5 percent of the 55 patients with vasospastic disorders but

without digital syncope, were men. Since all of the patients in the first group,

and some in the second, were instances of true Raynaud’s disease, this series

presents further confirmation for the view that though this disorder occurs

primarily in females, it affects males as well. The great predominance of

males in this series, as compared to the 23 percent reported b} Hines and

Christensen in group of civilians, is readily explained by the overwhelmingly

predominance of males in the Army. The analysis also confirms the view that

Raynaud’s disease and comparable conditions as they occurred in the Army

were quite similar to the same disorders as they are observed in civilian life.

It has been the general impression that transient episodes of color changes

in the digits of the male are usually secondary manifestations of occlusive

arterial disease. This opinion is not supported by the observations in the

vascular centers. Although some cases of obliterative arterial disease associHines, E. A., Jr., and Christensen, N. A.: Raynaud’s disease among men. J. A. M. A, 129: 1-4, Sep 45.
394 VASCULAR SURGERY IN WORLD WAR II

ated with Raynaud’s syndrome were seen, in none of the patients in this series

was there evidence that this type of arterial disease existed or that it might

subsequently appear. On the other hand, observations of these patients were

limited to period of months, and whether or not some will subsequently have

demonstrative evidence of organic vascular disease and will no longer fall into

the category of Raynaud’s disease can be determined only by followup studies.

It is important to emphasize, however, that nothing to suggest obliterative

arterial disease was evident during the period of hospitalization.

The theory that the stress and strain of Army life may be factor in the

precipitation of peripheral vascular disorders is not supported by the findings

in this series. In considerable number of patients the attacks began in

civilian life and in only small percentage did the disorder arise under conditions of combat or just prior to such activity. Emotional stress and excitement

initiated the color changes in 14 of 97 patients concerning whom these data were

available, while emotional instability or other neuropsychiatric disorders were

present in 18 cases. These proportions are somewhat similar to those of Hines

and Christensen who reported that in of their 100 male civilian patients,

attacks occurred with emotional excitation and that functional or neurotic

disorders were present in 29 patients. Nevertheless, military life may have

been factor in some instances. Soldiers are exposed to cold weather to far

greater extent than they are in civilian life and such exposure might aggravate

vascular disorder already existent or bring into activity latent disturbance.

In number of patients with digital syncope studied at Mayo General

Hospital the onset of attacks was antidated by frostbite. In of the 22 cases

of Raynaud-like syndrome without digital syncope observed at the same hospital, extremely severe vasospastic disease followed service-incurred frostbite.

The use of vibrating tools may possibly have been an etiologic factor in of

the 57 patients with digital syncope and in of the 55 in the group who did not

show this response, though in each of these instances the instruments were used

in civil life many years before the onset of the attack.

In spite of the fact that Raynaud’s disease and similar disorders seldom

resulted directly from military service, ill-defined heterogeneous difficulties with

associated vasospasm often followed, or were aggravated by, the stress of

Army life or by the motivation to be separated from the service. Though

many men with Raynaud’s disease and similar disorders served well in the

Armed Forces, it is believed that, in general, the Army policy of considering

such persons as ineligible for induction or enlistment was well founded.

See footnote 3, p. 393.
CHAPTER XV

Peripheral Vascular Disturbances

Post-Traumatic Vasomotor Disorders

Harris B. Shumacker, Jr., M. D.

and

David I. Abramson, M. D.

Although injury to an extremity is generally followed by signs and symptoms readily explained upon the basis of the trauma sustained and the resultant

dysfunction, there are in certain instances other changes superimposed which

can be accounted for only on the assumption that some reflex disorder has been

initiated by the local tissue damage.

Since 1900, when Sudeck first described syndrome in which acute

atrophy of bone followed an inflammatory process, this reflex post-traumatic

state has been the subject of numerous studies and has attracted widespread

interest. The many terms which have been employed to describe this clinical

condition bear witness not only to the widespread disturbances that may occur

but also to the lack of agreement on what constitutes the characteristic primary

alteration. The most constant finding is some type of vasomotor dysfunction.

In the affected limb there is usually increased vasomotor tonus or hyperemia,

also increased blood flow. Because of such manifestations, the comprehensive

term post-traumatic vasomotor disorders would seem the most appropriate

designation for the whole group of heterogeneous reflex affections which may

follow trauma.

This category of post-traumatic vasomotor disorders does not include such

related conditions as major causalgia and phantom limb pain which are syndromes with such characteristic features that they are best considered as

separate entities. Marked sympathetic overactivity may be present in certain

instances of occlusion or division of peripheral arteries as the result of trauma.

In those conditions, however, in which the occlusion of the vessel has significant effect upon the nutrition of the extremity, part of the subsequent difficulty arises from the direct decrease in the local blood flow, and this type of

vasospastic alteration is likewise best separated from the post-traumatic

vasomotor disorders. There is also good reason to exclude from this group

the vasospastic states which follow cold thermal injuries, that is, frostbite,

trenchfoot, and immersion foot, as well as the vasospastic states associated

with deep thrombophlebitis. Finally, those vasospastic disorders which

Sudeck, P.: Ueber die acute entzimdliche Knochenatrophie. Arch. f. klin. Chlr. 62; 147-156, 1900.

Amongthe names which have been given to the syndrome are the following; Sudeck’s atrophy, acute bone atrophy,

post-traumatic osteoporosis, post-traumatic painful osteoporosis, traumatic arthritis, peripheral trophoneurosis, reflex

nervous dystrophy, reflex sympathetic dystrophy, post-traumatic dystrophy, minor causalgia, traumatic angiospasm,

chronic traumatic edema, and post-traumaticedema.
396 VASCULAR SURGERY IN WORLD WAR II

are apparently the sole result of disuse do not belong in the category of posttraumatic vasospastic disorders. All of the conditions just listed have number of features in common, but each possesses certain special characteristics

which make it advisable to deal with it as distinct syndrome.

It is generally accepted that the primary mechanism responsible for posttraumatic vasospastic disorders is some type of reflex disturbance initiated by

the local injury. It is also accepted that the components of the sympathetic

nervous system are in some manner involved in the reflex arc. Beyond this,

no agreement has been achieved. Numerous theories have been advanced,

but no definite proof exists to establish the correctness of any. Similarly, no

agreement has been reached concerning the real cause of the osteoporosis

which so commonly occurs in association with post-traumatic vasomotor

dysfunction.

Concerning the true incidence of these late complications of injuries no

data are available, but the series of cases analyzed in this chapter may be assumed to be representative with respect to both clinical manifestations and

response to therapy.

Because the patients were seen after they had been treated in other Army

installations, information concerning initial manifestations and early therapy is

subject to the criticism that it was collected by other observers. Every effort,

however, was made to reconstruct the sequence of events and the results of

early treatment through careful perusal of prior clinical records, plus detailed

questioning of each patient withregard to early phases of his condition. Data

concerning late manifestations and results of late treatment are based upon

close personal observations during the period of hospitalization.

It is important to bear in mind in any analysis of post-traumatic vasomotor disorder that the patient with limb painful or swollen, or in which there

is annoying coldness or hyperhidrosis, has strong tendency to keep it at rest,

and that disuse may of itself cause certain alterations which are characteristically considered part of the post-traumatic syndrome, namely, reduction of

blood flow, coldness, cyanosis, hyperhidrosis, edema, and osteoporosis. For

this reason it is often difficult to evaluate the relative roles of trauma and of

the reflexes initiated by trauma, on the one hand, and of the resultant disuse

of the part on the other. Furthermore, it is important to recognize that

emotional stress or instability and other more pronounced neuropsychiatric

conditions may also be associated with evidences of increased sympathetic

activity. Persons who have undergone trauma may bring these psychiatric

mechanisms into play as the result of discouragement concerning recovery,

because of motivation for compensation, or because of the hope of other rewards

of incapacitating illness including avoidance of duty in the Army. In any

evaluation of vasomotor difficulties following service-incurred trauma it is

necessary, therefore, to keep in mind the possible role of both disuse and

psychiatric factors.
POST-TRAUMATIC VASOMOTOR DISORDERS 397

CLINICAL MATERIAL

One hundred and forty-two patients, all males, with post-traumatic vasomotor disorders were received in the vascular center of Mayo General Hospital

during World War II after they had been treated at other Army installations.

In instance limbs were affected in the same patient. The age range in this

series was from 20 to 38 years, the average age, 27 years.

The disorder became manifest after soft tissue wounds in 58 patients, after sprains in 19, and after crushing or other external injuries in 11. In 14 patients

it followed compound fractures of small bones, and in 7, simple fractures of such

bones. In 24 patients itresulted from compound fractures of long bones, and

in 5, from simple fractures of these. In it was the consequence of infection,

while in patient the surgical removal of small cyst was apparently the initiating cause. In addition to the precipitating injuries just listed, 19 patients

had associated nerve paralysis and had sustained lacerations of minor arteries.

One had incurred mild frostbite at the time of injury.

foot was affected in 110 patients and hand in 31. In addition, soldier

had vasomotor disturbances in an upper and lower extremity following injuries

to these. In patients without previous tendency to coldness of the hands or

feet, evidence of increased vasomotor tone was frequently present not only in

the injured limb but also to lesser extent in the contralateral limb; sometimes

these manifestations were present in all limbs. In such instances the symptoms in the uninjured extremities were generally slight, although soldier developed such severe cold sensitivity in both hands following injury to the left

forearm that he required bilateral dorsal sympathectomy.

In all but patient the vasomotor disorder began during Army service.

Twenty-five patients, however, had had tendency to coldness of the hands or

feet prior to the vasomotor difficulty, and an equal number had noted hyperhidrosis in varying degrees in the past. history of previous injury to the

affected limb was obtained in individuals, and of frostbite or trenchfoot in 4.

Eighty patients used tobacco. There was no really relevant family history in

any of these although such vascular difficulties as varicose veins, vascular

thrombosis, or hemorrhage had occurred in the families of 12.

CLINICAL SYNDROME

Initial Symptoms and Signs. The most usual story elicited on questioning

of the patients was that severe pain associated with swelling, coldness, and

cyanosis, often with excessive sweating, developed in the affected hand or foot

shortly after injury. Active use of the extremity was impossible because of

pain on movement or on weight-bearing. few had no significant pain but

instead noted evidence of excessive sympathetic activity, such as coldness,

cyanosis, and hyperhidrosis. In some, edema, out of proportion to the injury

sustained, was the most striking finding, while in others increased vasomotor
398 VASCULAR SURGERY IN WORLD WAR II

tonus without edema was noted. Marked weakness of the involved limb was

almost constantly present. In number of instances weakness of the affected

limb amounted to virtual paralysis. In the order of frequency, the most prominent initial symptoms and signs obtained through questioning and study of

clinical records were as follows: pain in 97 patients, swelling of the affected

hand or foot in 95, cyanosis in 93, coldness in 72, hyperhidrosis in 52, numbness

in 26, and pallor in 3.

The symptoms listed were generally noticed within periods ranging from

several days to few weeks after injury. In some patients, however, whose

initial trauma required immobilization of the limb in plaster, signs and symptoms suggestive of post-traumatic vasomotor disturbance did not become

evident until the cast was removed and the man became ambulatory. The

preceding complaints could be explained solely on the basis of the local tissue

injury.

It should be pointed out that there was nothing in the history or the clinical

record of these patients to suggest that the early circulatory alterations recorded

were the result of vasodilatation and increased blood flow, as Miller and De

Takats have observed in some patients in civil practice. In practically all of

the combat-incurred post-traumatic vasomotor disorders, the prominent initial

findings were those of sympathetic overactivity.

Initial Therapy. While details of the early therapy applied to the patients

under discussion are unfortunately meager, it is quite clear that in the majority

of instances no active effort was made during the first few weeks after wounding

to treat anything but the local injury. Wounds were properly debrided and

foreign bodies excised when these procedures were indicated. Limbs in which

fractures had been sustained were immobilized in plaster. These measures

seem to have been adequately applied. Only few patients were treated by

casts when there was no fracture or other specific indication for this measure.

Compresses were applied locally and sulfonamide drugs given by mouth or

penicillin administered parenterally when infection was present.

When it became apparent that some profound vasomotor disturbance was

superimposed upon the local injury, other methods of treatment were instituted.

Methods most commonly employed were contrast warm and cold baths, whirlpool baths, Buerger’s exercises, massage, and local heat. Little serious effort

seems to have been made to establish early active motion and weight-bearing.

Sympathetic blocks were employed in 32 patients but in only were they done

during the first month of the vasomotor difficulty. One of these patients

showed continued improvement after blocks had been carried out during the

second week following injury. When examined several months later he had

few sequelae. The other patient derived transient benefit from single block

performed on the day of the injury, and significant and lasting improvement

from several more performed months later.

Miller, D. S., and De Takats, O.: Post-traumatic dystrophy of the extremities. Sudeck’s atrophy. Surg., Oynec.

Obst. 75: 568-582, Nov 1942.
POST-TRAUMATIC VASOMOTOR DISORDERS 399

Late Symptoms and Signs. An average of about months elapsed

between occurrence of the initial injury to patients included in this series, and

the time of their admittance to the Mayo General Hospital. In the interval

the correct diagnosis had usually been established although some conditions

were still considered to be caused by deep venous thrombosis, thromboangiitis

obliterans, or some other primary vascular disorder.

In Table 48 are listed the chief complaints elicited on admittance and the

physical findings noted upon examination. Pain, edema, coldness, and cyanosis

were still the most common symptoms. Nearly one-fifth of the patients had

sensitivity of the affected part to cold; in few instances this disturbance was

extremely severe. Other patients complained of stiffness or numbness. Some

had chronic ulceration. Pain was primarily experienced on weight-bearing or

other activity. Although it was commonly described as an aching sensation,

it was throbbing in some instances and burning in others. In most cases it

prevented normal physical activity and its long duration had usually completely

destroyed the patient’s confidence in his ability to use the affected limb properly.

Two patients had moderate burning pain when the limb was at rest, but its

inconstancy eliminated true major causalgia from consideration as diagnosis.

Table 48. Symptoms and Signs in Post-Traumatic Vasomotor Disorders

Of the 111 patients with vasomotor difficulties involving the lower extremities admitted to the vascular center of Mayo General Hospital, 21 were confined

Chief complaints elicited on admittance (14% patients) Patients

Pain _____ 97

Edema 94

Coldness.. 80

Cyanosis. ______

67

Hyperhidrosis .___ ___ ___ 54

Sensitivity of part to cold *26

Stiffness ___________

24

Numbness 16

Chronic ulceration _________

Signs present on admittance (14% patients)

Muscle weakness 142

Cyanosis. 99

Affected limb cooler than contralateral one 80

Hyperhidrosis _____ _____ ____

80

70

Muscle atrophy.__ _. __

59

Affected and contralateral limbs cool or cold but equal in temperature 40

Stiffness of joints 30

Hypesthesia 23

Affected limb warmer than contralateral one 22

13

Chronic ulceration of skin

•Very severe in 6.
400 VASCULAR SURGERY IN WORLD WAR II

to bed when first admitted, 32 were ambulatory with the use of crutches, and

16 more could get about with canes. Forty-two walked without aid but with

definite limp. Those with involvement of the upper extremities tended to

guard the affected limb and to avoid using it.

In every instance examination revealed motor weakness of the affected

limb (Table 48) which sometimes amounted to virtual paralysis. Muscle

atrophy was commonly evident and stiffness of the joints quite frequent.

Hyperesthesia was occasionally present but not always associated with

definite sensory nerve injury. Edema of varying degrees was present in about

half of the patients. (Fig. 54A and B.) In some instances it was massive even

after prolonged bed rest (Fig. 55Aand B) in few it was present despite elevation

of the extremity, but in the majority it was mild or moderate. Cyanosis was

observed in the majority of patients, in the horizontal position in some instances

but in others only in dependency. Rubor and pallor were uncommon. Hyperhidrosis of varying degrees was often present; in some patients the sweat

literally ran off the involved hand or foot.

The affected memberwas generally cool or cold. In the majority of patients

accurate thermocouple studies of skin temperature were carried out; in the

remaining, temperature was judged by palpation alone. In 80 instances the

affected limb was cooler than the contralateral uninjured limb. In some of

these patients the differences in temperature were considerable while in others

they were slight, especially when the normal limb was itself excessively cool.

In 40 in whom temperatures of the abnormal and normal extremity were approximately equal, both limbs tended to be cool or cold. In some of these individuals

the affected limb cooled more rapidly than the uninjured limb upon exposure to

cold environment.

In 22 patients the involved hand or foot was warmer than the contralateral

limb. In 21 of the 22, the thermocouple readings of the affected part were at

the lower level of the normal range or even cooler. In the remaining patient

the skin temperature was abnormally high as result of infection.

In 88 patients oscillometric and skin temperature studies were made with

the following results:

One notable observation on physical examination of these patients was

that, although all had evidence of some vasomotor alteration and many presented edema, cyanosis, coldness, and hyperhidrosis, considerable number

exhibited some one of these changes out of proportion to the others. For

example, some individuals suffered from intense cyanosis without great deal

Oscillometric and temperature recordings less than in normal extremity 32

Oscillometric readings less and temperature equal 17

Oscillometric readings and temperature approximately equal 14

Oscillometric readings less but temperature higher 10

Oscillometric readings equal and temperature less 10

Oscillometric readings and temperature greater than in normal extremity

Oscillometric readings greater but temperature less
POST-TRAUMATIC VASOMOTOR DISORDERS 401

of edema, coldness, or increased sweating. Others presented massive edema

with minimal changes in color, temperature, or sweating. Still others showed

extreme local reduction in temperature or considerable hyperhidrosis or both,

without significant edema or cyanosis.

Most of the patients had assumed the attitude and behavior of the chronic

invalid. They were weary from prolonged disability and hospitalization and

their viewpoint toward the possibility of eventual recovery was usually hopeless

or relatively hopeless. Some appeared to embrace the concept that their

condition was sufficiently disabling for them to look forward to separation from

the service. In only 11 of the 142 patients, however, was true neuropsychiatric disorder diagnosed by psychiatric consultants. In this small group the

general attitude and behavior differed in no great degree from the attitude

and behavior of the group as whole except that few showed evidences of

anxiety. On the other hand, all 11 patients had certain local findings which

were helpful in segregating them from other patients. The most common

observation was forced effort in response to request to perform certain

movement. The effort was associated with gross tremor or with little or no

movement of the part but with obvious contraction not only of the muscles

ordinarily utilized in the movement requested but of their antagonists as well.

When, for example, patient was attempting to extend his foot in response

to request, it was often apparent that both the extensors and the flexors

were being brought into state of tonic contracture so that no movement at

all resulted except possibly coarse tremor. This sign, more than any other,

was helpful in establishing the presence of psychomotor block.

Special Examinations. In number of patients reflex dilatation by means

of body warming was carried out. In all but the rate of rise in skin temperature was parallel in the affected and in the normal extremity. In the

exceptions lag was noted in the injured limb. In all instances, however,

there was no difference in the ultimate temperature elevation in the injured

extremity as contrasted with the normal one, despite lower initial controlled

skin temperature readings in the involved limb.

In several patients the reactive hyperemia test was performed. Results

in the affected limb were uniformly normal, except in one patient in whom

there was delay in the appearance of the flush.

Records of roentgenologic examination of the hands or feet made prior to

admittance to Mayo General Hospital were available in 51 of the 142 patients.

In 42 there was evidence of generalized or spotty osteoporosis. The charge

was minimal in 6, moderate in 28, and marked in 8. In the other no abnormalities were observed on the roentgenograms.

THERAPY

The treatment given the 142 patients with post-traumatic vasomotor

disorders at the vascular center of Mayo General Hospital can be divided into
402 VASCULAR SURGERY IN WORLD WAR II

four categories, namely, active exercise and physical therapy, neuropsychiatric

measures, lumbar sympathetic block, and lumbar sympathectomy. As

matter of convenience, the treatment of osteoporosis will be considered separately. It is recognized that these divisions are somewhat arbitrary and

overlapping.

For example, whether or not neuropsychiatric disorder was present, and

regardless of whether expert psychiatric treatment was required, it was felt

necessary to gain the confidence of the patient and to impress upon him both

the necessity for his active cooperation and the favorable outcome that might

be expected if he cooperated. Such instructions and suggestions on the part

of the attending physician constituted, in reality, psychiatric treatment. Again,

no matter what other type of therapy was carried out, active use of the involved

extremity was part of the routine. It was learned early in the management of

these patients that little could be accomplished by psychiatric interviews,

sympathetic blocks, or sympathectomy unless the patient was repeatedly

urged to take advantage of any resulting improvement in his condition by

following up the gain with persistent use of the affected limb. It was only in

this manner that atrophy, weakness, stiffness, and improper stance or gait

could ultimately be corrected.

Active Exercise and Physical Therapy

In 95 of the 142 patients, active use of the involved extremity supplemented by physical therapy constituted the chief treatment employed. When

the patients were first seen the importance of activity was pointed out and

explained to them in terms which they could readily understand. The role

that disuse was playing in their condition was stressed and it was emphasized

that vicious cycle had been set up which would result in continued difficulty

as long as inactivity persisted.

In those individuals who had demonstrable edema of lower extremity,

an attempt was made to bring the swelling under control before anything else

was done. These patients were put to bed with the extremity elevated until

all swelling had disappeared. If edema recurred on activity, an elastic support

was used together with periods of bed rest with the limb elevated. Careful

observation of the patient made it possible to permit activity to degree

slightly less than that at which edema reappeared. The use of the elastic

support was continued until swelling was no longer present on dependency.

If patient was confined to bed on his admittance to the hospital, the

therapeutic program was aimed at making him ambulatory as rapidly as circumstances permitted. short period of ambulation with crutches and then

with cane was sometimes necessary before unaided walking was accomplished.

Widespread petechial hemorrhages sometimes appeared in the skin of the

affected extremity when patient first began to walk after prolonged period

of immobilization of the limb. They usually cleared up promptly as activity
POST-TRAUMATIC VASOMOTOR DISORDERS 403

increased. Patients who were admitted using crutches or canes were persuaded to discard them immediately. Since all patients who had been bedridden or who had been using aids usually showed timidity and favored the

affected limb when they first began to walk, careful attention was paid early

in the reconditioning program to the acquisition of normal stance or gait.

It was not always easy to accomplish this, partly because pain was frequently

associated with early movement (though it tended to decrease as the men became more active) and partly because most tended to estimate their improvement by the distance they could cover rather than by the correctness of their

gait. They were made to understand, however, that more benefit was derived

from walking short distance properly than long distance improperly. Emphasis was placed on the fact that only when correct gait was employed would

all the muscles be brought into play and strengthening and improvement in

tone accomplished.

In addition to the active use of the affected limb which was the principal

type of physical therapy utilized, substantial benefit was usually obtained

through gentle massage and directed active and resisted exercise of all the weak

muscles. Passive exercises and manipulations were found to be of little help.

Whirlpool baths were used on some of the first patients to be treated, but in

general no improvement was observed following their use and so they were

omitted. It was necessary to emphasize to all of the patients that they could

accomplish much more by voluntary exercise at frequent intervals throughout

the day than by sole reliance on the relatively short period of treatment supervised by the physical therapist.

The same principles of treatment were employed for the upper and for the

lower extremities.

Results. As improvement appeared, the patients usually underwent

change in attitude and became decidedly more optimistic concerning the outcome of their disability. Concomitantly with their altered state of mind, they

seemed to pursue the program more vigorously and to improve more rapidly.

As result, edema diminished and gait became relatively normal. If discomfort persisted it was less severe and appeared only after the patient had walked

for distances varying from to or more miles. Along with this improvement

there were observed an increase in muscle power and an alleviation of the

vasomotor disturbances. Almost invariably limbs which had been cold, wet,

and cyanotic when first seen, gradually became warmer, dryer, and of better

color.

In 50 of the 95 patients in whom active exercise and physical therapy were

the chief methods of treatment, results were satisfactory. Five of the remaining

patients were under observation for too brief time to permit final evaluation

ofresults. In the other 40, few, if any, beneficial effects were noted. It should

be emphasized again that in some respects many of the patients analyzed under

other methods of treatment also represent failures with active exercise and
404 VASCULAR SURGERY IN WORLD WAR II

physical therapy, since these measures were employed adequately in all but

few patients prior to the institution of other methods.

One patient may be considered as typical of those in whom active exercise

and physical therapy produced successful results;

Case Report

When this patient entered the Mayo General Hospital he was unable to use his fingers

and complained of marked edema, pain, coldness, and hyperhidrosis of the right hand. The

bones of the right forearm had been fractured on several occasions prior to the onset of

symptoms. When the hand was first examined all of the fingers were edematous and stiff

(Fig. 54A). He was given an ordinary surgical glove to wear and encouraged to use the

fingers as much as possible. At the same time, an intensive course of physical therapy was

instituted. Part of this called for the patient to squeeze soft rubber ball. This he did

during most of the day. At the end of 14 days, edema had completely disappeared and he

could move the fingers of the right hand almost as well as those of the left (Fig. 54B).

Figure 54- A. Massive edema of right hand in patient with vasomotor disorder following

trauma. B. Disappearance of edema several weeks after institution of intensive active

exercise and physical therapy.

Disposition. By the time the patients in this group were ready for disposition those who had demonstrated satisfactory response to therapy were either

free of residual vasomotor signs and symptoms or whatever manifestations

persisted were minimal. In some the rather generalized increase in vascular

tonus previously present had tended to decrease as the affected limb was restored to more normal state. Even when patients were not completely recovered, however, it was felt that further hospitalization for the vasomotor

condition was unnecessary—and might be actually harmful—since there was

every reason to believe that symptoms and signs would become less and less

apparent with continued physical activity and the passage of time.

Twenty-nine of the 95 patients in this group were therefore transferred to

various other sections of the hospital for the correction of other medical or

surgical conditions, 14 were sent to convalescent facilities for advanced re-
POST-TRAUMATIC VASOMOTOR DISORDERS 405

conditioning, were discharged directly to duty, and the remainder were separated from the service.

Neuropsychiatric Measures

Standard neuropsychiatric measures were used in of the 11 patients in

this group. In 8, treatment was carried out by the psychiatrist. In the

ninth patient it was carried out by the ward officer under the direction of the

psychiatrist. The routine usually included suggestive therapy under sodium

amytal narcosis or hypnosis. Careful, concerted efforts were always made to

give the patient insight into his condition and to make him understand that

he had no organic disorder which would prevent his recovery if he would

continue to push himself to the limit in the active use of the affected limb.

In the remaining patients psychiatric measures were not regarded as

necessary. In of these the psychiatrist thought that the complaints of

cyanosis, coldness, swelling, and pain in the foot on weight-bearing were largely

psychosomatic, but they cleared up so satisfactorily under ordinary physical

activity that psychiatric measures were not invoked. When this patient was

transferred to convalescent hospital for advanced reconditioning his only

complaint was aching in the affected foot after he had walked for distance of

miles. The other patient made fair progress with active exercise of the

affected upper extremity until improvement reached plateau; he was left

with some residual cyanosis, increased sweating, and weakness.

Results. The results of psychiatric treatment in the patients treated

were classified as good in 4, poor in 4, and fair in 1.

Two patients in whom no improvement was observed after psychiatric

measures were transferred to neuropsychiatric center for more intensive

therapy. One of them (Case 8, Table 49) had complained of swelling, hyperhidrosis, and cyanosis of the foot following compound fracture of the proximal

phalanx of toe, the result of an accidentally self-inflicted wound months prior

to admittance. His symptoms did not improve with activity but there was

some reduction in swelling following lumbar sympathectomy. Initial progress

was excellent but after he returned from convalescent furlough he still had

some swelling and weakness of the foot. The psychiatrist was of the opinion

that definite hysteria was present, since improved strength in the foot and

more normal walking could be demonstrated under hypnosis. Several subsequent treatments were given but the final result was poor.

The second patient transferred to neuropsychiatric center for further

treatment had also been admitted with swelling, cyanosis, weakness, and pain

in the foot on weight-bearing. He had improved considerably with active

exercise and physical and occupational therapy but following convalescent

furlough complained of increased weakness and pain and, in addition, of nervousness, anorexia, and insomnia. He had also developed tremor and some

weakness in one of his hands. The psychiatrist felt that this man was suffering
406 VASCULAR SURGERY IN WORLD WAR II

Table 49. Sympathectomy in Post-Traumatic Vasomotor Disorders

[Indication: Persistent Edema]

Case

No.

Operation,

months

after

Injury

Original Injury Manifestations Results

4.0 Compound fracture,

tibia and fibula.

Massive edema, leg. Ununited fracture, cyanosis, small ulcer. (Attempt at bone graft abandoned

because of edema.)

Edema considerably reduced. Foot

warm, dry, well colored. Successful bone graft.

8.0 Simple fracture, 2d

and 3d metatarsals

and cuneiform.

Marked edema, foot and leg, persisting with bed rest. Cyanosis,

coldness, hyperhidrosis, stocking

hypesthesia. Pain on weightbearing requiring crutches.

Edema largely disappeared. Foot

warm, dry, well colored. Pain only

after walking miles or more.

Hypesthesia decreased.

11.0 Foot crushed-.. Massive edema, foot and leg, persisting with bed rest, elevation,

and typhoid vaccine. Coldness,

hyperhidrosis, hypesthesia, motor

paralysis. Pain on weight-bearing. (Conversion hysteria, unaffected by psychotherapy.)

Reduction of in. in circumference of

foot, and l$i in. in circumference of

leg within days. Edema largely

subsided. Foot warm, dry.

Hypesthesia slightly decreased.

Could walk with cane fairly well.

5.0 Soft tissue wound,

foot.

Massive edema, foot and leg, persisting with bed rest, elevationand

long courses of penicillin and sulfadiazine. Moderate rest pain.

Severe local infection with increased local heat.

Reduction of 1H in. in circumference

of foot and in. in circumference

of leg within 36 hours. Edema disappeared but subsequently recurred with flareup of Infection,

again to disappear with elevation.

Pain disappeared, ulcer healed.

Walks well.

Unknown Compound fracture,

tibia and fibula.

Massive edema ankle, severe osteomyelitis.Edema slightly lessened. Outcome

unsettled.

6.5 Foot crushed Massive edema, foot and ankle, persisting to moderate degree with

bed rest. Coldness, hyperhidrosis,

cyanosis, and hpyesthesla of foot.

Marked paresis. Atrophy. Pain

on weight-bearing. Patient bedridden.

Marked Improvement. Edema gone

except slight after long standing.

Sensation normal. Strength much

improved. Foot warm, dry, well

colored. Slight pain after walking

mile.

4.5 Soft tissue wound,

lower extremity.

Marked edema, foot and ankle.

Pain on weight-bearing requiring

cane. Cyanosis. Affected foot

warmer and oscillometry better

than normal foot. Weakness and

atrophy. Tiblal nerve paralysis.

Steady improvement, final disappearance of symptoms.

9.0 Compound fracture,

phalanx.

Moderate edema. Pain on weightbearing, causing limp. Cyanosis,

hyperhidrosis. Weakness. (Patient subsequently found to have

hysteria)

Little improvement. Swelling and

limp still present. Foot warm and

dry.
POST-TRAUMATIC VASOMOTOR DISORDERS 407

from an anxiety state and when no improvement was secured with sodium

amytal narcosis and other treatment, recommended his transfer to another

hospital.

In third patient in whom an unsatisfactory result was obtained with

neuropsychiatric measures, definite evidence of conversion hysteria was present

but considerable, though incomplete, improvement occurred after sympathectomy (Case 3, Table 49).

Of the patients in whom the results were classified as good are of

interest:

Case Reports

The first was patient who was admitted to the vascular center of Mayo General Hospital months after an injury to the right leg. He received this injury when he was kicked

during football game. He gave history of previous trauma to the same limb year earlier, followed by pain, swelling, and cyanosis which decreased slowly and finally disappeared.

Within few days after the recent injury the return of these same symptoms and signs were

noticed. They increased in severity and eventually he could walk only on crutches.

series of 10 sympathetic blocks resulted in transient improvement in the strength of the

affected foot. When examined it was immediately evident that he was unwilling to do

very much for himself. He appeared apprehensive and was rather jumpy wdiile being

questioned. There was marked paresis of all the movements of the foot and ankle but efforts

were associated with tremor and with tonic contractions of the antagonistic muscles.

The psychiatrist felt that this patient had hysteria and treated him with suggestive

therapy under sodium amytal narcosis. During this procedure the affected foot, which

had been cold, wet, and extremely cyanotic, became warm, dry, and of good color. The

patient could move it freely and strongly through full range of motion. He was made to

walk and did so with practically normal gait. After this single treatment, which was followed by careful and full explanations regarding the nature of his condition and progress, he

improved daily. When he was discharged after being hospitalized for month, the foot was

normal in color and warmth, edema was no longer present, and there was only slight reduction in motor power. The range of motion was normal. He experienced no pain until he

had walked mile and half. There was, however, no improvement in the moderate osteoporosis present on admittance.

The second patient was admitted to the hospital months after he had sustained injuries of the soft tissue of the left thigh and leg from shell fragment. The injury had been

followed by immediate paralysis and numbness of the foot but flexion and sensation on the

sole had returned at the end of weeks. At the time of admittance he complained of swelling, cyanosis, coldness, and sweating of the left foot, with tingling and aching pain on attempted weight-bearing. He walked with crutches. Examination of the left foot showed

cyanosis, reduction in skin temperature, moderate hyperhidrosis, paralytic limitations of

eversion, and complete loss of extension of the affected foot and toes. There was some

hypesthesia of the foot, with anesthesia in the distribution of the saphenous and the lateral

sural nerves.

The neurosurgeon had no doubt that the patient had sciatic nerve injury with partial

peroneal paralysis. Efforts at active use of the limb with foot-drop brace were futile, and

since fairly good response was obtained with sympathetic block, lumbar sympathectomy

was performed (Case 10, Table 50), There was considerable improvement following this

procedure and weight-bearing was possible with the use of crutches; at the end of week he

discarded these for cane. The foot was now warm and dry, and there was only minimal

edema in the leg and none in the foot. There was also less pain on walking.

330323 0—55 27
408 VASCULAR SURGERY IN WORLD WAR II

Table 50. Sympathectomy in Post-Traumatic Vasomotor Disorders

[Indication; Pain on Weight-Bearing orRest Pain]

Case

No.

Operation,

months

after

Injury

Original Injury Manifestations Results

5.0 Foot crushed... Pain on weight-bearing requiring

crutches. Marked coldness, cyanosis, hypesthesia, moderate

edema. Atrophy, calf.

Walks without limp, pain only slight

after prolonged walking. Foot

warm, dry, well colored.

10 7.0 Soft tissue wound,

thigh.

Pain on weight-bearing requiring

crutches. Coldness, cyanosis,

hyperhldrosls, slight edema. Apparent peroneal palsy. Atrophy,

calf.

Pain decreased. Walks with cane.

Foot warm, dry, well colored.

Subsequently found to have hysteria. Complete cure, including

motor and sensory return, after

single amytal narcosis.

11 9.0 Periostitis, tibia Pain on weight-bearing requiring

crutches. Coldness, cyanosis,

hyperhldrosls. Atrophy, calf.

Complete relief.

12 7.0 Soft tissue wound,

foot.

Pain on weight-bearing requiring

crutches. Moderate edema, cyanosis, weakness, and atrophy,

calf.

Moderate improvement on weightbearing. Walks without cane but

limps. Some pain persistent.

Foot warm and dry. Edema less.

13 7.0 Soft tissue wound,

foot.

Pain on weight-bearing requiring

crutches. Coldness, cyanosis,

slight edema. Atrophy, calf.

Much improvement. Pain only

after walking miles or more.

Foot warm, dry, well colored.

Edema first reduced, then disappeared.

14 9.5 Simple fracture, metatarsal.

Pain on weight-bearing causing

limp. Slight edema, cyanosis,

weakness, coldness, atrophy.

Much improvement. Pain only

after walking mile. Edema less.

Foot warm and dry. Foot

stronger.

15 6.6 Chip fracture, second

and thirdphalanges.

Pain on weight-bearing requiring

cane. Slight edema, cyanosis,

weakness.

Steady improvement, then complete

relief.

16 6.0 Soft tissue wound,

foot.

Pain on weight-bearing. Moderate

edema, cyanosis, reduced oscillometry. Atrophy and weakness.

Much improved. No discomfort

until after walking more than

mile. No edema. Foot warm and

well colored.

17 7.5 Soft tissue wound,

foot.

Pain on weight-bearing causing

limp. Marked coldness, cyanosis, hyperhldrosls. Weakness

and atrophy.

Marked improvement. No discomfort until after walking more than

miles. Foot warm, dry, well

colored.

18 6.0 Foot crushed ... Pain on weight-bearing requiring

cane. Slight edema, coldness,

cyanosis, hyperhidrosis. Weakness, atrophy, hypesthesia.

Much improved. Able to walk or

miles without pain. Foot warm,

dry, well colored. Still slight

edema. Foot stronger. Sensation

normal.
POST-TRAUMATIC VASOMOTOR DISORDERS 409

Table 50. Sympathectomy in Post-Traumatic Vasomotor Disorders—Continued

[Indication: Pain on Weight-Bearing or Rest Pain]—Continued

Two months later the sciatic nerve was explored and found to respond well to faradic

stimulation. week after the operation psychiatric consultation established diagnosis

of hysteria. As the result of single interview under sodium amytal narcosis the patient

regained all movements, had return of sensation, and walked unaided normally and without

pain.

This case illustrates most emphatically the necessity of bearing in mind

the possible psychiatric basis of post-traumatic vasomotor complaints and of

instituting appropriate psychiatric therapy before attempting other, more

heroic procedures.

Disposition. Except for the soldiers transferred to neuropsychiatric

centers for further treatment, all the patients in the group treated by neuropsychiatric measures were separated from the service even though some of

them showed marked improvement in, or even recovery from, the vasomotor

disorders for which they had been hospitalized.

Sympathetic Block

Thirty-two patients received sympathetic blocks prior to their admittance

to Mayo General Hospital; the procedure was carried out on an average of

months after the onset of the disorder, with range of from to 22 months.

From to 28 blocks had been given to each individual.

Sympathetic blocks were carried out in number of the patients with

post-traumatic vasomotor disorders after they were received at the Mayo

General Hospital, but in only instances was the method employed as

therapeutic measure. In the remaining patients the blocks were carried out

as test procedure to determine the advisability of sympathectomy.

Results. An analysis of the medical records, supplemented by questioning

the patients, made it appear that 12 of the 32 patients who received sympathetic block prior to their arrival at the Mayo General Hospital had noticed no

subsequent change in their condition other than some temporary elimination

of coldness, cyanosis, and sweating during the period of anesthesia. In 13

patients there appeared to be definite though transient benefits from the procedure. In patients there was evidence of slight or moderate permanent

improvement, and in patients good permanent results were obtained.

Case

No.

Operation,

months

after

injury

Original Injury Manifestations Results

19 9.0 Compound fracture,

lower leg.

Moderate burning rest pain, increased with dependency. Moderate edema, cyanosis, coldness.Much improved. Pain much less.

Edema less. Foot warm. Slight

cyanosis in dependency.

20 Unknown. Simple fracture Moderate burning pain at rest, cyanosis, coldness. Partial peroneal

palsy.

Much improved. Pain much less.

Foot warm, dry, well colored.
410 VASCULAR SURGERY IN WORLD WAR II

In evaluating the sympathetic blocks performed before the patients were

seen at the Mayo General Hospital, it was apparent that in few instances

effective anesthesia of the sympathetics had not been obtained. This was

evidenced by the fact that the limb remained cold and wet following the injection. In others the possible therapeutic effect upon walking was compromised

by associated inadvertent blocking of the somatic nerves, with resulting temporary anesthesia and paralysis, which prevented the use of the lower extremities during the period of the effective sympathetic block. Futhermore, it was

apparent that in most of the patients no effort had been made to make the

patient walk or otherwise actively exercise his affected limb immediately after

the injection. In only few of the patients was advantage taken of the improvement by insistence upon progressively increased use of the limb and it

was in this group that some benefit over period of hours or days was noted

following the procedure. There is no question that if sympathetic blocks are

to achieve maximum benefit, the involved extremity must be subjected to

weight-bearing and walking or other active exercise immediately after the

injection, and that activity must be continued to the point of tolerance. Only

when such plan is employed can the effectiveness of the procedure properly

be evaluated.

Two of the patients in whom sympathetic blocks were employed as

therapeutic measure after they reached the Mayo General Hospital had

syndromes characterized by coldness, hyperhidrosis, and weakness of the hand.

Another had rather marked edema of the hand without any other significant

change. The remaining patients complained of edema, coldness, cyanosis,

and hyperhidrosis of the injured foot. Treatment was instituted from to 12

months following injury. Three patients received only single sympathetic

injection while had treatments each. In every instance there was definite,

steady improvement following the blocks, manifested by marked diminution

in coldness, hyperhidrosis, and edema, return of good color, also increase in

motor power and function. Each of these patients had previously been making

earnest efforts to use the extremity actively and to the best of his ability but

without apparent improvement. From the sequence of events there was little

doubt that the block rather than other therapeutic efforts was primarily

responsible for the altered clinical picture. It is of interest that pain was not

prominent complaint in any of the patients who experienced lasting improvement as result of sympathetic block.

Sympathectomy

Sympathectomy was the principal method of treatment in 34 patients,

in of whom the operation was performed twice. Three of these patients have

already been mentioned in the neuropsychiatric category but are again analyzed

under this heading for the sake of completeness.

In all in whom the lower extremity was involved, lumbar sympathectomy

was carried out under spinal anesthesia through an anterior extraperitoneal
POST-TRAUMATIC VASOMOTOR DISORDERS 411

approach; the second and third lumbar sympathetic ganglia, with the intervening chain, were excised. Sympathectomy of the upper extremity was

performed through posterior muscle-splitting incision with resection of

portion of the third rib and of the transverse process. The second and third

thoracic ganglia were decentralized; the chain was severed between the third

and fourth ganglia and the isolated segment encased in silk cylinder. Intradural section of the second and third anterior nerve roots and extradural section

of the corresponding posterior roots were steps in the procedure. There were

no deaths and no complications in any of these patients.

Decision to perform sympathectomy was made on the basis of number

of factors. In patients with ulcers, it rested primarily upon the chronicity of

these lesions and the presence of associated vasospasm. In patients with

evidence of excessive sympathetic activity, sympathetic procaine anesthesia proved reliable test for judging results which would follow sympathectomy.

In those with edema, preliminary testing with procaine block was not reliable

indication of the effects to be expected of sympathectomy. In very few,

demonstrable transient diminution in swelling occurred, but in number of

others it was necessary to determine whether the increase in the size of the

extremity which occurred during an hour of walking immediately following the

injection was less than that observed during comparable interval on another

occasion. If it was thought to be less following the injection, then sympathectomy was resorted to. In most patients with edema, however, no really

convincing evidence concerning the result to be anticipated from sympathectomy could be derived from preliminary sympathetic block. In spite of the

indefiniteresults of preliminary testing, the therapeutic effect of sympathectomy

was frequently extremely satisfactory.

In patients with pain, results of preliminary testing with sympathetic

procaine anesthesia were also so variable as to be considered unreliable.

Following the injection some patients were surprised to find that they could

move the affected part freely through wide range of motion without any

discomfort and that they could walk or otherwise exercise either with no pain

or with much less discomfort than previously experienced. In such instances

it was felt that sound evidence existed that sympathectomy would be effective.

In others, however, sympathetic anesthesia had no beneficial effect upon the

pain associated with exercise, yet in these good results frequently followed

sympathectomy.

Results. To simplify the analysis, patients upon whom sympathectomy

was performed have been divided into groups, namely, those with considerable

persistent edema, those with pain on walking, those with excessive sympathetic

activity, and those with chronic ulceration of the skin. This division is somewhat arbitrary since symptoms and signs were seldom limited to any one of

the categories mentioned. Some of the patients with edema, for example, had

pain also on weight-bearing and presented evidence of vasoconstriction, while
412 VASCULAR SURGERY IN WORLD WAR II

those whose chief complaint was pain on weight-bearing likewise presented

excessive vasomotor tonus, often associated with slight or moderate edema.

Similarly, patients with chronic ulceration gave evidence of increased vasomotor

activity and suffered from edema and discomfort on walking. Nonetheless,

this division serves useful purpose in presenting the information in more

concise fashion and selection has been made according to the primary indication

for operation.

In of the patients upon whom sympathectomy was performed primarily

because of persistent edema (Table 49), the procedure was carried out on

average of about months after injury, the range being to 11 months. In

patient edema was only moderate, in it was marked, in the remaining it

was massive. All of these had had trial of bed rest, with elevation of the

affected limb, and later, when they became ambulatory, of elastic support.

In of the patients edema persisted with bed rest alone, and in of these it

did not subside even after prolonged period of elevation. Six patients had

evidence of vasospasm and 1, in whom infection was present, also had definite local hyperemia (Case 4).

In of the patients in this group (Case 1) in whom edema was associated

with an ununited fracture of the tibia, exploration. was undertaken with the

idea of performing bone graft, but the procedure had to be abandoned because of the marked waterlogging of all the tissues. There was considerable

reduction in the edema following sympathectomy and when the bone graft

subsequently undertaken, the surgeon estimated that the condition had improved by about 90 percent. In another patient, however, in whom massive

edema was associated with compound fracture and osteomyelitis of the ankle

(Case 5), only slight improvement followed sympathectomy.

One case from this group is of special interest:

Case Report

This patient, with massive edema (Case 4), had sustained soft-tissue injury of the

left foot from shell fragment. The foot and leg were enormously swollen and local infection

was present (Fig. 55A) associated with fever and weight loss. Intensive treatment consisting

of repeated debridement, repeated incision and drainage, and sulfonamide and penicillin

therapy over long period, with immobilization and elevation of the limb, had produced no

improvement whatsoever. sympathetic block produced no demonstrable diminution of

the edema but pain was transiently diminished. Sympathectomy was performed months

after the injury. Within 36 hours the circumference of the foot had been reduced by

inches, that of the leg by 4)4 inches. Over the next few days the edema disappeared completely, as did the infection, and healing occurred with only tiny ulcer remaining. Subsequent recurrence of the infection, with transient recurrence of edema, responded well to

elevation and rest. Following this episode the wound healed completely (Fig. 55B), edema

disappeared entirely, and the patient could walk normally and with comfort.

The other patients in the group upon whom sympathectomy was performed for persistent edema presented other signs and symptoms more commonly seen following injury. Four were unable to bear weight properly be-
POST-TRAUMATIC VASOMOTOR DISORDERS 413

Figure 55. A. Massive edema and ulceration of left foot and lower leg in patient with posttraumatic vasomotor disorder and resistant infection. No improvement followed continued

bed rest, elevation of the extremity, and sulfonamide and penicillin therapy. B. Healing of ulcer and disappearance of edema after lumbar sympathectomy.

cause of pain, thefifth walked with decided limp. All complained of weakness,

had virtual paralysis, and had hypesthesia. Three of the had signs of

intense sympathetic hypertonus with coldness and hyperhidrosis. The fourth

had persistent hyperhidrosis and cyanosis. The fifth had cool foot which,

however, was warmer than the contralateral limb. By means of an oscillometer it was determined that the volume How of blood to the injured extremity

was greater than that to the uninjured one. In of these patients (Cases 2,

6, and 7) there was either partial or complete subsidence of edema following

sympathectomy. All could walk better, without discomfort and for longer

distances, than before operation. Hypesthesia was improved or was no longer

present. In patient (Case 7), who was hospitalized sufficiently long for conclusions to be warranted, there was no recurrence of edema during the period

of observation.

The other patients upon whom sympathectomy was performed for persistent edema have been discussed previously under the heading of neuropsychiatric therapy. One, who had transient improvement in edema following sympathectomy (Case 8, Table 49), was eventually found to have conversion

hysteria which responded poorly to psychotherapy. The history of the second

patient (Case 3) is instructive because it illustrates the therapeutic effect of

sympathectomy in an hysterical individual who also showed poor response to

psychotherapy: Case Report

Following crushing injury of the left foot, this patient had marked swelling, coldness,

hyperhidrosis, and hypesthesia (Fig. 56A). Paralysis was almost complete. No improvement was observed following psychiatric interviews and no benefit other than transient
414 VASCULAR SURGERY IN WORLD WAR II

Figure 56. A. Edema of leftfoot in patient with post-traumatic vasomotor disorder and hysteria 11

months after injury. This picture was taken after weeks of continuous bed rest with

elevation of the extremity. Response to psychotherapy was poor. B. Appearance of foot 10 days after lumbar sympathectomy. Note almost complete disappearance of edema.

warmth and dryness of the foot followed sympathetic block. Sympathectomy was performed

11 months after the original injury. Within 48 hours after operation the edema, which had

persisted with bed rest and elevation, practically disappeared. The patient, although he

walked with limp and required foot-drop brace and cane, was converted from bedridden to an ambulatory patient (Fig. 56B) during this brief period. Further psychotherapy

was of no value and, since plateau of improvement had been reached, he was separated

from service.

Sympathectomy was performed in 10 patients who complained of pain on

weight-bearing and in who had pain at rest (Table 50). At the time of operation was confined to bed and refused to walk, walked with crutches, and

with canes. The other walked with limp and favored the injured limb. In

of the 12 there was positive evidence of vasospasm and had slight or moderate edema. Cyanosis was present in all 12.

One of the patients who had moderate improvement after sympathectomy

has already been mentioned (Case 10). He was subsequently found to have

hysteria and complete cure occurred after single interview under sodium

amytal narcosis.

In the remaining patients results varied from good to excellent. Some

were able to walk several miles before the onset of discomfort while others had

no residual pain at all. Both patients who had complained of rest pain showed

considerable improvement. In every instance edema either disappeared or was
POST-TRAUMATIC VASOMOTOR DISORDERS 415

present only to slight degree, even after prolonged dependency. All patients

now had warm, dry feet and only one showed residual cyanosis. Muscle

strength also improved in every instance. By the time the patients left the

hospital, there was an increase in the size of the muscles even if definite atrophy

had previously existed.

It is important to emphasize that in this group, except for or patients

treated early in the experience, all had been subjected to rigid regimen of

active exercise prior to operation without definite relief from symptoms. Even

the few who followed no planned program of calisthenics had been encouraged to

walk and to exercise the affected limb.

On the indication of excessive sympathetic activity (Table 51), 13 operations were performed on 12 patients. Eight of the procedures were dorsal and

Table 51. Sympathectomy in Post-Traumatic Vasomotor Disorders

(Indication: Excessive Sympathetic Activity]

Case

No.

Operation,

months

after

injury

Original injury Manifestations Results

21 8.0 Soft tissue wound, calf Marked coldness, entire foot and leg.

Cyanosis, hyperhldrosls, moderate

edema. Heel cord contracture, stiffness, and weakness, foot and toes.

Foot warm, dry, well colored. No

lessening of or weakness, and

stiffness persisted. Subsequently tendo Achlllls lengthening.

Useful foot.

22 6.5 Compound fracture, astragalus and navicular;

division, extensor tendons.

Marked coldness, hyperhldrosls, cyanosis. Slight edema, long, deep

transverse scar, dorsum foot.

Foot warm, dry, comfortable.

Subsequent tendon repair only

partly successful. Good wound

healing.

23 9.5 Compound fracture, femur Marked coldness, hyperhldrosls, cyanosis. Moderateedema.

Complete relief.

24 22.0 Cellulitis, lowerextremity. Marked coldness, cyanosis, hyperhldrosis, and epidermophytosis.

Pain on weight-bearing, limp; Weakness, slight edema, hypesthesla.

Muchimproved. Foot warm, dry,

well colored. No epidermophytosis, no edema. Hypesthesla

improved. No pain. Still some

weakness.

25 12.0 Sprain, lower extremity... Coldness, cyanosis, hyperhldrosls.

Cold sensitivity. Slight swelling

and stiffness on walking. Weakness.

Muchimproved. Foot warm, dry,

well colored. No cold sensitivity. Little or no discomfort

on walking. Still some weakness.

26 9.0 Compound comminuted

fracture, phalanges and

5. Laceration flexor tendons.

Hyperhldrosls. Marked cold sensitivity. Cyanotic rubor.

Complete relief. Subsequent tendon repair.

27 9.0 Traumatic amputation, 3d

finger.

Coldness, hyperhldrosls, weakness.

Phantom-limb pain.

Complete relief. No pain. Warm,

dry hand. Strength largely regained.
416 VASCULAR SURGERY IN WORLD WAR II

Table 51. Sympathectomy in Post-Traumatic Vasomotor Disorders—Continued

[Indication: Excessive Sympathetic Activity]—Continued

were lumbar sympathectomies. Ten of the 12 patients in this group complained before operation of excessive coldness, generally associated with both

cyanosis and hyperhidrosis, at ordinary environmental temperatures. Six had

cold sensitivity manifested by marked coldness, stiffness, and discomfort on

exposure to low temperature. The with involvement of the lower extremity all had slight or moderate edema and had also pain on weight-bearing.

One (Case 27), who had had an amputation of finger, had moderate phantomlimb symptoms.

Following operation, patients had complete relief and the other were

very much improved. Cold sensitivity was diminished in each patient in whom

it had been present. The limbs were dry, warm, and well colored following

operation. Hypesthesia, which had been present in (Case 24), was considerably improved. Corrective operative procedures upon the affected limbs

in (Cases 21 and 22) were followed by prompt healing of the wounds.

In patients (Table 52) operation was performed chiefly because of the

persistence of chronic ulcers. In both, although repeated efforts at skin grafting had failed, healing occurred fairly promptly after sympathectomy. In

(Case 34) it was apparent before sympathectomy was performed that transfer

of full thickness skin would eventually be required, but it was thought that

the chance of success would be enhanced if this could be done after epithelization of the ulcer and correction of the vasospastic disorder. In other patients

chronic ulcers healed satisfactorily with rest and saline compresses, without sympathectomy.

Case

No.

Operation,

months

after

injury

Original injury Manifestations Results

28 8.0 Soft-tissue wound, arm.

Median nerve palsy.

Coldness, cyanosis, hyperhldrosis.

Some burning. Cold sensitivity.

Markedrelief.

29 8.5 Compound fracture, 5th

metacarpal. Ulnar

nerve palsy.

Coldness, cyanosis, hyperhldrosis. Complete relief.

30 15.0 Compound comminuted

fracture, humerus. Median and ulnar nerve

palsy.

Coldness, cyanosis, cold sensitivity,

hyperhldrosis of thumb.

Complete relief.

31 9.0 Laceration, flexor tendons

2, 3, 4. Amputation

5th finger.

Coldness, cyanosis, hyperhldrosis.

Cold sensitivity. Weakness.

Complete relief.

32 11.0 Compound comminuted

fracture,left ulna. Ulnar

nerve paralysis.

Cold sensitivity. Coldness, cyanosis,

aching, throbbing, and stiffness on

exposure. Hyperhldrosis.

Complete relief.
POST-TRAUMATIC VASOMOTOR DISORDERS 417

Table 52. Sympathectomy in Post-Traumatic Vasomotor Disorders

[Indication: Chronic Ulcers]

In all patients treated by sympathectomy, strenuous active exercises were

insisted upon after short period of convalescence. It was the universal

experience that such activity could be undertaken with little or no discomfort

after the operation and that steady subsequent improvement would occur as

the patient continued to take advantage of his increased ability to perform

physical exercise.

Except for one patient transferred to neuropsychiatric center (Case 8,

Table 49), second discharged because of hysteria (Case 3, Table 49), and

third separated because of marked pes planus (Case 21, Table 51), all those

treated by sympathectomy in whom no further surgery was necessary for correction of other combat-incurred defects were transferred to convalescent

facilities for advanced reconditioning or return to duty.

Effect of Treatment Upon Osteoporosis

Comparative roentgenograms of patients with osteoporosis made at the

time of admittance to the hospital and some months later after institution of

treatment were available for study in 24 cases. In 11 of the patients no alteration in the degree of osteoporosis was noted in the final roentgenograms. In

this group the first film, taken between to 14 months after the original trauma

(an average of about months), showed slight osteoporosis in 2, moderate bone

changes in 8, and marked changes in 1. Final roentgenograms were obtained

from to 17 months afterinjury, with an average of about 11 months. Average

time interval of observation was thus about months.

The other 13 patients showed definite improvement in respect to osteoporosis in the films taken after treatment. The original films were taken from

2.5 to months after trauma with an average of about months. These first

Case

No.

Operation,

months

after

injury

Original injury Manifestations Results

33 21.0 Simple fracture, tibia and

fibula, evulsion of skin.

Ulcer by cm. over

internal malleolus.

Pain on weight-bearing; edema,

cyanosis and reduced oscillometry. Foot cool but warmer

than normal extremity.

Split, sliding, full thickness and pedicle

grafts failed before sympathectomy.

After sympathectomy ulcer healed

rapidly and permanently. Foot

warm, dry, of good color.. Edema

much less. Walking improved.

34 12.0 Compound fracture, fibula. Ulcer by 3H cm.

on lateral surface leg.

Aching rest pain; pain on weightbearing; edema, cyanosis, coldness and hypesthesia.

Small deep and split grafts failed before sympathectomy. After sympathectomy ulcer healed rapidly,

transfer graft successful. Foot

warm, dry, well colored. Hypesthesia gone. Edema less. No pain

on weight-bearing.
418 VASCULAR SURGERY IN WORLD WAR II

films, revealing reversal toward the normal state, were obtained from to 12

months after injury. There was an average, then, of about months between

the original films and the films which indicated improvement. The original

roentgenograms showed slight osteoporosis in patient, moderate bone changes

in 6, and marked changes in 6. Of the patients who originally showed marked

changes, showed normal structure in the final film and showed only moderate

osteoporosis. In the remaining patient the films revealed only slight improvement. In of patients who originally had moderate osteoporosis, evidence

of only mild involvement was present after treatment; in the other the

roentgenograms revealed normal or practically normal condition. The

single patient who originally had slight osteoporosis had normal appearing

bones on the last examination.

In analyzing the roentgenologic changes in osteoporosis from the standpoint of treatment employed in these patients, it is of interest that out of

patients treated by exercise, physical therapy, or psychotherapy, and of 15

patients treated by sympathectomy, showed some improvement. Two other

patients treated by sympathectomy, in whom no change in the degree of osteoporosis was observed after treatment, had fractures of the long bones which

had required prolonged immobilization before operation, and it is possible

that the factor of continued disuse may have played role in the persistence

of the osteoporosis.

COMMENT

Patients who have sustained trauma to an extremity usually have symptoms readily explained as the result of local tissue injury. certain number,

however, have superimposed upon these, other manifestations which can be

interpreted only on the basis of some reflex activity initiated by the local

trauma. Patients with vasomotor disorders of this kind may have an initial

and transient period of hyperemia, or their difficulties may begin with signs of

intense vasoconstriction. Later, the great majority show evidence of sympathetic hyperactivity. Primary manifestations in the acute stage are predominantly pain and swelling, although in smaller number of patients coldness, hyperhidrosis, and cyanosis are more prominent. Later in the course

of the illness the commonest complaints are swelling and pain on exercise and

weight-bearing. Coldness, cyanosis, and hyperhidrosis are frequently noted

and some suffer from distressing cold sensitivity. Many have edema which is

present at rest, though it is more frequently noted when the limb is dependent.

Persistent ulceration may be present when the skin is denuded.

patient with painful or edematous extremity, or an extremity which

is the site of distressing coldness and hyperhidrosis, is strongly tempted to

keep it at rest. Disuse itself may bring about reduction in the blood flow

with associated coldness, cyanosis, hyperhidrosis, edema, muscle atrophy, and

osteoporosis. These are all alterations which are part of the post-traumatic
POST-TRAUMATIC VASOMOTOR DISORDERS 419

syndrome. Consequently, it is often difficult to evaluate the relative roles

of the trauma and the reflexes initiated by it on the one hand, and of the

resultant disuse on the other.

Continued disuse of the injured extremity also tends to bring about

rather fixed mental attitude which hampers return to normal activity. This

factor may be the result of fear, discomfort, discouragement concerning recovery, or of some motivation to prolong the disability such as desire for

compensation, avoidance of military duty, separation from service, or other

rewards of invalidism.

Finally, emotional stress and instability, as well as certain of the more

clear-cut psychiatric conditions, are often associated with increased sympathetic activity. Not infrequently those who have sustained an injury

may bring such emotional and psychiatric mechanisms into play. Any

casualty with post-traumatic vasomotor disturbance must therefore be

studied from this standpoint as well as from the purely physical.

Initial handling of the local injury should include such measures as

debridement, removal of foreign bodies, reduction of fractures, and active

treatment of infection. Although immobilization and bed rest should be

utilized when they are indicated, early mobilization is advisable in most

instances. Some patients, in fact, can prevent the post-traumatic syndrome, or

overcome it when it develops shortly after injury, by simple persistence in

forced active exercise. It is essential to instill in the patient confidence in

his ability to make satisfactory recovery, to eliminate any tendency toward

chronic invalidism, and to correct any coexisting psychiatric ailment.

In many individuals, however, the difficulty cannot be alleviated so simply.

In some of these such procedure as direct blocking of the sympathetic pathways by procaine infiltration produces markedly beneficial effects. Not

infrequently, as soon as the injection is completed, pain and hypesthesia

disappear, temperature and color return to normal, and motor function is

restored. If foot is involved, it is not unusual to find that after sympathetic

blocks the patient can immediately bear weight and walk normally. In

manypersons single injection will suffice, while in others series of treatments

is necessary. If beneficial, but only transient, effect follows sympathetic

anesthesia, it is quite possible that sympathectomy will produce complete

cure. Periarterial sympathectomy has been suggested for milder cases. In

certain patients in whom the site of local irritation, such as painful scar or

thrombosed vessel is clearly evident, good results follow excision of the trigger

points which might propagate the reflex disturbance. Sometimes local infiltration of procaine in the region of the injury results in dramatic improvement;

this method is possibly also of value in preventing the development of posttraumatic disturbances.

In the treatment of the later stages of post-traumatic vasomotor disorders,

the situation is complicated both by the fixed mental attitude of the patient
420 VASCULAR SURGERY IN WORLD WAR II

which is that of the chronic invalid, and by the extensive atrophy and motor

weakness which result not only from the initial injury but also from the superimposed disuse. It is important to utilize psychotherapy in encouraging

continued and gradually increasing active exercise of the affected limb and

to employ more specific psychotherapeutic measures in those instances in

which psychiatric factors are an accompaniment of, if not the primary basis

for, the disability. Regardless of any other type of treatment, it is important

to avoid edema by period of bed rest with elevation of the limb and, if necessary, by the use of an elastic support.

In general, sympathetic blocks have little therapeutic value when the syndrome is of long duration, but may prove very useful in some patients, particularly those in whom edema is the primary manifestation or in whom evidence

of increased sympathetic activity is predominant.

If the measures outlined have been tried faithfully and yield unsatisfactory

results, sympathectomy should be considered. If the patients are properly

selected, results are usually excellent.

Although numerous individual reports testify to the value of various

therapeutic measures in the management of post-traumatic vasomotor disorders, it is impossible to establish from the data recorded in the literature

the incidence of failures with the various methods of treatment. Experience

with both military and civilian patients, however, emphasizes the importance

of evaluating carefully all possible therapeutic aids in any given patient and

of neglecting no useful adjuvant in treatment.

The group of patients analyzed in this chapter were all individuals in

whom sequelae of trauma persisted and who required prolonged hospitalization

for vasomotor disorders. It is significant that initial therapy, except in two

patients in whom sympathetic blocks were carried out promptly, included

none of the procedures listed as desirable under the circumstances. One

patient experienced steady improvement following two blocks during the second

week after injury and had few sequelae when seen some months later. The

other had transient benefit from the single block carried out on the day of

injury and significant, lasting improvement from several blocks carried out

several months later.

An analysis of group of military personnel has decided advantages.

Military regulations afforded the opportunity to follow these patients carefully

for as long period of hospitalization as was required. Furthermore, in all

patients in this series the same motive was present with regard to the rewards

which might possibly arise from continued disability. Analysis of comparable group of civilian patients is much more difficult. Such patients

differ considerably in age and also in the factors which tend to make the persistence of complaints profitable or futile. Most civilians are necessarily

hospitalized for as brief periods of time as possible and observations upon them

limited to those intervals and to office visits. In general, however, experiences
POST-TRAUMATIC VASOMOTOR DISORDERS 421

with civilian and military patients complement one another. The manifestations of the post-traumatic disorders and the results of their treatment

have been much the same in both military and civilian groups.

The chief point of interest in regard to therapy which emerges from this

study is that the degree and duration of physical disability associated with

post-traumatic vasomotor disorders are dependent in large part upon the

amount of time that elapses between the onset of the condition and the initiation of active and adequate therapy. In most patients in this series early therapy was negligible and ineffective and, as result, distressing sequelae persisted

for many months and necessitated prolonged hospitalization. In contrast to

the long period of hospitalization in these patients is the generally satisfactory

course of events in civilian patients who are treated actively soon after injury.

The period of incapacity is usually much shorter in civilian patients, especially

when possible financial compensation is not factor.

In the treatment of the late manifestations of post-traumatic vasomotor

disorders the duration of therapy is necessarily longer than in the early phases

and more intense program of treatment is required. In addition, there is

considerably less likelihood of completely successful outcome and of the disappearance of all symptoms.
CHAPTER XVI

Sympathectomy in Circulatory

Disturbances of the Extremities

Norman E. Freeman, A4. D.

Sympathectomy was not part of the therapeutic armamentarium in

World War because it had been used in man only occasionally and tentatively

up to that time. Since then large series of cases have been reported from

civilian practice giving the indications for the operation, the technical methods, and the results to be expected. Significant data concerning the operation were

gathered from the military experience in World War II particularly because of

the concentration of patients with vascular injuries and disturbances into

centers for specialized treatment. The unequaled wealth of clinical material

thus provided served to confirm and reemphasize certain concepts of the

value of sympathetic denervation in the treatment of circulatory disturbances

of the extremities.

GENERAL INDICATIONS

There are two chief reasons for the employment of sympathetic denervation of the extremities, namely, the prevention of vasoconstriction and the

relief of pain. The importance of sympathectomy in the prevention of vasoconstriction is apparent from Ochsner’s statement that the prognosis in any

patient with peripheral arterial disease depends upon the degree of vasospasm

because the therapy largely concerns the relief of vasospasm. As to the relief

of pain, although the exact mechanism by which pain in the extremities is

relieved by interruption of sympathetic pathways is still not clear, the fact

that manypatients are thus greatly relieved has been accepted by most surgeons

working in the field.

third, though much less frequent, indication for sympathectomy is the

control of hyperhidrosis. Excessive sweating is due to abnormal activity on

the part of the sympathetic nervous system and occasionally may become so

incapacitating that surgical intervention is required. This is particularly true

in instances of deficient circulation associated with vasospasm in the extremities.

Hyperhidrosis may at times constitute serious disability, chiefly because the

resulting maceration of tissues predisposes them to infection.

Ochsner, A., and DeBakey, M.: Peripheral vasculardisease; critical survey of its conservative and radical treatment.

Surg. Qynec. Obst. 70: 1058-1072, Jun 1940.

Ochsner, A.: Indications and technic for the interruption of Impulses traversing the lumbar sympathetic ganglia.

8. Clin. North America23: 1318-1334, Oct 1943.
SYMPATHECTOMY IN CIRCULATORY DISTURBANCES 423

INCIDENCE

Most of the 887 sympathectomies performed at the three vascular centers

in the Zone of Interior during World War II were carried out on the basis of

one or the other of the indications just listed. The 672 patients upon whom

the operations were performed were all males and over 60 percent were in their

twenties. The figures from Ashford General Hospital are typical: The average

age of the patients subjected to operation there was about 22 years, the age

range 19 to 38 years.

Six hundred seventy operations were lumbar ganglionectomies and 217

were upper thoracic preganglionic sympathetic ramisectomies. Sympathectomy was performed for extremity in 472 patients, for extremities in 190

(bilateral), for extremities in 5, and for all extremities in patients.

Lumbar Sympathectomy. The indications for which lumbar sympathectomy was performed, and the proportionate distribution of cases, were as

follows:

Trenchfoot and frostbite, with or without gangrene, 43 percent.

Thromboangiitis obliterans of the lower extremities, 19 percent.

Vascular insufficiency, 19 percent. This group included patients with

impaired circulation following ligation of major peripheral arteries; patients

with arterial occlusion resulting from arteriosclerosis, thrombosis, and embolism; and patients on whom prophylactic sympathetic denervation was

performed in order to facilitate the development of collateral circulation prior

to excision of aneurysms of arteriovenous fistulas.

Raynaud’s disease and vasospastic states, 10 percent. This group included not only patients with true Raynaud’s disease but also those who

complained of sensitivity of cold; those suffering with post-traumatic vasospastic states in which the factor of abnormal arterial vasoconstriction had been

the primary reason for surgery; and those suffering from miscellaneous conditions such as acrocyanosis, hyperhidrosis, and scleroderma.

Pain, percent. The majority of the patients in this group were suffering

from causalgia and from post-traumatic osteoporosis (Sudeck’s atrophy).

Thrombophlebitis, percent.

Thoracic Sympathectomy. The indications for which thoracic sympathectomy was performed, and the proportionate distribution of cases, were as

follows:

Raynaud’s disease and vasospastic states, 36 percent.

Vascular insufficiency, 35 percent.

Causalgia and other conditions associated with pain, 23 percent.

Thromboangiitis obliterans of the upper extremity, percent.

PREOPERATIVE TESTING

The vascular centers were equipped with facilities for special diagnostic

tests for the evaluation of the circulatory status of patients with disturbances

330323 0—55 28
424 VASCULAR SURGERY IN WORLD WAR II

of the peripheral circulation. In most instances, prior to sympathectomy,

measurements of the skin temperature by means of thermocouples were made

in constant temperature rooms, and pulsations of the peripheral arteries were

determined by means of the oscillometer. The capacity of the blood vessels

to dilate following release of vasoconstrictor tone was also observed.

The chief indication for sympathectomy, as already noted, is abnormal

vasoconstriction or vasospasm. Vasoconstriction is the normal physiologic

response of the body to cooling. It occurs both in normal patients and in those

with diseased or injured blood vessels. The diagnosis of an abnormal degree

of vasoconstriction is simple in such conditions as Raynaud’s phenomenon, for

instance, in which so-called digital syncope can usually be produced by exposure

of the patient to cold shower, but in less severe cases it is far more difficult

to reach conclusion and diagnostic measures have developed only gradually.

Brown, in 1926, was the first to approach the problem of placing vasomotor tone in man on quantitative basis by comparing the rise in the skin

temperature of the digits with the rise in the oral temperature after the administration of typhoid vaccine; the change in the surface temperature of the

foot provided the index of vasodilatation. White, in 1930, used paravertebral

injection of procaine hydrochloride to block the sympathetic nerves to the

extremity as test to evaluate the benefit of sympathetic ganglionectomy.

Morton and Scott, in 1931, used general, spinal, and local anesthesia to release

vasomotor tone and designated the average maximum vasodilator response

for healthy arteries as “the normal vasodilatation level.” Gibbon and Landis,

in 1932, differentiated vasospastic from occlusive arterial disease by the vasodilatation with associated rise in the skin temperature which occurs upon heating

unaffected extremities or portions of the body.

The tests described, which are based on the vasodilating capacity of the

extremity, are useful in estimating the degree of organic vascular occlusion

present in patient, but they do not indicate the relative degree of vasoconstriction which intermittently or constantly affects the blood supply to the

peripheral tissues. In order to make the diagnosis of abnormal vasoconstriction in this series, it was necessary, therefore, to utilize certain clinical signs.

The combination of peripheral cyanosis, increased sweating, and constriction of the superficial veins of the extremities used by Freeman and

Montgomery as clinical evidence of high vasomotor tone proved useful at

the vascular centers in the selection of patients with intermittent claudication

Brown, O. E.; Treatment ofperipheral vasculardisturbances of the extremities. J. A. M. A. 87; 379-383, Aug 26.

White, J. C.: Diagnostic blocking of sympathetic nerves to extremities with procaine; test to evaluate the benefit

of sympathetic ganglionectomy. J. A. M. A. 94: 1382-1388, May 30.

Morton, J. J., and Scott, W. J. M.; Methods forestimating thedegree of sympathetic vasoconstriction inperipheral

vasculardiseases. New England J. Med. 204: 955-962, May 31.

Gibbon, J. H., Jr and Landis, E. M.: Vasodilatation in lower extremities in response to immersing forearms In warm water. J. Clin. Investigation 11; 1019-1036, Sep 1932.

Freeman, N. E., and Montgomery, H.: Lumbar sympathectomyin treatment ofintermittent claudication; selection

of cases by claudicationtest with lumbar paravertebral procaine injection. Am. Heart J. 23: 224-242, Feb 1942.
SYMPATHECTOMY IN CIRCULATORY DISTURBANCES 425

for sympathectomy. It was recognized, however, that more objective method

was desirable.

White and Smithwick, on the basis of variations in surface temperature

of the extremities in patients exposed to low room temperatures (20° C.),

differentiated “cold handed” from “hot handed” individuals. Naide, on

the basis of skin temperature changes during the cooling period and subsequent vasodilatation stage of the test described by Gibbon and Landis, 10 devised

quantitative test for basal vascular tone. Later he found it necessary to

note only the response of the digital skin temperature of the hands to the preliminary cooling in order to separate their patients into those with high

degree of vascular tone and those with normal or low tone. He advocated

the use of this test in the selection of patients for sympathectomy because he

found that while the collateral circulation after major arterial occlusion was

excellent in 88 percent of his patients with low vascular tone, equally good

circulation was present in only 34 percent of those with high tone.

Forty-five patients with arterial injuries were studied by this test at DeWitt General Hospital prior to sympathectomy. The results were in agreement with the clinical evidence in 32 but did not conform with it in 13 patients.

The results of operation indicated that the tests were valid in 20 patients, but

in 11 others subsequent events showed that it had been misleading. In the

remaining patients restoration of the continuity of the artery made postoperative evaluation by this method impossible. In this same group of 31

patients the end results in 26 were what might have been expected from

study of the clinical signs of abnormal vasoconstriction. Naide’s test was

frequently of value in confirming the clinical evidence of high vasomotor tone

though it was occasionally misleading, and only rarely was it of diagnostic

significance.

possible explanation of the discrepancy between the results of the cold

test and the impression gained on clinical observation is that the physiologic

stimulus present at the time the examinations were made in the hospitals,

such as excitement or mild emotional disturbance, differed from the stimulus

present during exposure to cold. Another possible explanation is differences in

the type of stimulus used. Finally, since the arterial occlusion in each case

resulted from trauma, it is quite within reason that reflex vasoconstriction

might have been set up in the region supplied by the injured vessels; this is

purely local phenomenon which might be quite unaffected by the general

vasomotor tone of the upper extremities as measured by the test.

The experience at the vascular center of DeWitt General Hospital with

this and the other tests listed led to the conclusion that valid qualitative

White, James C., and Smithwick, Reginald H.: The Autonomic Nervous System. 2nd ed. New York, The

Macmillan Company, 1941.

Naide, M.: Test for vascular tone In humans and its application to the study of vascular diseases with special reference to the etiology and prevention of thrombophlebitis. Am. J. M. Sc. 207; 606-620, May 1944. 10 See footnote 6, p. 424.
426 VASCULAR SURGERY IN WORLD WAR II

test for the diagnosis of abnormal vasoconstriction was still to be developed.

Experience at the other centers were to the same effect.

OPERATIVE TECHNIQUE

Lumbar Sympathectomy

All lumbar sympathectomies at the vascular centers in the Zone of In- terior were carried out through an extraperitoneal approach. At both Ashford General Hospital and Mayo General Hospital, the operation was performed through transverse, anterior, muscle-splitting incision. At DeWitt

General Hospital similar approach was used, with incision of the muscles

of the abdominal wall. 11 Spinal analgesia was used in all but few cases,

and in those endotracheal nitrous-oxide-oxygen anesthesia was employed.

Atlas, 12 who made careful study of the anatomic variations of the lumbar sympathetic nerves, found that ganglion is constantly present lying on

the disc between the second and third lumbar vertebrae and noted recurrence

of sweating along the medial side of the foot when it was not removed. This

observation was borne in mind in sympathectomies performed at the vascular

centers, and in all the second and third lumbar ganglia, with the intervening

chain, were excised. Occasionally the first or the fourth lumbar ganglion was

also removed.

In the large series of operations reported from Mayo General Hospital

the patients were given regular diet and allowed to be up on the day after

operation. The period of disability was considerably longer following the

more extensive muscle-cutting procedure.

Thoracic Sympathectomy

All upper thoracic or dorsal sympathectomies performed at the vascular

centers were, in reality, preganglionic sympathetic ramisectomies, since the

ganglia were not removed but were simply decentralized. At Ashford and

Mayo the posterior muscle-splitting incision was used. The operation was

done by the technique advocated by Smithwick, 13 according to which the

roots of the second and third intercostal nerves are severed either within, or

just outside of, the dura, while the sympathetic chain is divided below the

third dorsal ganglion. The upper portion of the sympathetic chain, together

with the decentralized second and third thoracic ganglia, is then sutured to

the muscles outside of the thoracic cage in order to forestall regeneration.

In the patients operated on at Mayo General Hospital root section was

occasionally omitted. It was carried out in all patients at the other centers.

No differences in clinical results were noted.

11 Harris, R. I.: Role of sympathectomy in treatment of peripheral vascular disease. Brit. J. Surg. 23: 414-424, Oct

1935.1J Atlas, L. N.: Sympathetic denervation limited to the blood vessels of the leg and foot. Ann. Surg. 116: 476-479,

Sep 1942.

'*

Smithwick, R. H.: Problem of producing complete and lasting sympathetic denervation of the upper extremity

by preganglionic section. Ann. Surg. 112; 1085-1100, Dec 1940.
SYMPATHECTOMY IN CIRCULATORY DISTURBANCES 427

At DeWitt General Hospital preference was given to the anterior approach

first described by Royle and later adapted by Gask 14 and by Telford 15 in England, and by De Takats 16 in this country. The sympathetic chain is exposed

behind the pleura through supraclavicular incision and is divided below the

third thoracic ganglion. The connections of the second and third ganglia are

then cut and the decentralized chain sutured to the upper end of the scalenus

anticus muscle.

Endotracheal nitrous oxide-oxygen-ether was the anesthetic of choice for

this operation. The postoperative discomfort and period of disability were

shorter following thoracic sympathectomy through the anterior supraclavicular approach than after the dorsal operation.

SYMPATHECTOMY IN PERIPHERAL VASCULAR

DISTURBANCES Trenchfoot and Frostbite

At the time patients with trenchfoot and frostbite were observed at the

vascular centers, which was always several weeks after the initial incident,

the acute inflammatory reaction characteristic of these conditions had usually

subsided and only disabilities resulting from damage to the soft tissues, peripheral nerves, and blood vessels remained.

In most instances skin temperature and oscillometric determinations were

made, while studies of the response to paravertebral injection of procaine were

found to be especially useful in the selection of patients for sympathectomy.

The criteria for operation used at Ashford General Hospital, which were much

the same as those prevailing at the other centers, included diminution in arterial

pulsations at the foot level as determined by oscillometer, skin temperature

constantly below 79° F., and constant cyanosis and sweating of the feet.

Generally speaking, results obtained from sympathectomy were both

subjectively and objectively beneficial in patients thus selected. In detailed

analysis of one series of 55 patients with trenchfoot and frostbite it was found

that in 35 .with gangrene, lumbar sympathectomy had been performed in 10

instances bilaterally. Though healing ultimately occurred in all 35, most of

the patients required minor amputations and some, various types of skin grafts.

Eleven of the 20 patients without gangrene were also treated by sympathectomy

of both lower extremities. In this group the complaints of coldness, cyanosis,

and annoying sweating of the feet were relieved by the operation, but as

rule complaints of pain and tenderness, present in three-fourths of the patients,

were not relieved.

The results of sympathectomy at the vascular centers suggest that the

residual hyperactivity of the sympathetic nervous system following trauma

from cold (in addition to the actual destruction of tissue) and characterized

14 Gask, Q. E.: Surgery of the sympathetic nervous system. Brit. J. Surg. 21: 113-130, Jul 1933.

19 Telford, E. D.: Technique of sympathectomy. Brit. J. Surg. 23 Oct 1935.

19 De Takats, G.; Effect of sympathectomy on peripheral vascular disease. Surgery 2: 46-60, Jul 1937.
428 VASCULAR SURGERY IN WORLD WAR II

by vasospasm, increased sweating, and sensitivity to cold can be relieved by

this method. On the other hand, pain and tenderness, which are probably

secondary to tissue trauma, usually do not respond to sympathectomy.

Thromboangiitis Obliterans

Before any patient with thromboangiitis obliterans was selected for

sympathectomy, his vascular status was determined by means of the oscillometer with skin temperature measurements. Special attention was also paid

to the capacity of the collateral vessels to dilate after release of vasomotor tone

following spinal analgesia and paravertebral block. In few patients with

marked circulatory impairment, although increase in skin temperatures was

slight, considerable improvement in the condition was noted after sympathectomy. As White 17 commented, wide clinical experience is essential in selecting

the patients for operation from the small group in which sympathectomy has

been shown by experience to be sometimes surprisingly worthwhile even though

preliminary tests do not indicate striking relief of vasospasm. Harris, 18 in

harmony with this concept, wrote that it was his practice to use lumbar sympathectomy in all severe cases of thromboangiitis obliterans regardless of the

results of the preoperative tests.

In the vascular centers it became more and more the tendency in the

selection of patients for sympathectomy in cases of thromboangiitis obliterans,

to rely on clinical evidence of abnormal vasoconstriction, as shown by cyanosis,

sweating, and the presence of constricted veins. Demonstrations of improvement in the ability of the patient to walk after paravertebral block was particularly useful in the selection of individuals for early operation.

At Ashford General Hospital the indications for sympathectomy were

eventually crystallized about as follows: (1) Evidence of large vasospastic

element characterized by cyanosis, coldness, and sweating. (2) Pain, constantly

present. (3) Quantitative elevation of temperature after spinal analgesia or

sympathetic block. (4) The presence of ulcers or gangrene. At the other

centers the indications for sympathectomy were essentially the same. In

numerous instances at all centers the indications were multiple.

Resection of the sympathetic ganglion was carried out for extremity

in 33 of the 152 patients with thromboangiitis obliterans whose records were

available for this analysis, and for extremities (bilateral) in 18 patients. The

operation was also performed in of the patients in whom extremities were

affected. Good results were observed in all. Gangrenous areas demarcated

and separated promptly and healing was rapid. Ulcers also healed. Resting

pain was relieved or partially relieved. Functional capacity, particularly the

ability to walk, was greatly increased. Oscillometric readings and measurements of skin temperatures furnished objective evidence of subjective improvement.

17 White, J. C.: Progress in surgery of the autonomic nervous system, 1940-1942. Surgery 15: 491-517, Mar 1944,

18 Harris, R. I.: Obliterativevascular disease; treatment by sympathectomy. Canad. M. A. J. 45: 529-533, Dec 1941.
SYMPATHECTOMY IN CIRCULATORY DISTURBANCES 429

Minor amputations were necessary in 12 of the patients treated by sympathectomy on the indication of thromboangiitis obliterans, but only of the 53

patients were not improved at all. Major amputation of the leg was required in of these unimproved patients, but in instance it was necessary because

of contractures about the knee and ankle and not because of the vascular

disease per se. It is of interest that the patients who were not at all improved by sympathectomy had all continued to smoke in spite of advice and

prohibitions to the contrary.

There was general agreement in all the vascular centers that sympathectomy is the treatment of choice in thromboangiitis obliterans, especially

in the more severe cases. The disease is frequently associated with abnormal

vasoconstriction, and the circulation will be improved to the extent that

circulatory deficiency can be relieved by removal of this added factor. On

the other hand, De Takats’ 19 warning should be heeded: “Sympathectomy

deprives the extremity of its vasoconstrictor tone. It does not influence the

course of Buerger’s disease.” In other words, as long as obliteration of blood

vessels continues to recur, the disease may be improved or arrested, but it

cannot be said to be cured.

Raynaud's Disease and Vasospastic States

In the group of patients with Raynaud’s disease and other vasospastic

conditions, study of the circulation after removal of vasomotor tone was of

great significance as preoperative test. In group of 57 patients the response

to paravertebral block was used for this purpose in 37, the effects of spinal

anesthesia were observed in 17, and the results of the vasodilatation test (reflex

heat) were used in patients. Differentiation was made between patients with

true Raynaud’s disease and other vasomotor disorders on the basis of the production of actual spasm of digital arteries characterized by digital syncope on

immersion of the entire body for minutes in cold shower. It was sometimes observed that digital syncope was not produced by this procedure even

through characteristic attacks were occasioned in cold weather. The occurrence of typical attacks was therefore considered more significant than the

results of the test. The urgency of the indications for sympathectomy depended

upon the severity and frequency of arterial spasm, especially if destruction of

the digital pulp had occurred or was impending. When cold sensitivity and

frequency of attacks were incapaciting, sympathectomy was regarded as

mandatory.

At Ashford General Hospital considerable improvement was noted in all

30 patients upon whom sympathectomy was performed for Raynaud’s disease.

This operation was carried out for involvement of extremity in patients,

of extremities (bilateral) in 23, of extremities in 2, and of extremities in

patients. Although after operation digital syncope could still be elicited by

i» De Takats, Q.: Value of sympathectomy in the treatment of Buerger’s disease. Surg., Qynec. Obst. 79; 359-367,

Oct 1944.
430 VASCULAR SURGERY IN WORLD WAR II

the cold shower test, it was considerably diminished in degree, extent, and

duration. Within to weeks of operation definite evidence of partial resumption of vasomotor tone in the upper extremity, which could be prevented

by blocking the peripheral nerves with procaine, was noticed in patients

subjected to multiple procedures. The experience at Ashford General Hospital

is in harmony with that reported by the other centers.

Although patients with Raynaud’s disease of the upper extremities were

considerably improved by sympathectomy, they were not cured and none

could be returned to duty. Results observed after sympathectomy of the lower

extremities were, as expected, better than those obtained by operation on the

upper extremities. This difference is probably to be explained by the anatomic

arrangement of the vasoconstrictor nerves to the upper, in comparison with

the lower, limbs.

Post-traumatic Vasospastic States. Patients with post-traumatic vasospastic

states had variety of complaints of which vasospasm, edema, and pain were

the most common. This group was differentiated from patients with causalgia,

post-traumatic painful osteoporosis (Sudeck’s atrophy), and various reflex

dystrophies chiefly on the basis of clinical evidence of abnormal vasoconstriction. They are discussed in Chapter XV.

Causalgia

Paravertebral injection of procaine into the region of the thoracic or

lumbar sympathetic ganglia was the one really significant preoperative diagnostic test in selection for sympathectomy of patients who were suffering from

causalgia and other painful conditions of the extremities. The prompt relief

ofpain after the injection was usually striking and conclusive. Skin temperature

and oscillometric determinations were significant only in demonstrating that

the sympathetic block had been successful. Subsequent sympathectomy was

generally effective in relieving the condition. Equally good results were obtained in patients with pain in either the upper or the lower extremity. Of the

57 patients treated for causalgia by sympathectomy at Mayo General Hospital,

excellent results were reported in 46, and good effects in 9. In patients the

end result was described as fair or poor. Sympathectomy was performed

chiefly because of pain in the extremities in 60 patients at Ashford General

Hospital. The operation was almost uniformly effective in relieving this

symptom.

The exact mechanism through which sympathectomy relieves pain in the

extremities is not fully understood. The dramatic relief afforded by sympathetic

block furnishes, however, strong clinical evidence to support the concept that

nerves mediating painful sensations from the extremities actually traverse the sympathetic ganglia. Attempts to demonstrate their presence, whether by

anatomic studies or by physiologic investigations, have generally been unsuccessful, although some observations in this field arc promising. In order to
SYMPATHECTOMY IN CIRCULATORY DISTURBANCES 431

explain the clinical observations other concepts have been advanced. Lewis 20

suggested that the relief of pain after sympathectomy is the result of the persistently increased blood flow through the cutaneous vessels consequent upon

loss of vasomotor tone. The essential disturbance, according to Livingston, 21

is “central perturbation of function involving the spinal cord centers”; he also

suggested that the “sympathetic nerves may contribute to the development of

peripheral tissue changes, which may lead to additional afferent impulses.”

Both of these explanations are based on the concept that relief of pain in

causalgia depends on paralysis of efferent sympathetic nerves with consequent

loss of vasomotor tone. Clinical evidence, however, suggest that the relief

observed depends on the suppression of afferent sensory stimuli. Only the

failure of experimental investigation to reveal the transmission of pain stimuli

from the extremities across sympathetic ganglia prevents the acceptance of the

simpler explanation which accords so readily with clinical observations.

Probably the most reasonable explanation of causalgic pain is that advanced

by Doupe 22 and coworkers who ascribe its peculiar qualities to direct cross

stimulation of sensory fibers by efferent sympathetic impulses at the point

where the nerve trunk is injured, rather than to the indirect action of the vasoconstrictor response which they also produce. Final explanation of the mechanism of the relief achieved in causalgia and other painful conditions of the

extremities by sympathectomy or by injections of procaine around the sympathetic ganglia must await further experimental evidence. There was general

agreement in the vascular centers, however, that sympathectomy, whatever

the mechanism, was quite effective in the treatment of these painful conditions.

Vascular Insufficiency

Records show that in the category of vascular insufficiency were included

(1) those patients with impaired circulation following ligation of major vessels

of the extremity, (2) those in whom arterial thrombosis developed at the site of

trauma, and (3) those in whom sympathectomy was performed as prophylactic

measure prior to operation for arterial lesions. Sympathectomy was performed

in well over half of these patients for symptoms arising from obstruction of the

main arterial supply to the limb. Preoperative tests included skin temperature and oscillometric determinations, also observation of the vascular supply

after spinal analgesia or paravertebral block.

The chief indications for sympathectomy in patients in the first two categories were impaired circulation, nerve paralysis, gangrene, and ulceration.

The results of sympathectomy in this group were extremely satisfactory. In

spite of the severe impairment of circulation, improvement was noted in all

patients. Ulceration and gangrenous areas healed although minor amputations

Lewis, Thomas; Pain. New York, The Macmillan Company, 1942. J1 Livingston, William K.: Pain Mechanisms. Physiologic Interpretation of Causalgla and Its Related States.

New York, The Macmillan Company, 1943.

Doupe, J.;Cullen, C. H., and Chance, O. Q.: Post-traumatic pain and the causalgic syndrome. J. Neurol., Neurosurg. Psychlat. 7: 33-48, Jan-Apr 1944.
432 VASCULAR SURGERY IN WORLD WAR II

and skin grafts were necessary in some. Satisfactory progress in nerve recovery

took place. Amputation of the extremity was ultimately necessary in only

patients, in of whom circulatory impairment was not the cause; the operation

was done for contracture and recurrent osteomyelitis.

The chief indications for sympathectomy after excision of aneurysms or

arteriovenous fistulas were sensitivity to cold, nerve damage, impaired circulation, and pain. In all instances cold sensitivity and pain were relieved by

operation. Improvement in the function of peripheral nerves also resulted.

Amputation was necessary in only one patient; thrombosis of the collateral

vessels developed after excision of femoral arteriovenous aneurysm. The

circulation improved following sympathectomy, but gangrene of the foot

developed later and amputation became imperative.

Ninety-three of the 155 sympathectomies available for analysis and categorized as operations for vascular insufficiency were performed for prophylactic

reasons in order to facilitate the development of collateral circulation before

operation. In spite of the arterial lesions circulation was adequately maintained

in the majority of the patients before operation, but there were instances

of gangrene and others in which circulation was impaired. Associated

nerve damage was present in 25 patients but in all improvement followed

sympathectomy.

The chief indication for sympathectomy in the group of prophylactic

operations was poor collateral circulation as determined, prior to excision of

the arterial aneurysm or arteriovenous fistula, by the Matas-Moschcowitz test:

The main artery was temporarily occluded at the site of the arterial lesion, the

distal tissues were rendered ischemic for minutes by an Esmarch bandage,

and the time necessary for flushing of the extremity after release of the bandage,

noted. The collateral circulation was regarded as good if, while the main

artery was still occluded, color returned to the distal portion of the extremity

in 60 seconds or less. If flushing was delayed more than minutes, the collateral circulation was considered unsatisfactory.

In the patients in this group observed at DeWitt General Hospital the

average time required for color to return to the extremity before sympathectomy was minutes and 15 seconds. After the operation the time was reduced

to 45 seconds. Definite improvement in the collateral circulation, as determined by the fluorescein wheal test, was also noted in these patients.

The indications for sympathectomy following traumatic or therapeutic

occlusion of major arteries gave rise to no differences of opinion when actual

gangrene or ulceration, ischemic paralysis, pain, and other results of impaired

circulation were present. All of these are conditions known to be greatly

improved by sympathectomy. They may also be prevented if sympathectomy

is performed as soon as vascular impairment becomes evident, as advocated by

Learmonth 23 in the treatment of acute vascular injuries. In two patients

23 Learmonth, J. R.: Surgery of blood vessels. Edinburgh M. J. 47: 225-240, Apr 1940.
SYMPATHECTOMY IN CIRCULATORY DISTURBANCES 433

included in this series the foot became extremely ischemic after ligation of the popliteal artery for an arterial lesion. Sympathectomy was performed immediately, in each instance while the patient was still underthe original anesthetic, and results in both patients were excellent.

There was not complete agreement at the vascular centers, however, over

the advisability of sympathectomy as prophylactic procedure either before

or after excision of aneurysms and arteriovenous fistulas. The surgeons at

Mayo General Hospital and DeWitt General Hospital were in favor of the

procedure. The surgeons at the vascular center of Ashford General Hospital

were not. In contrast to 149 operations performed for vascular insufficiency

at Mayo and DeWitt General Hospitals, only of the 469 sympathectomies

performed at the Ashford center were for this condition. Elkin, at Ashford,

has repeatedly stated that it is his personal belief, based on experience, that

sympathectomy is not necessary in such cases if sufficient time has been allowed

to elapse for collateral circulation to develop. In his opinion, 24 “It is an

assumption, and nothing more or less than that, that gangrene is prevented

by sympathectomy.” His extensive experience in vascular surgery makes it

quite clear that sympathectomy is not required to prevent gangrene, and there

were no instances of it following excision of aneurysms or arteriovenous fistulas

at the Ashford General Hospital where interruption of the sympathetic pathways

has been omitted.

On the other hand, in spite of the Ashford experience, the question arises

as to the degree of vascular insufficiency which persists after operation. The

collateral circulation in the patients managed at that hospital without sympathectomy may have been quite adequate to maintain tissue nutrition while

they were at rest so that gangrene did not develop after operation, but whether

it was sufficient to permit normal activity after they left the hospital is another

matter. The improvement noted at the other centers after sympathectomy

in patients who had undergone ligation of major arteries, and in others who

complained of symptoms of vascular insufficiency after excision of arterial

lesions, indicated the value of this procedure in these circumstances. Digger’s 25

experience may also be cited in this connection. He wrote:

In the literature dealing with the treatment of traumatic vascular lesions of important

blood vessels, much is said, and properly, about the cure of the lesion and the avoidance

of acute ischemic gangrene, but remarkably little consideration is given to the permanent

reduction of blood supply to the tissues, especially the muscles, distal to the lesion.

Bigger noted excellent immediate results following excision of arteriovenous fistulas when sympathectomy was omitted but found late results less

satisfactory. Of patients examined between months and years after

operation, had marked symptoms of chronic circulatory deficiency distal to

the obstruction. Bigger therefore concluded that permanent interruption of

24 Elkin, D. C.: Personal communication to the author. 25 Bigger, I. A.; Treatment of traumatic aneurysms and arteriovenous fistulas. Arch. Surg. 49: 170-179, Sep 1944.
434 VASCULAR SURGERY IN WORLD WAR 11

the sympathetic nerves to the extremity may help prevent chronic circulatory

deficiency distal to the obstruction. Others share his opinion. Learmonth 26

advocated sympathectomy in all patients in whom permanent ligation of the

femoral or popliteal arteries is expected and Gage and Ochsner 27 recommended

chemical section of the sympathetic nerves before operations on major arteries.

Since the development of collateral circulation determines the ultimate

outcome in vascular operations involving ligations of major arteries to the

extremities, and since abnormal vasoconstriction apparently interferes with the

development of collaterals, sympathectomy should perhaps be reserved for

those patients who show evidence of increased vasomotor tone. Prophylactic

sympathectomy, although it increases the assurance of an adequate postoperative blood supply, might well be reserved for those patients in whom the

location of the arterial lesions and the results of the preoperative tests indicate

that severe disturbances of circulation may follow ligation of the major artery

to the extremity. Even in those patients it might be justifiable to hold the

operation in reserve and to perform it only in the event that arterial ligation

leaves an incapacitating circulatory disturbance.

Unnecessary Prophylactic Sympathectomy. Though preoperative sympathectomy improves the collateral circulation in patients with aneurysms and

arteriovenous fistulas upon whom vascular surgery is to be performed, prophylactic operation is not always necessary. Spontaneous closure of the

fistula and spontaneous cure of an aneurysm may occur (see Chapter XII).

Moreover, the main artery to the extremity may prove not to be the one involved, or subsequent arterial repair may be found to be possible.

Clinically satisfactory spontaneous closure of subclavian arteriovenous

fistula and spontaneous cure of femoral arterial aneurysm were observed

following sympathectomy at one vascular center and case similar to the

latter was observed at another center. Sympathectomy, however, cannot be

given full responsibility for inducing the closure since spontaneous cures were

recorded in similar cases in which sympathectomy was not carried out. It

is self-evident that in these instances prophylactic sympathectomy was

unnecessary. On the other hand, spontaneous cure of an aneurysm or spontaneous closure of an arteriovenous fistula may occasionally be followed by

sufficient impairment of circulation to necessitate subsequent sympathectomy.

Inaccurate localization of an arterial lesion before operation may also lead

to unnecessary sympathectomy. branch rather than the main artery may

be the vessel involved. This happened in several instances in this combined

series. In instances the lateral circumflex femoral or the profunda femoris

artery was involved instead of the femoral artery. In other instances

geniculate artery was involved instead of the popliteal as had been supposed.

In still another instance the transverse cervical branch, instead of the sub28 See footnote 23, p. 432. 27 Gage, M., and Ochsner, A.: Prevention of ischemic gangrene following surgical operationsupon the major peripheral

arteries by chemical section of the cervicodorsal and lumbar sympathetics. Ann. Surg. 112: 938-959, Nov 1940.
SYMPATHECTOMY IN CIRCULATORY DISTURBANCES 435

clavian artery, was the site of the arterial lesion. In case reported from

vascular center an arteriovenous fistula, which involved the arch of the aorta

and the superior vena cava, could not be excised and sympathectomy of the

left upper extremity was therefore performed unnecessarily.

Restoration of the continuity of the artery instead of excision of the lesion

may also make preliminary sympathectomy unnecessary. In several instances

of arteriovenous fistulas in this series, and in small number of arterial aneurysms, successful repair of the arteries and restoration of the circulation rendered the prophylactic sympathectomy which had been performed quite superfluous. It may be argued that preliminary sympathectomy possibly contributed to the success of the arterial repair. In patients, however,

suture of the artery was successfully employed without preliminary sympathectomy, while in instances, in both of which sympathectomy had been

done, arterial repair was not successful.

Thrombophlebitis

Many patients with longstanding thrombophlebitis were referred to the

vascular centers for treatment of the resulting disabilities which included

cyanosis, sweating, diminished peripheral circulation, and pain. Temporary

relief following paravertebral block suggested that lumbar sympathectomy

might be of benefit in these patients. The value of this method in the early

treatment of thrombophlebitis of the lower extremities, first advocated by

Leriche and Kunlin, 28 had been well established before World War II by the

subsequent studies of Ochsner and DeBakey. 29

Seven patients referred to the vascular centers for the treatment of late

thrombophlebitis were treated by this method. Although the sweating and

peripheral vasoconstriction present were abolished and pain was moderately

relieved, congestion and edema caused by venous obstruction were not benefited. In or patients operated on at Ashford General Hospital on this

indication, complaints of cyanosis, edema, congestion of the limb, and pain on

walking were increased after the operation. The other patient was slightly

improved. On the face of the evidence, therefore, sympathectomy does not

seem of value in the treatment of the late residua of thrombophlebitis.

ANALYSIS OF RESULTS

The 887 sympathectomies performed in the vascular centers in the Zone of

Interior were carried out without single fatality attributable to the operation.

This record may in part be ascribed to the fact that the patients were mostly

young and healthy, and in part to the fact that sympathectomy has become

standardized procedure which, in the hands of well-qualified surgeons, should

always carry small risk.

Leriche, R., and Kunlin, J.: Traitement immMiat des phlfibites post-op6ratoires par 1’infiltrationnovocalnique du

sympathique lombaire. Presse m6d. 42: 1481-1482, 22 Sep 34. *•

Ochsner, A., and DeBakey, M.: Treatment of thrombophlebitis by novocain block of sympathetics; technique

of injection. Surgery 5: 491-497, Apr 1939.
436 VASCULAR SURGERY IN WORLD WAR II

The possibility of sterility as the result of interference with ejaculation

after bilateral lumbar sympathectomy might constitute definite contraindication to the performance of this operation, especially in young men.

Ochsner 30 has maintained that bilateral resection of the first lumbar interferes

with ejaculation, and White and Smithwick 31 stated “After removal of the

[superior hypogastric] plexus or injury to the first lumbar ganglia the power of

ejaculation is lost,” but added in footnote “We are obtaining increasing

clinical evidence that males may not be sterile or have any alteration of sexual

function after bilateral excision of the first or even the upper three lumbar

ganglia.” In the majority of sympathectomies performed at the vascular

centers, the first lumbar ganglion was not removed. Lake 32 found in patients

normal numbers of spermatozoa after bilateral resection of the second, third,

and fourth lumbar ganglia, and De Takats and Helfrich 33 reported similar

findings after extensive bilateral lumbodorsal sympathectomy.

Particular attention was paid to this problem in studying the patient

upon whom sympathectomy was performed. No patients complained of difficulty with ejaculation in the group reported from Mayo General HospitalThree patients at Ashford General Hospital claimed temporary impotence but

the bilateral operation had not been performed in any of them and it seems

probable that the condition was on an emotional basis.

Complications and Sequelae. While it was inevitable that certain number of incidental complications should have occurred, such as infections and

hematomas in operative wounds, these were infrequent. Pneumothorax, once

unilateral and once bilateral, followed thoracic sympathectomy in instances. It was readily treated by aspiration of the pleural cavity. Inadvertent resection of the fourth rib instead of the third, during sympathectomy

by the dorsal approach, led to incomplete denervation in patient. Transient spinal radiculitis developed in patient after dorsal sympathectomy.

Following lumbar sympathectomy number of patients complained of

pain in the thigh and of paresthesias in the distribution of the genitofemoral

nerve. The incidence of this complication was reported as 25 percent from

Ashford General Hospital and was about the same at the DeWitt General

Hospital. On the other hand, it was notably lower at Mayo General Hospital—not more than percent—and in only patients did the pain persist

for more than 10 days. The infrequent occurrence of this troublesome symptom at this center may possibly be explained by the more limited operative

exposure which was used. The pain in the thigh, although annoying, disappeared spontaneously. Sweating of the body may be greatly increased after

30 See footnote 2, p. 422. 31 See footnote 8,p. 425. 32 Lake, N. C.: Sympathectomy and sterility. Brit. M. J. 1; 843, 24 Jun 44. 33 De Takats, G., and Helfrich, L. S.: Sterility of the male after sympathectomies. J. A. M. A. 117: 20-21, Jul 41.
SYMPATHECTOMY IN CIRCULATORY DISTURBANCES 437

quadrilateral sympathectomy, with resultant paralysis of the sweat glands of

all extremities, and patients complained of excessive perspiration after

their operations.

After thoracic sympathectomy partial recurrence of vasospasm characterized by digital syncope was frequently observed, especially in patients with

Raynaud’s disease, when the cold shower test was given. This was not true

of the patients upon whom the lumbar operation had been performed. This

observation, which is in keeping with that of the majority of surgeons working

in this field, has been the subject of considerable controversy. Lewis 34 noted

that vasoconstriction still took place in the fingers after excision of the stellate

and upper thoracic ganglia. He therefore ascribed the vasospasm in Raynaud’s

disease to “local fault,” the assumption being that the blood vessels of the

digits are abnormally sensitive to cold while the vasomotor reactions are

normal. The possibility that the recurrent vasoconstriction is caused by

sensitization of the blood vessels to circulating adrenalin as the result of

sympathetic ganglionectomy was advanced by Freeman, Smithwiek, and

White. 35 It was to avoid this sensitization phenomenon that Smithwiek 36

suggested the preganglionic type of sympathectomy which has now come to

be so extensively practiced. Even after this operation, however, residual

vasospasm is frequently noted in patients with Raynaud’s disease. It was

reported from ail of the vascular centers.

The fact that blocking the peripheral nerves with procaine, as previously

noted, was followed in two patients by noticeable elevation in temperature of

the digits (an observation which confirms those of other investigators) indicates that there is some persistent innervation by vasoconstrictor fibers.

Kuntz and Dillon 37 attributed residual vasoconstriction to efferent fibers

arising from the first dorsal root, since they had found evidence of such neural

pathways in the experimental animal. Ray, Hinsey, and Geohegan 38 showed

by stimulation of the anterior roots in man that preganglionic impulses may

be transmitted through the first dorsal root. Regeneration of preganglionic

nerves has also been suggested as an explanation. Obviously, the problem of

how to produce lasting preganglionic denervation of the upper extremity is

not yet fully solved.

3* Lewis, T.: Experiments relating to the peripheral mechanism involved in spasmodic arrest of the circulation in

the fingers, variety of Raynaud’s disease. Heart 15; 7-101, Aug 1929.

3» Freeman, N. E.; Smithwiek, R. H., and White, J. C.: Adrenal secretion in man; reactions of blood vessels of

human extremity, sensitized by sympathectomy to adrenalin and to adrenal secretion resulting from insulin hypoglycemia. Am. J. Physiol. 107 529-534, Mar 1934.

s* See footnote 13, p. 426.

Kuntz, A., and Dillon, J. B.: Preganglionic components of the first thoracic nerve; their role in sympathetic

innervation of the upper extremity. Arch. Surg. 44: 772-778, Apr 1942.

a* Ray, B. S.; Hinsey, J. C., and Geohegan, W. A.: Observations on the distribution of the sympathetic nerves to

the pupil and upper extremity as determined by stimulation of the anterior roots in man. Ann. Surg. 118 647-655,

Oct 1943.

Index

Abramson, Maj. David I.: 310-317, 378, 383-394, 395-421

Acrocyanosis: 391

distinguished from Raynaud’s syndrome:

386

Adkins, Capt. Trogler F.: 86-92

Administration and organization of vascular centers: 3-5

laboratory tests: 28

physical examinations: 23-28

records: 15, 16, 19-22

Alaska: 387

Aleutian theater:

Allen, E. V.; 377

Allen’s blanching test: 29

Amputation

directives on primary: 108, 109

in arterial embolism: 382

in battle casualties with acute arterial

wounds: 66-70

by cause: 66, 67 comparative American, German,

Russian: 66, 67

by management, methods of: 112, 125,

137 by repair, arterial, types of: 112

effect of

fractures, associated, on incidence:

76, 77

site of wound: 67-70, 77-80

by artery: 69

on incidence: 78

comparative extremity wounds,

British World War I, American World War II: 77, 78

of brachial and femoral arteries, on

incidence: 78, 79, 80

of extremities, comparative upper

and lower, on incidence: 78,

79

timelag, on incidence in extremity

wounds: 73, 74, 75

type of wound, on incidence in extremity wounds: 80-82

Amputation—Continued

in battle casualties with acute arterial

wounds—continued

following

gangrene

gas; 67, 84, 85

comparative American, German, Russian: 66, 67

ischemic: 84

infection; 66, 67, 84, 85

ligation; 112

with and without concomitant

venous ligation, British World

War I; 105

with and without concomitant

venous ligation, comparative

British World War I, American World War II; 108

sympathectomy and sympathetic

block: 137

trauma: 66, 67

comparative American, German,

Russian: 66, 67

vascular wounds: 67

in thromboangiitis obliterans: 380, 429

in trenchfoot and frostbite; 427 in vascular insufficiency: 431, 432

primary, in management of combat

wounds: 85, 108, 109

directives on: 108

Anastomosis

end-to-end: 111, 161, 279, 280, 292-294

case reports: 96, 279, 280

nonsuture: 119-126, 272, 273

case reports: 116-118, 119-121, 122-

124

Aneurysms. See also Aneurysms and arteriovenous fistulas; Specific arteries,

arteriography, as method of study: 51, 52

as complication following combat injuries: 139-142

case reports: 140-142

policies of management: 71, 139, 140

blood pressure, method of intra-aneurysmal measurement: 58, 59

330323 0—55 29
440 VASCULAR SURGERY IN WORLD WAR II

An eurysms Continued

circulation, collateral, preoperative determinations. See also Vascular status, methods of determination,

claudication time: 33, 338

Delbet’s sign: 31, 32, 33

occlusive compression: 32, 33

reactive hyperemia: 33-36

cirsoid

of arm, sympathectomy as adjunct

measure: 333, 334

of foot, sympathectomy as adjunct

measure: 333, 355, 356

of head, case report: 237, 238

treated Zone of Interior: 155, 162,

236, 237

diagnosis: 154, 157

false

case reports; 128, 129, 134

in battle wounds: 127-129

general discussion: 149-180

of axillary artery

case report: 140

repair of: 292-294

spontaneous cure, case report: 365

treated Zone of Interior: 155, 161

sympathectomy as adjunct measure:

323, 324, 349, 352, 354

of brachial artery

repair of: 290-292, 292-294, 294-297,

312, 313

case report: 286

spontaneous cure, case report: 363, 364

treated Zone of Interior: 155, 161

sympathectomy as adjunct measure:

323, 324, 349, 352, 354

of carotid artery

spontaneous cure, case reports: 362, 363

treated Zone of Interior: 155, 161

of cervical, deep, artery

case report; 174, 175

treated Zone of Interior; 155, 161

of femoral artery

false, rupture of, case report: 134

repair of: 294-297 case report: 284, 285

spontaneous cure: 324, 326, 335, 339,

340, 434

case reports: 128, 129, 364

treated Zone of Interior: 155, 161

sympathectomy as adjunct measure:

323, 324, 329, 330, 333, 336, 349, 354

Aneurysms—Continued

of gastrocnemius artery

treated Zone of Interior: 155, 161

of gluteal, superior

treated Zone of Interior; 156, 161

of iliac artery

treated Zone of Interior: 156, 161

sympathectomy as adjunct measure: 349

of innominate artery

case report: 250-251, 252-254

treated Zone of Interior; 156, 161

sympathectomy as adjunct measure:

330

of peroneal artery

treated Zone of Interior: 155, 161

of popliteal artery

repair of: 296-297

spontaneous cure, case report: 364

treated Zone of Interior: 155, 161

sympathectomy as adjunct measure:

323, 324, 329, 330, 336, 349,

353, 354

of radial artery

treated Zone of Interior: 155, 161

of subclavian artery

case reports: 175, 251, 252

repair of: 290-292, 313

treated Zone of Interior: 155, 161

sympathectomy as adjunct measure:

330,352

of temporal, superficial, artery

treated Zone of Interior: 155, 161

of thoracic, lateral, artery

treated Zone of Interior; 156, 161

of thoracoacromial artery

treated Zone of Interior: 156, 161

of tibial artery

spontaneous cure, case reports: 364,

365

treated Zone of Interior: 155, 161

of ulnar artery

spontaneous cure, case report: 366,

367 treated Zone of Interior: 155, 161

reparative procedures. See Arterial

repair.

roentgenography, as method of study:

50-55

spontaneous cures; 361-367, 370-374

following sympathectomy: 324, 335,

339, 340, 345, 362, 363, 364, 373,

434
INDEX 441

Aneurysms—Continued

spontaneous cures—continued

of axillary, case report: 365

of brachial, case report: 363, 364

of carotid, case reports: 362, 363

of femoral, case reports: 128, 129, 364

of popliteal, case report: 364 of tibial, posterior, case report: 364,

365

of ulnar, case report: 366, 367

surgical procedures for exposure and

management: 225-263, 269-273

iliac vessels: 263

lower extremity: 226-232

mediastinum: 242-256

neck: 238-242

scalp: 236-238

upper extremity: 232-236

vertebral vessels; 256-263

surgical techniques in operative treatment; 161

sympathectomy as adjunct measure in

operative treatment: 318-360

regional frequency

postoperative: 348

preoperative: 321, 322

Aneurysms and arteriovenous fistulas

anesthesia in operative procedures: 163

causative factors: 149, 150

complications: 173-176

postoperative: 173-176

failures: 174

fatalities: 174-176

case reports: 174-176

preoperative: 165-173

associated injuries in aneurysms:

166

associated injuries in arteriovenous

fistulas: 167

diagnosis: 153, 154, 157, 181, 182

distribution of, by artery: 155, 156, 157

general considerations: 149-180

incidence, Zone of Interior: 154-157

multiple lesions: 176-180, 355, 356

case report: 177-180

pathogenesis: 150-154

results of operative treatment: 173-176

site and regional frequency: 155, 156, 157

therapy: 161-163. See also Aneurysms,

surgical procedures for exposure

and management; Anticoagulant

therapy; Arterial repair; Specific

arteries.

Aneurysms and arteriovenous fistulas

Continued therapy—continued

chemotherapy and antibiotics: 164,

165

operative techniques: 161-163 results; 173-176 postoperative care: 164

preoperative care: 71, 163, 164

sympathectomy: 173, 318-360, 423, 431, 432-434. See also Sympathectomy as adjunct measure.

Angiospasm, traumatic: 395

Antecubital fossa, surgical procedures for

exposure of vessels: 233-236

Antibiotic therapy. See Chemotherapy

and antibiotic therapy.

Anticoagulant therapy (dicumarol, hep- arin)

counteractant: 293, 312, 317

in arterial repair, Zone of Interior:

173, 272, 291, 293, 296, 301, 310-317

methods of administration: 310-312

in battle casualties: 74, 92, 98, 99

complications' following use, case report: 113

in arterial repair, case reports: 119-122

Aorta

arteriovenous fistulas of

sympathectomy as adjunct measure:

331

treated Zone of Interior: 156, 162

injury, frequency of, comparative British

World War I, American World

War II: 69

repair of, transverse suture, case report:

302-307

surgical procedures for exposure: 242-

245, 304, 305

Armies

Fifth: 65, 97

First: 65

Ninth: 65

Seventh: 65

Third: 65

Army Nurse Corps: 19

Arterial

compression: 82

costoclavicular, of subclavian, case

report: 158-160

occlusive, test: 32, 33
442 VASCULAR SURGERY IN WORLD WAR II

Arterial—Continued

compression—continued

of carotid artery

in operations on innominate artery:

247

in operations on vertebral artery: 260

concussion: 82

injuries. See Wounds, arterial, acute

battle-incurred,

laceration; 81, 82

ligation. See Ligation,

repair

in overseas theaters: 109-126

by anastomosis, end-to-end: 111

case report: 96

by anastomosis, nonsuture: 119-126

case reports; 116, 117, 119-121,

122

by prosthetic devices 115-118

by suture; 109-113

case reports: 111, 113

by sutured vein graft; 113-115

effect on incidence of amputation:

112, 125

in Zone of Interior: 161, 162, 264-301

anticoagulants in: 173, 272, 291,

293, 296, 301, 310-317

associated injuries in: 289

general discussion of: 264-269

principles of: 269-273

sympathectomy as adjunct measure:

272, 296, 435

techniques used DeWitt Vascular

Center, and results: 273-288

end-to-end anastomosis: 279, 280

case reports: 279, 280

longitudinal suture: 274, 275

case reports: 274, 275

transvenous suture: 276-279

case reports: 276-279

transverse suture: 280-286, 288

case reports: 280-286, 302-307

techniques used Mayo Vascular

Center, and results: 288-301

end-to-end suture: 292-294

lateral arteriorrhaphy: 290-292

ligation and transfixion of arteriovenous fistula: 272, 289,

290

vein transplant: 294-297

thrombosis. See Thrombosis,

transection: 81, 82

wounds. See Wounds, arterial, acute

battle-incurred.

Arteriography, as method of study of

aneurysms: 51, 52

of arterial repair; 298

Arteriorrhaphy, lateral, as method of

repair: 290-292

Arteriosclerosis: 380-382, 386

amputation in: 382

therapy: 382

Arteriovenous fistulas. See also Aneurysms and arteriovenous fistulas;

Specific arteries,

as complication

following battle wounds; 139-142

case report: 140,141

policies of management in overseas

theaters: 71, 72, 139, 140

blood volume, effect on; 191-199

cardiac failure, congestive, in patients

with: 183, 191, 199, 206, 207, 221

case report; 165-173

cardiac manifestations of: 182-191

cardiac output, effect on: 183-191

cardiac size, effect on: 206-224

alteration in, correlated with

duration of arteriovenous fistula: 223

location of arteriovenous fistula:

223, 224

size of arteriovenous fistula: 223

temporary occlusion of arteriovenous fistula; 224

methods of measurement: 207, 222

circulation, effect on; 181-205

blood volume: 191-199

alterations in, correlated with

cardiac output: 197, 198

cardiac size: 198

duration of arteriovenous fistula:

198

size of arteriovenous fistula: 197-

198

methods of measurement: 192-194, 195-198

cardiac output: 183-191

alterations in, correlated with

cardiac enlargement: 190, 191

duration of arteriovenous fistula:

189

size of arteriovenous fistula: 189,

191

size of vessel: 189

methods of measurement: 185-187

cirsoid aneurysm

of arm, sympathectomy as adjunct

measure: 333, 334
INDEX 443

Arteriovenous fistulas—Continued cirsoid aneurysm—continued

of foot, sympathectomy as adjunct

measure: 333, 355, 356

of head

case report: 237, 238

treated Zone of Interior: 155, 162,

236, 237

diagnosis: 154, 157, 181, 182

general discussion: 149-180

multiple lesions, case report: 177-180

occlusion, temporary, and effects on

heart rate, stroke volume, cardiac

output: 186, 199-204, 219, 224

methods of measurement: 200, 201

of aorta

repair of, case report; 302-307

treated Zone of Interior: 156, 162

sympathectomy as adjunct measure: 331

of axillary artery

repair of: 272, 289, 292-294

treated Zone of Interior: 155, 162

sympathectomy as adjunct measure:

323, 352

of brachial artery

spontaneous cure, case reports: 368,

369, 370

treated Zone of Interior: 155, 162

sympathectomy as adjunct measure:

323, 331, 350

of carotid artery

case report: 176, 255

repair of: 272, 282, 289

case reports: 275, 280, 281

spontaneous cure, case report: 368

treated Zone of Interior; 155, 162

of cervical, transverse, artery

treated Zone of Interior; 155, 162

of circumflex, lateral, artery

treated Zone of Interior: 155, 162

of femoral, profunda femoris and branch,

arteries

infection of, Streptococcus viridans

septicemia, case report 165-173

ligation, thrombosis following: 315,316

repair of: 272, 289, 290-292, 292-294,

294-297, 313

case reports: 274, 279, 280, 283-285

spontaneous cure, case reports: 368,

369

Arteriovenous fistulas—Continued of femoral, etc.—continued

treated Zone of Interior; 155, 162

sympathectomy as adjunct measure: 323, 325, 329, 330, 334,

337, 350, 354, 355

of geniculate artery

treated Zone of Interior: 155, 162

of gluteal arteries

treated Zone of Interior: 155, 162

of humeral, posterior circumflex, artery

treated Zone of Interior: 155, 162

of hypogastric artery

treated Zone of Interior: 156, 162

sympathectomy as adjunct measure: 337

of iliac artery

treated Zone of Interior: 156, 162

sympathectomy as adjunct measure: 354

of innominate artery

case reports: 249-251, 255

treated Zone of Interior: 156, 162

of interosseous, common, artery

treated Zone of Interior: 155, 162

of lingual artery

treated Zone of Interior: 155, 162

of mammary, internal, artery

case report: 251

treated Zone of Interior: 156, 162

of obturator artery

treated Zone of Interior: 156, 162

of occipital artery

treated Zone of Interior: 155, 162

of peroneal artery

treated Zone of Interior: 155, 162

of plantar artery

treated Zone of Interior: 155, 162, 182

of popliteal artery

repair of: 272, 289

case reports: 276, 277, 281-283

treated Zone of Interior: 155, 162

sympathectomy as adjunct measure: 324, 325,327,333,334, 353

of radial artery

treated Zone of Interior: 155, 162

of scapular, transverse, artery

treated Zone of Interior: 155, 162

of subclavian artery

case reports: 175, 176, 254-256

repair of: 290-292

case reports: 277-279, 283
444 VASCULAR SURGERY IN WORLD WAR II

Arteriovenous fistulas—Continued

of subclavian artery—continued

spontaneous cure; 331, 340, 434

case report: 368-369

treated Zone of Interior: 155, 162

sympathectomy as adjunct measure:

323, 331, 332, 350

of subscapular artery

treated Zone of Interior; 156, 162

of thoracoacromial artery

treated Zone of Interior: 156, 162

of tibial arteries

case report: 177-180

treated Zone of Interior: 155, 162

sympathectomy as adjunct measure:

353

of ulnar artery

treated Zone of Interior: 155, 162

sympathectomy as adjunct measure:

334

of vertebral artery

case reports: 261-263

treated Zone of Interior; 155, 162

phlebography, as method of study: 52-54

spontaneous cures: 367-374

following sympathectomy: 331, 340,

345, 367, 373, 434

case report: 368-369

of brachial, case reports: 368, 369,

370

of carotid, case reports: 368

of femoral, case reports: 368, 369

of subclavian, case report: 368,369,434

surgical procedures for exposure and

management: 225-263, 269-273

iliac vessels: 263

lower extremity; 226-232

mediastinum; 242-256

neck: 238-242

scalp: 236-238

upper extremity: 232-236

vertebral vessels: 256-263

surgical techniques in operative treatment: 162

sympathectomy as adjunct measure in

operative treatment: 318-360

regional frequency

postoperative: 348

preoperative: 321-322

teleoroentgenography, as method of

study: 55, 182, 190, 207

Arteritis: 386

Artery. See Specific arteries.

Artery—Continued

injuries of. See Wounds, arterial, acute battle-incurred,

repair of. See Arterial repair.

Arthritis, post-traumatic: 395

Ashford General Hospital

analysis of cases: 375

arteriosclerosis: 381

arteriovenous fistulas involved in

vertebral artery; 261-263

blood volume: 192-195, 197, 198, 199

cardiac output: 185-188, 189

effect of temporary occlusion: 200-202,

204, 205

Raynaud’s disease: 385, 386, 387, 394,

429, 430

thromboangiitis: 378

equipment of: 13

establishment:

examination methods: 23-27, 29-55

laboratory tests: 28

operative technique: 58, 426

organization: 3,

patient loads: 5, 6-10

personnel: 12

postoperative results; 173

recording methods; 19-23

sympathectomy: 427-429, 433, 435, 436

Atlas, L. N.: 426

Auster, L. S.: 100

Axillary artery

aneurysms of

following battle wounds, case report:

140

spontaneous cure, case report: 365

treated Zone of Interior; 155, 161

arteriovenous fistulas of, treated Zone of

Interior: 155, 162

cold sensitivity and low exercise tolerance, following ligation, sympathectomy as treatment: 339, 349,

357

injury of, frequency, comparative British

World War I, American World

War II: 69

repair

end-to-end suture: 292-294

ligation and transfixion arteriovenous

fistula: 272, 289

surgical procedures for exposure: 232—

233, 238-242

resection of clavicle: 239-242
INDEX 445

Axillary artery—Continued

sympathectomy

as postoperative measure: 349, 352,

354, 357, 359, 360

as preoperative measure: 320. 321,

323, 324, 330, 334

wounds of, effect

of associated fractures and wounds,

on incidence of amputation: 77

on incidence of amputation: 78

Axillary vein thrombosis, test for: 38

Babcock, W. W.: 247

Ballance, C. A.: 370, 371

Ballistocardiography, as method of measuring

cardiac output: 185-187

heart rate, stroke volume: 200, 201

Bardenheuer, operative approach to mediastinum; 243

Barker, N. W.: 302, 308, 309

Batzner, K.: 115

Belgium: 387

Bernheim, B. M.: 109, 110, 265

Bethune tourniquet: 55

Bickham technique. See Matas-Bickham

technique.

Bickham, W. S.: 265

Bigger, I. A.: 267, 268, 433, 434

Bird, C. E.: 318

Blackburn, G.: 61

Blakemore, A. H.: 119, 123, 248, 272

Blakemore-Lord-Stefko, method of arterial

repair: 119-126, 272, 273

Blalock, A.: 308

Blood

anticoagulants (dicumarol, heparin)

counteractant: 293, 312, 317

in arterial repair: 173, 272, 291,

293, 296, 301, 310-317

in battle casualties; 74, 92, 98, 99

complication following use, case

reports: 113

in arterial repair, case reports:

119-122

methods of administration and tests:

310-312

loss, in battle casualties: 76, 88

pressure, intravascular, intrasaccular

method of measurement: 58, 59

vessels. See Vascular status, methods of

evaluation,

repair of. See Arterial repair.

Blood Continued

vessels—continued

surgical procedures for exposure. See

Aneurysms, surgical procedures

for exposure and management,

volume, effects of arteriovenous fistulas

on: 191-199

alteration correlated with

cardiac output: 197, 198

cardiac size: 198

duration of arteriovenous fistula:

198

size of arteriovenous fistula: 197, 198

methods of measurement: 192-194,

195-197

Boinet: 361

Bone atrophy, acute: 395

Bone fractures. See Fractures.

Boulitte oscillometer: 13, 40

Bowlby, A.: 64

Brachial artery

aneurysms of

spontaneous cure, case report: 363, 364

treated Zone of Interior: 155, 161

arteriovenous fistulas of

spontaneous cure, case reports: 368,

369, 370

treated Zone of Interior: 155, 162

cold sensitivity and low exercise tolerance, following ligation, sympathectomy as treatment: 339, 349, 357

injury, frequency of: 68-70

comparative British World War I,

American World War II: 69

comparative British World War I,

American World War and

World War II; 68

Volkmann’s ischemic contracture following: 142-145

case report; 144, 145

repair of

end-to-end suture 292-294, 312, 313

lateral arteriorrhaphy: 290-292

transverse suture, case report: 286

vein transplant: 294-297, 313

surgical procedures for exposure: 232-

236

sympathectomy

as postoperative measure: 349, 350,

352, 354, 357, 359, 360

as preoperative measure: 320, 322,

323, 324, 331
446 VASCULAR SURGERY IN WORLD WAR II

Brachial artery—Continued

wounds of, effect

of associated fractures and wounds, on

incidence of amputation: 77

of site, on incidence of amputation: 80

on incidence of amputation: 78, 79

Bradshaw Lecture: 103

Branham, H. H.: 200

Branham’s (Nicoladoni’s) sign: 31, 200,

202, 203, 205

Brannon, E. S.: 189, 198, 204

Brasdor-Guinard method: 248

British experience; 76, 78, 79

in World War I: 60, 61, 64, 68, 69, 77,

83, 85, 107, 110

in World War II: 61, 116

British Isles: 64

British surgeons: 61, 95, 110, 116, 144

Brodie-Trendelenburg test: 37

Brooks, B.: 100, 103, 106

Brown, George E.: 192, 424

Bruneau, J.: 99

Bucky tray: 52, 53

Buerger’s disease: 429. See also Thromboangiitis obliterans.

Buerger’s postural exercises: 379, 398

Burwell, C. S.: 190, 191, 192

Callander, C. L.: 222, 361

Canadian surgeons: 116

Cardiac

enlargement in patients with arteriovenous fistulas: 206-224

failure, congestive, in patients with

arteriovenous fistulas: 183, 191, 199,

206, 207, 221

case report: 165-173

index, method of computing: 186

manifestations of arteriovenous fistulas:

182-191

output

effect of arteriovenous fistulas on:

183-191

correlated with

cardiac enlargement: 190, 191

duration of arteriovenous fistula:

189

size of arteriovenous fistula:

189, 191

size of vessel: 189

method of measurement: 185-187

Cardiac—Continued

output—continued

effect of temporary occlusion of

arteriovenous fistulas on: 199-205

size

alterations in patients with arteriovenous fistulas: 206-224

correlated with

duration of arteriovenous fistula: 223

location of arteriovenous fistula:

223, 224

size of arteriovenous fistula: 223

temporary occlusion of arteriovenous fistula: 224

methods of measurement: 207, 222

Carlisle Barracks, Pa.: 12

Carlisle dressing: 87

Carotid artery

aneurysms of

spontaneous cure, case reports: 362,

363

treated Zone of Interior: 155, 161

arteriovenous fistulas of

case reports: 176, 255

spontaneous cure, case report: 368

treated Zone of Interior: 155, 162

compression of, preoperative: 32

in operations on innominate artery:

247

on vertebral artery: 260

injury, frequency of, comparative British World War I, American World

War II; 69

repair of

ligation and transfixion of arteriovenous fistula: 272, 282, 289

longitudinal suture, case report: 275

transverse suture, case report: 280,

281

surgical procedures for exposure: 238-

245

Carrel, A.: 264, 265

Carrel method: 109, 271

Carter, Col. B. N.: vii

Causalgia; 145

postoperative complication in aneurysms

and arteriovenous fistulas; 174

preoperative complication: 165

sympathectomy as treatment: 145, 332,

334, 344, 349, 351, 423, 430, 431

case report: 369

CBI. See China-Burma-India theater.
INDEX 447

Cervical artery

deep

aneurysms of

case reports: 174, 175

treated Zone of Interior: 155, 161

transverse

arteriovenous fistulas of

treated Zone of Interior; 155, 162

Chemotherapy and antibiotic therapy

overseas theaters: 60, 111, 130

Zone of Interior: 164, 165

China-Burma-India theater: vii, 65

Christensen, N. A.: 393, 394

Circular Letters

No. (MTOUSA), 10 Mar 45: 70, 97,

No. 13 (NATOUSA), 15 May 43: 70, 97

No. 23 (ETO), 17 Mar 45: 108

No. 46 (NATOUSA), 29 Aug 44; 70

No 101 (ETO), 30 Jul 44: 108, 127, 156

No. 178 (SGO), 23 Oct 43: 80, 81, 101,

108

Circulation

adequacy, tests of. See Vascular status,

methods of evaluation,

collateral, poor or not determinable,

sympathectomy as treatment: 322-

332, 341-343, 423, 431, 432

tests of. See Vascular status, methods

of evaluation,

effects of arteriovenous fistulas on:

181-205

blood volume: 191-199

cardiac output: 183-191

local signs: 181

effects of temporary occlusion of arteriovenous fistulas on cardiac output, pulse rate and pressure, stroke

volume: 199-205

impaired. See also Sympathectomy,

following battle wounds; 146-148

case reports: 146-148

following vascular operations on lesions of short duration: 359, 360

Circumflex artery, femoral, lateral

arteriovenous fistula of

treated Zone of Interior: 155, 162

Cirsoid aneurysm

of arm; 333, 334

of foot: 333, 355, 356

of head, case report: 237, 238

treated Zone of Interior: 155, 162,

236, 237

Civil War: 63

Claudication, intermittent

following ligation and arterial repair:

146, 147, 287, 297, 338, 339, 357

in arteriosclerosis: 380

pancreatic tissue extracts as treatment: 382

in thromboangiitis obliterans: 375, 376

pancreatic tissue extracts as treatment: 379

reflex vasodilatation test in: 46

sympathectomy as treatment: 146, 147,

338, 339, 345, 357, 424, 425, 428

time test: 33, 338

Clavicle

replacement with bone chips: 241, 242

resection of: 239-241

Clostridial myositis; 165

as indication for amputation: 66, 67, 84,

85

incidence, comparative American, German, Russian: 66, 67

Coenen-Henle phenomenon: 56, 58

Cohen, S. M.; 98, 138

Cold sensitivity. See Specific arteries.

See also under Ligation; Sympathectomy.

in arteriosclerosis: 380, 381

Collins oscillometer: 14, 40

Colsen, K.: 345

Compression

arterial: 81, 82

costoclavicular of subclavian artery, case

report: 158-160

occlusive, test: 32, 33

of carotid artery: 32

in operations on innominate artery:

247

on vertebral artery: 260

Concussion arterial: 82

case report: 136

Congress of Central Mediterranean Forces

Army Surgeons: 95

Consultant, Surgical; vii

Controlled temperature, humidity room: 18

Cowell’s case: 116

Coyle, Capt. J. T.: 130

Cullen, C. H.: 431

Dallis, N. P.; 380

DeBakey, Col. Michael E.: vii, 60, 345, 435
448 VASCULAR SURGERY IN WORLD WAR II

Debridement, in battle wounds: 85, 95,

101, 130

directives on: 70, 101

Decker, P.; 107, 110

Delbet’s sign: 31, 32, 33

Delbet’s test: 31

Depropanex, in intermittent claudication:

379, 382

DeTakats, G.: 28, 427, 429, 436

DeWitt General Hospital

analysis of cases arterial repair: 267-301

Raynaud’s disease; 385-394

thromboangiitis; 378, 379

clinical research at: 16

equipment of: 14, 15, 18

established:

examination methods: 23-27, 29-55, 425,

426

laboratory tests; 28

operative technique: 57, 58, 59, 426, 427

organization: 3,

patient loads; 11

personnel; 12

recording methods; 19-23

sympathectomy; 319, 432, 433, 436

Dicumarol. See Anticoagulant therapy.

Dillon, J. B.: 437

Diodrast

in arteriography: 51, 52, 121

in phlebography: 52-54

Directives

on vascular centers, establishment of;

1-3

on wounds

amputation, primary; 108 debridement; 70, 101

ligation of concomitant vein: 72, 107

management in overseas theaters;

61, 62, 70-72, 156

posture of wounded extremity; 97

thrombosis: 80, 81

Djemil-Pascha: 265

Dock, W.: 184

Doupe, J.: 431

Drummond, H.: 104

Drury, A. N.: 184, 203

Duncan, G.: 100

Durham, R. H.; 380

Dystrophy, reflex nervous, reflex sympathetic, post-traumatic; 395

Ebert, R. V.: 196

Edema

chronic traumatic: 395

in aneurysms and arteriovenous fistulas,

postoperative, sympathectomy as

treatment: 351, 352, 353, 358

in post-traumatic vasomotor disorders:

399, 400, 401

case report; 404

sympathectomy as treatment: 399,

400, 402, 406, 412-415

case reports: 412, 413, 414

Edmunds, W.: 370, 371

Electrocardiography: 50

Elkin, Col. Daniel E.: 1-16, 149-180,

181-205, 225-263, 433

Ellis, L. B.: 192, 203

Embolism, arterial, incidence Zone of

Interior: 382

Emotional factors in vascular disorders*

22, 387, 390

Endoaneurysmorrhaphy: 161, 163, 264

265

End-to-end anastomosis: 111, 161, 279, 280, 292-294

case reports: 96, 279, 280

England: 387, 391

Eppinger, E. C.: 190

Equipment and supplies: 13-15

shortages: 17, 18

Erb, W.: 377

Esmarch bandage: 34, 35, 432

ETO. See European theater.

Europe: 64, 65, 107

European theater; vii, 2, 62

complications of acute arterial injuries:

126, 127

incidence of acute arterial injuries: 64-66

in relation to amputation; 66-68

ligation of concomitant vein; 107

management policies: 71, 72, 97, 108, 127

primary amputations: 108

supplemental therapeutic measures in

arterial repair

posture: 97, 98

refrigeration: 100, 101

Evans, B. H.: 95

Evans blue dye T-1824; 192-195

Evans, W. A., Jr.: 197

Exercise, active, and physical therapy

in osteoporosis; 418
INDEX 449

Exercise, active, and physical therapy—Continued

in vasomotor disorders: 398, 402-405,

410, 419

case report: 404

Exercise, tests of lower and upper extremities: 29

tolerance low. See Claudication, intermittent; Sympathectomy.

Fasciotomy

case report: 119-122

in Volkmann’s ischemic contracture:

142-145

case report; 144, 145

in wounds of popliteal artery: 144

case report: 122

Femoral artery, profunda femoris and

branch

aneurysms of

false, rupture of, case report; 134

spontaneous cure: 235, 324, 326, 339,

340, 434

case reports; 128, 129, 364

treated Zone of Interior: 155, 161

arteriovenous fistulas of

infection in, Streptococcus viridans

septicemia, case report: 165-173

spontaneous cure, case reports: 368,

369

treated Zone of Interior: 155, 162

circulatory insufficiency following ligation: 287

case reports: 146-148

cold sensitivity and low exercise tolerance, following ligation: 287, 297,

338, 339, 357

sympathectomy as treatment: 338,

339, 345, 357

hematoma, pulsating, spontaneous cure,

case report: 128, 129

injury, frequency of: 68-70 comparative British World War I, American World War II: 69

comparative British World War I,

American World Wars and 11:68

following fracture of femur and inadequate cast padding: 76

Volkmann’s ischemic contracture following: 142, 143

ligation of, followed by thrombosis: 315,

316

Femoral artery, profunda femoris and

branch—Continued repair of

case report; 113

end-to-end suture: 292-294

case reports: 279, 280

lateral arteriorrhaphy: 290-292

ligation and transfixion arteriovenous

fistula: 272, 289

longitudinal suture, case report: 274

nonsuture anastomosis, case report:

119-121

transverse suture, case reports: 283-

285

vein transplant: 294-297, 313

surgical procedures for exposure: 226

sympathectomy

as postoperative measure: 349, 350,

354, 355, 357, 359, 360

as preoperative measure; 320, 321, 323,

324, 325, 330, 333, 334, 335, 336,

337, 340, 434

case reports: 329, 330

wounds of, effect

of associated fractures and wounds, on

incidence of amputation: 77

of site, on incidence of amputation: 80

on incidence of amputation: 78, 79

Fey, B: 84

Fibrin foam: 260, 288, 312, 316

Fibula, resection of: 230, 231

Fick catheter, method of measuring cardiac

output: 185-189

Fluorescin wheal test: 44, 45

Foote, J. J.: 100

Fractures

associated injuries with

aneurysms and arteriovenous fistulas:

165, 166, 167

arterial wounds, effect on incidence of

amputation: 76, 77

casts for, improper padding, causing

arterial damage: 76

in arterial repair: 289

osteoporosis following: 418

vasomotor disorders, post-traumatic, following: 397, 406, 408, 415, 417

France; 104, 109, 387, 391

Franz, Carl: 64, 84

Freemen, Lt. Col. Norman E.; 2, 59, 131-

135, 264-301, 302-309, 385-382, 422-

437
450 VASCULAR SURGERY IN WORLD WAR II

Frostbite: 19

amputation in: 427

Raynaud’s disease following: 385, 387,

394

Raynaud-like disorders following; 391

394

sympathectomy as treatment: 423, 427,

428

vasomotor disorders following: 397

Frouin, A.: 271

Gage, I. M.: 318, 345, 434

Ganglionectomy

incidence of amputation following: 137

stellate, test to predetermine results: 29

Gangrene

gas: 90, 165

as indication for amputation: 66, 67,

84, 85

as preoperative complication, Zone of

Interior: 165

ischemic

as indication for amputation: 84, 85

as result of acute occlusion of major

arteries: 83-85

following

arterial and concomitant venous

ligation: 102-108

fracture of femur and inadequate

cast padding: 76

hematoma formation in axillary,

femoral, popliteal injuries: 84

ligation of politeal artery; 61, 62

ligation of subclavian, brachial,

common iliac: 84

tourniquets: 89

in aneurysms and arteriovenous fistulas: 165, 174

sympathectomy as treatment: 332, 333, 334, 345, 354, 355, 356, 358

in Raynaud’s disease, sympathectomy

as treatment: 389, 391

in thromboangiitis obliterans, sympathectomy as treatment: 380, 428, 429

in trenchfoot and frostbite, sympathectomy as treatment: 427

in vascular insufficiency, sympathectomy as treatment: 431, 432, 433

Cask, G. E.: 427

Gastrocnemius artery

aneurysm of, treated Zone of Interior:

155, 161

Geniculate artery

arteriovenous fistulas of, treated Zone of

Interior: 155, 162

Geohegan, W. A.: 437

Gerlach, F.: 202

German Army: 111

German experience in World War I: 64,

84, 110

German experience in World War II: 66,

67, 387

German surgeons: 110

Gibbon, J. H., Jr.: 424

Gibson, J. G., Jr.: 196, 197

Gibson, J. J.: 193

Giddy, P.: 345

Gigli saw: 230, 239, 241, 243, 244

Gluteal artery, inferior and superior

arteriovenous fistulas of, treated Zone of

Interior: 155, 162

Gnilorybov, T. E.: 110

Goodman, C.: 110

Goyanes, J.: 265

Grafts, vein, sutured: 113-115, 294-297

Greenough, J.: 242

Gregersen, method of measuring plasma

volume: 195

Gregersen, M. I.: 193, 195

Gross, R. E.: 190

Gubner method: 169

Gubner, R.: 207, 222

Guinard method. See Brasdor-Guinard

method.

Gunderman’s sign: 31

Hallion: 37

Hallowed: 264

Halsted’s principles: 266

Hamilton manometer: 59

Hamman, L.: 165

Harke, W.: 202

Harris, R. I.: 428

Harrison, T. R.: 184

Heart. See Cardiac.

Heat in management of battle wounds:

72, 101

Heifetz, C. J.: 256

Heinbecker, P.: 99, 100

Helfrich, L. S.: 436

Hematoma

following injury

gangrene resulting: 84

popliteal artery, case reports 95,

96
INDEX 451

Hematoma—Continued

following injury—continued

gangrene resulting—continued

tourniquet as battlefield measure; 88

operations on aneurysms and arteriovenous fistulas: 174

repair, arterial, using anticoagulants:

291, 298, 313

pulsating

diagnosis: 128

in battle wounds: 127-129

case reports: 128, 129, 134

surgical management: 129

Hemiplegia, as postoperative complication:

174

Hemorrhage

control methods

in battle casualties; 70, 71, 85-92

packs: 70, 71, 85, 86

stitch ligature: 71

tourniquets: 70, 86-92

case reports: 89, 90, 91, 92

following operation on aneurysms and

arteriovenous fistulas; 174, 288, 300,

313, 314

secondary

following

battle wounds: 129-135

case reports: 131, 132, 134

infection: 127, 130, 291, 300

case report: 175, 176

repair: 112, 291, 300

therapy: 133-135

wounds, type of, as antecedent: 133

Henle phenomenon. See Coenen-Henle

phenomenon.

Henry, Arnold K.: 230, 258

Heparin. See Anticoagulant therapy.

tolerance test: 28

Hess, O. W.; 95

Hines, E. A., Jr.; 393, 394

Hinsey, J. C.: 437

Hoche, O.: 107

Holland: 387

Holman, E.: 184. 191,198,199,204, 221,222

Homans’ dorsiflexion test: 29, 30, 31

Homans, J.: 375, 376, 377, 378

Hopfner, E.: 119, 264

Horsley, J. S.: 271

Horton, B. T.: 377, 379

Hospitals, named

Ashford General. See Ashford General

Hospital.

Hospitals, named—Continued

DeWitt General. See Dewitt General Hospital.

Jones, Percy, General. See Mayo Gen- eral Hospital.

Letterman General. See DeWitt Gen- eral Hospital.

Mayo General. See Mayo General Hospital.

Torney General. See DeWitt General

Hospital.

Hospitals, numbered

8th Evacuation Hospital: 119

20th General Hospital: 131

Humeral artery, posterior circumflex

arteriovenous fistulas of, treated Zone of

Interior: 155, 162

Hunterian Oration: 103

Hunter’s canal: 226

Huyler: 381

Hyperhidrosis

following quadrilateral sympathectomy:

390, 393, 436, 437

in post-traumatic vasomotor disorders:

399, 400, 410

sympathtectomy, sympathetic block, as

treatment: 355, 356, 415, 416, 422

Hypnosis, in vasomotor disorders: 405

Hypogastric artery

arteriovenous fistulas of

treated Zone of Interior: 156, 162

sympathectomy as adjunct measure:

337

Iceland; 387

Iliac artery

aneurysms of, treated Zone of Interior:

156, 161

arteriovenous fistulas of, treated Zone

of Interior: 156, 162

injury, frequency of, comparative British

World War I, American World War

II: 69

low exercise tolerance following ligation:

357

surgical procedures for exposure: 263

sympathectomy as postoperative measure: 349, 354, 357, 359, 360

wounds, effect

on incidence of amputation; 78, 79

comparative British World War I,

American World War II; 78
452 VASCULAR SURGERY IN WORLD WAR II

Incisions

for exposure of blood vessels: 225-263

iliac: 263

in lower extremity; 226-232

in mediastinum: 242-256

in neck; 238-242

in scalp: 236-238

in upper extremity: 232-236

vertebral: 256-263

plastic, general discussion: 226

in antecubital space: 233-236

in foot: 231, 232

in leg: 228

in neck: 238, 239

in popliteal space: 226-228

India: 131

Infection

asantecedent of vasomotor disorders; 397

as cause of secondary hemorrhage; 127,

130, 291, 300

case report: 175, 176

as complication, postoperative: 174

as indication for amputation: 66, 67, 84,

85

following battle wounds: 82, 84, 85, 111,

130

in arterial repair: 269, 288, 291, 297, 298

septicemia, Streptococcus viridans, in

arteriovenous fistula: 165-173, 207

Innominate artery

aneurysm of

case report: 252-254

treated Zone of Interior: 156, 161

arteriovenous fistulas of

case reports: 249-251, 255

treated Zone of Interior: 156, 162

surgical procedures for exposure: 238-245

resection of clavicle: 239-242

sympathectomy

as postoperative measure: 359, 360

as preoperative measure: 320, 330, 331

Inter-Allied Conference of Surgeons: 104

Interosseous artery, common

arteriovenous fistula of, treated Zone of

Interior: 155, 161

Iran: 387

Ischemia. See also Gangrene, ischemic;

Sympathectomy,

following acute battle-incurred wounds:

126, 127

Ischemic

contracture, Volkmann’s. See Volkmann’s ischemic contracture.

Ischemic—Continued

lesions, sympathectomy as treatment:

343, 345, 358, 359

pain, test: 30

paralysis, sympathectomy as treatment:

352-355, 358

Italian campaign: 130

Italy: 64, 86, 89, 95, 124, 125, 387

Jacobson, W. H. A.: 105

Jahsman, W. E.: 380

Janes, J. M.. 116

Jeger, Ernest: 119

Johns Hopkins Hospital: 222

Jonas, L.: 191

Jones, Percy, General Hospital: 2, 3, 5, 10,

14. See also Mayo General Hospital

Vascular Center. Joseph, N. R.: 190

Kahn, Capt. J. W.: 378, 381

Kahn, J. H.: 203

Kennedy, J. A.: 192

Kerr’s trigger reflex test: 46, 47

Khenkin, V. L.: 115

Killian, H.: Ill, 112, 115

King, B. G.: 248

Kirk, Norman T. See Surgeon General,

The.

Kleinsasser, Maj. LeRoy J.;

Kocher, operative approach to mediastinum: 243

Kramarov: 67

Kramer, M.: 203 Kroop, I.: 165

Kunlin, J.: 435

Kuntz, A.: 437

Laceration, arterial: 81, 82

LaGarde, L. A.: 63

Lambert, R.: 264

Lampert, Maj. Herbert H.; 310-317 Lande, H.: 165

Landis, E. M.: 424

Langley, G. H.; 99

Large, A.: 100

Learmonth, J. R.: 432, 434

Lebsche knife: 244

Lee, R. L: 311

Leriche, R.: 146, 435

Letterrnan General Hospital Vascular Center: 2, 11, 14, 15. See also DeWitt

General Hospital Vascular Center.
INDEX 453

Lewis, T.: 44, 184, 203, 431

Lexer, E.: 115, 119, 265

Ligation

and transfixion of arteriovenous fistulas

in repair: 272, 289, 290

claudication, intermittent, following: 287,

297, 338, 339, 357

cold sensitivity and low exercise tolerance,

following, sympathectomy as treatment: 146, 147, 338, 339, 345, 357,

358

impaired circulation following: 83-85,

287, 297

sympathectomy as treatment: 423,

431, 432, 433

in management

of aneurysms and arteriovenous fistulas: 161, 162, 433, 434

of battle wounds: 71, 72, 102, 112, 125

of artery and concomitant vein: 102-108

results: 105, 108

thrombosis following: 315, 316

Lindskog, G. E.: 243

Lingual artery

arteriovenous fistula of, treated Zone of

Interior: 155, 162

Lipton, S.: 165

Livedo reticularis, in Raynaud’s disease:

389, 391

Livingston, W. K.: 431

Lord, J. W.: 119, 123, 272

Lumbar sympathectomy. See Sympathectomy, lumbar.

Lyle, H. H. M.: 373

Lyster bag: 61

Mahorner test. See Ochsner-Mahorner

tests.

Makins, G. H.: 60, 61, 64, 68, 83, 85, 103,

104, 106, 107, 109, 110, 115, 116, 133,

135, 302

Mammary artery, internal

arteriovenous fistula of, treated Zone of

Interior: 156, 162

case report: 251

Manual Military Surgical: 61

Manual of Therapy: 71, 72, 97, 108, 127

Mason, J. M.: 221

Massell, Capt. Theodore B.: 44

Matas-Bickham technique: 278, 309

Matas compressor: 201

Matas, endoaneurysmorrhaphy: 161, 163,

264, 265

Matas-Moschcowitz reactive hyperemia test;

33-36, 322, 432

Matas, R.: 33, 34, 105, 115, 221, 247, 256,

264, 265, 266, 322, 361, 371, 372

Maurer, A.: 64, 105

Maxillary artery, external

hemorrhage, secondary, case report; 132

May Institute for Medical Research: 14 Mayfield, F. H.: 145

Mayo General Hospital

analysis of cases: 152

alteration in cardiac size in arteriovenous fistulas; 206-224

arterial repair: 267-301

post-traumatic vasomotor disorders: 397-421

Raynaud’s disease: 385-394

spontaneous cure of aneurysms and

arteriovenous fistulas: 361-374

thromboangiitis; 378

anticoagulant therapy; 310-317

equipment of: 14

establishment: 2, examination methods; 23-27, 29-55

laboratory tests: 28

operative technique: 243, 244, 426

organization:

patient loads: 5, 10, 11

personnel: 12

recording methods: 19-23

sympathectomy: 319-360, 430, 433, 436

McGee, James C. See Surgeon General,

The.

McGuire, J.; 192, 199, 279

Mediastinum, surgical procedures for exposure and management of vessels

in: 242-256

Medical Corps: 12

Mediterranean-North African theaters: vii,

30, 62, 66, 82, 86, 95

blood chemistry: 114

complications of acute arterial injuries:

126, 127

equipment: 119

fasciotomy: 144

incidence of acute arterial injuries:

64-66

in relation to amputation: 66-68

indications for amputations; 85

ligation of arteries: 102

management policies: 70, 71, 97, 108,

127

nonsuture anastomosis; 119
454 VASCULAR SURGERY IN WORLD WAR II

Mediterranean-North African theaters

Continued primary amputation: 108

secondary hemorrhage: 130

supplemental therapeutic measures in

arterial repair

posture; 97, 98

refrigeration: 100, 101

timelag between wounding and surgery:

73

Merrill, A. J.: 189

Mignon, A.: 64

Miller, H.; 165

Mocquot, P.: 84

Monckeberg-type sclerosis; 381

Montgomery, H.: 424

Montgomery, M. L.: 106

Morton, J. J.: 424

Moschcowitz, L.: 33

Moschcowitz test. See Matas-Moschcowitz

test.

MTO. See Mediterranean theater.

Murphy, J. B.: 265

Murray, G. D. W.; 115, 116

Naide, M.: 49, 50, 425

Naide’s test: 49

Narcosis, sodium amytal, in vasomotor

disorders; 405

National Research Council, Division of

Medical Sciences: 61

Neller and Schmidt test: 44

Nerve

associated injuries

with arterial repair: 268, 269, 289

with vascular lesions: 76, 77, 165,

166, 321, 322

conduction interruption tests: 47-49

crushed peripheral, treatment in intractable pain: 380

damage, associated with impaired circulation, sympathectomy as treatment: 333, 334, 343, 351, 352, 358,

359

paralysis

associated with vasomotor disorders: 397

sympathectomy as treatment: 352-

355, 358, 359, 431, 432

Neuropsychiatric therapy in vasomotor

disorders: 401, 402, 405-409

case reports: 407-409

Nickerson, J. L.: 204

Nicoladoni, C.: 199, 200

Nicoladoni’s sign. See Branham’s (Nicoladoni’s) sign.

Nonsuture anastomosis: 272, 273

in battle casualties: 119-126

case reports: 116, 117, 119-122

North Africa: 387, 391

North African theater. See MediterraneanNorth African theaters.

Obturator artery

arteriovenous fistula of, treated Zone of

Interior: 156, 162

Occipital artery

arteriovenous fistula of, treated Zone of

Interior: 155, 162

Occlusion

acute arterial, results of, in various

wars: 83-85

Occlusive and obliterative arterial diseases

(organic) associated with Raynaud’s

disease: 386

Ochsner, A.: 318, 422, 434, 435, 436

Ochsner-Mahorner tests: 37

Ogilvie, W. H.: 61

Operative approaches to blood vessels. See Aneurysms, surgical procedures for

exposure.

Ophthalmoscopy, as diagnostic aid; 28

Oscillometry

as diagnostic aid: 40, 41

as method of assessing results of therapy:

287, 298, 299

Osier, Sir W.: 220, 221, 224

Osteoporosis, post-traumatic: 395, 396,

417, 418

Ottaway, J. P.; 100

Oxygen therapy, in management of battle

casualties: 98

Pacific theaters: vii, 65, 100

Padutin, in intermittent claudication: 379

Pain. See also Causalgia; Sympathectomy,

in post-traumatic vasomotor disorders:

399

sympathetic block as treatment: 410

sympathectomy as treatment: 408,

409, 414, 415.

in thromboangiitis obliterans: 21, 376

treatment for intractable: 380

Pancreatic tissue extracts

in arteriosclerosis: 382

in thromboangiitis obliterans: 379

Park, E. A.: 308

Patients in vascular centers: 5-11, 19
INDEX 455

Patterson, Lt. Col. Russell H.:

Payr, E.: 119

Pechon instrument: 40

Pemberton, J. de J.: 192, 302, 308, 309

Pendergrass, R. C.: 222

Percy Jones General Hospital Vascular

Center: 2. See also Mayo General

Hospital Vascular Center. Peripheral vascular disturbances

arteriosclerosis: 380-382. See also Arteriosclerosis,

thromboangiitis obliterans: 375-380.

See also Thromboangiitis obliterans.

thrombosis, spontaneous arterial, and

embolism; 382

vasomotor disorders, post-traumatic;

395-421. See also Vasomotor disorders, post-traumatic,

vasospastic disorders; 383-394. See also

Raynaud’s disease and like disorders.

Peroneal artery

aneurysms of, treated Zone of Interior:

155, 161

arteriovenous fistulas of, treated Zone of

Interior: 155, 162

injury, frequency of, comparative British

World War I, American World

War II: 69

surgical procedures for exposure: 228-

231

resection of fibula: 230, 231

Perrig, H.: 256

Personnel: 2, 3-5, 11-12, 17

lack of: 2, 17

Perthes test: 37

Phlebography, as diagnostic aid: 52-54

Physical therapy

in thromboangiitis obliterans: 379

in vascular centers: 4-5

in vasomotor disorders: 398,402-405, 410

case report: 404

Pitkin’s menstruum: 99, 113

Plantar artery

arteriovenous fistulas of, treated Zone of

Interior: 155, 162

surgical procedures for exposure: 231, 232

Plastic

incision lines. See Incisions, plastic,

prosthetic tubes in arterial repair: 116

Plethysmography, as diagnostic aid: 43, 44

330323 0—55 30

Popliteal artery

aneurysms of

spontaneous cure, case report: 364

treated Zone of Interior: 155, 161

arteriovenous fistulas of, treated Zone of

Interior: 155, 162

cold sensitivity and low exercise tolerance, following ligation: 297, 338, 339,

357

gangrene

as result of acute occlusion: 83, 84

following fracture of femur and inadequate cast padding: 76

following ligation: 61, 62

injury, frequency of: 68-70

comparative British World War I,

American World War II: 69

comparative British World War I,

American World Wars and II:

68

hematoma following, case reports: 95,

96

managed by expectant treatment, case report: 93-95

Volkmann’s ischemic contracture following: 142-145

repair of

end-to-end suture: 96

ligation and transfixion of arteriovenous fistula: 272, 289

nonsuture anastomosis, case reports:

116-118, 122-124

suture, case reports: 95, 96, 111

transvenous suture, case report: 276,

277

transverse suture, case report: 281-

283

vein transplant: 294-297, 313

surgical procedures for exposure: 226-

228

sympathectomy

as postoperative measure: 349, 353,

354, 357, 359-360

as preoperative measure; 323, 324, 325,

330, 333, 334, 336

case reports: 327, 329, 330, 341

wounds of, effect

of associated fractures and wounds, on

incidence of amputation: 77

on incidence of amputation: 78, 79

Postempski, P.: 264

Post-traumatic vasomotor disorders. See

Vasomotor disorders, post-traumatic.
456 VASCULAR SURGERY IN WORLD WAR II

Postural exercises, Buerger’s: 379, 398

Posture of wounded extremity: 97, 98

Psychologic factors in vascular disorders:

22, 420

Punin: 105

Quich curve: 311

Quich method; 311

Radial artery

aneurysms of, treated Zone of Interior:

155, 161

arteriovenous fistulas of, treated Zone of

Interior: 155, 162

injury, frequency of, comparative British

World War I, American World War

II: 69

surgical procedures for exposure: 233-236

wounds of, effect

on incidence of amputation: 78, 79

Ragan ischemic pain test. See Schecter and

Ragan ischemic pain test.

Ragan, Maj. Charles A.; 30

Ranhin, Brig. Gen. Fred W.: vii

Rawson, A. J.: 190, 195

Ray, B. S.: 437

Raynaud’s disease with digital syncope:

384-391, 392-394, 423, 429, 430

associated diseases: 386

bilateral involvement of extremities:

388, 392, 429

clinical manifestations: 387-389, 392-394

diagnosis: 384-386, 392, 393

etiology: 385, 387, 394

gangrene in; 389, 391

general discussion: 383-386

incidence: 386, 387, 393

livedo reticularis in: 389, 391

tests and diagnostic aids: 388, 390, 429

therapy: 390, 391, 393

sympathectomy: 390, 391, 393, 423,

429, 430

trophic changes in: 389, 390, 391

Raynaud-lihe disorders: 391-394, 423, 429,

430

differential diagnosis: 392, 393

etiology: 391, 394

incidence: 391

therapy: 391, 392

sympathectomy: 392, 423, 429, 430

Reactive hyperemia test (Matas): 33-36,

322, 342, 432

Red Cross: 4,

Reflex vasodilatation test: 46, 47

Refrigeration in management of battle

wounds: 73, 74, 99-101

Rehn, E.: 115

Reid, M. R.: 134, 192, 199, 221, 279, 374

Renal artery

injury, frequency of, comparative British

World War I, American World

War II: 69

Repair of arterial wounds. See Arterial

repair.

Rieder, W.: 203

Rienhoff, W. F., Jr.; 165

Roentgenography as diagnostic aid: 50-55

arteriography; 51, 52

phlebography: 52-54

soft tissue techniques: 54

teleoroentgenography: 55

Rogers, L.: 102

Rose, C. A.: 95

Rowntree, L. G.: 192

Russian experience: 67

Russo-Finnish War: 84

Russo-Japanese War: 63

Saint, J. H.: 192

Salomon, R.: 83

Samuels plantar test: 29

Samuels pulsimeter; 40

Sanders oscillating bed: 14

Sandzen, S. C.: 95

Sauerbruch and Schumacher operative approach to vessels in mediastinum: 243

Scalenus anticus syndrome: 386

preoperative test: 38

Scapular, transverse

arteriovenous fistulas of, treated Zone of

Interior: 155, 162

Scarpa: 370

Schecter and Ragan ischemic pain test; 30

Schecter, Capt. Adolph A.: 30

Schmidt, E. R.: 44

Schneider, H.: 115

Schroeder, H. A.: 190

Schumacher, operative approach to mediastinum: 243

Sclerodactylia: 386, 389

Scleroderma: 386, 389, 392

Sclerosis, medial (Moncheberg type): 54,

381

Scott, W. J. M.: 424

Seefeld, P. H.: 302, 308, 309
INDEX 457

Sehrt, E.: 104

Sencert, L.: 84

Septicemia, Streptococcus viridans, in

arteriovenous fistula: 165-173, 207

Shoemaker sternal shears: 244

Shumacker, Lt. Col. Harris B., Jr.: 3,

149-180, 206-224, 225-263, 264-301,

310-317, 318-360, 361-374, 383-394,

395-421

Sicilian campaign: 130

Silbert, S.: 377, 378

Simeone, Col. Fiorindo A.: 60-148

Skin

resistance determinations: 43

temperature tests: 38, 39, 400, 424

Smithwick operation: 348

Smithwick, R. H.: 425, 426, 436, 437

Snyder, J. M.; 100

Soubbotitich, V.: 83, 220

South African War: 103

South Pacific. See Pacific theaters.

Spanish-American War; 63

Spasm, arterial. See Vasospasm.

Spontaneous cures of aneurysms and

arteriovenous fistulas. See Aneurysms, spontaneous cures; Arteriovenous fistulas, spontaneous cures.

Sprains, vasomotor disorders following: 397

Starch-iodine test: 42

Starr, I.: 189, 190, 191

Statistics. See also Wounds, arterial,

acute battle-incurred,

aneurysms, arteriovenous fistulas, treated

Zone of Interior: 155, 156, 161, 162

arterial injuries: 62-70

previous wars; 63, 64

World War II: 64-66

patient loads, hospitals, Zone of Interior:

5-11

Raynaud’s disease: 386, 387, 393

Raynaud-like disorders: 391, 393

sympathectomy, Zone of Interior: 423

thromboangiitis obliterans: 375

vasomotor disorders, post-traumatic: 397

Stead, E. A., Jr.: 189, 193, 196, 199

Stefko, P. L.; 119, 123, 272

Storck, Lt. Col. Ambrose H.; 17, 302

Subclavian artery

aneurysms of

case reports: 175, 251, 252

treated Zone of Interior: 155, 161

Subclavian artery—Continued

arteriovenous fistulas of

case reports; 175, 176, 254, 255

spontaneous cure: 331, 340, 434

case report: 368, 369

treated Zone of Interior: 155, 162

cold sensitivity and low exercise tolerance, following ligation, sympathectomy as treatment; 339, 350,

357

costoclavicular compression of, case

report: 158-160

injury, frequency of, comparative British

World War I, American World War

II: 69

repair of

lateral arteriorrhaphy: 290-292, 313

transvenous suture, case report; 277-

279

transverse suture, case report: 283

surgical procedures for exposure: 233-

236, 238-245

resection of clavicle: 239-242

sympathectomy

as postoperative measure: 350, 352

357, 359, 360

as preoperative measure: 320, 323, 330,

331, 335, 434

Subscapular artery

arteriovenous fistulas of, treated Zone

of Interior: 156, 162

Sudeck’s atrophy; 395, 430

decalcification of bones, by roentgenogram: 51

Supplies. See Equipment and Supplies.

Surgeon General, The: vii, 154, 156

Surgeon General’s Office: 62, 108, 127

Suture

material

in ligation: 134, 135

in vascular repair: 271

repair of arteries; 109-113

end-to-end: 111,161,279, 280, 292-294

case reports: 96, 279, 280

lateral: 290-292

ligation and transfixion of arteriovenous fistulas: 272, 289, 290

longitudinal: 274, 275

case reports: 274, 275

transvenous: 276-279

case reports: 276-279

transverse: 280-286, 288, 302-309

case reports: 280-286, 302-307
458 VASCULAR SURGERY IN WORLD WAR II

Suture—Continued

types used: 271, 272

Sweating tests: 42

Sympathectomy

amputation following, in comparable

wounds; 137

as adjunct measure in operative treatment of aneurysms and arteriovenous fistulas: 173, 318-360, 423,

431-435

coincidental sympathectomy, indications and results: 336-338, 346

postoperative sympathectomy, indications and results; 346-360

additional vascular operation required; 354, 355

causalgia, mild: 349, 351

cold sensitivity and low exercise

tolerance: 146, 147, 348-351,

357, 358

cold sensitivity, peripheral nerve

lesions, sympathetic over-activity: 349, 350, 351, 359

edema, persistent; 351, 352, 353, 358

gangrene, impending; 354, 356, 358

hyperhidrosis and cyanosis: 355, 356

ischemia: 358

nerve damage, severe peripheral,

impaired circulation: 351, 352,

358, 359

paralysis, ischemic: 352, 353, 354, 358

preoperative sympathectomy, indications and results: 318-336

artery ligated and another vascular

operation required: 333, 334,

344

causalgia, gangrene and infection,

nerve lesions: 332, 333, 334,

344, 345

circulation, collateral

impaired with associated nerve

lesions: 333, 334, 343

ischemic lesions; 332, 333, 334,

343,345

not determinable: 330-332, 343

poor: 322-330, 334-336, 341-343

vasospasm: 332, 333, 344

prophylactic sympathectomy: 431-

435. See also Sympathectomy,

preoperative, collateral circulation poor, not determinable,

complications and sequelae: 320, 390,

436, 437

Sympathectomy—Continued

dorsal. See Sympathectomy, thoracic,

effects, special, on

cold sensitivity and low exercise tolerance: 338, 339, 345, 357, 358

collateral circulation; 341-343

ischemic lesions: 343, 345, 358, 359

peripheral nerve lesions: 343

persistent edema: 358

spontaneous cures of aneurysms and

arteriovenous fistulas: 340-341,

345

vasospasm; 344

in arteriosclerosis: 382

in battle casualties; 74, 137-139, 146-

148

in causalgia: 145, 332, 334, 344, 349,

351, 423, 430, 431

case report: 369

in circulatory disturbances of extremities;

146-148, 422-437. See also Vasomotor disorders, post-traumatic,

in concussion, arterial: 82

in osteoporosis: 417, 418

in repair, arterial: 126, 272, 293, 296,

435

in theaters of operations; 74, 137-139,

146-148

in thromboangiitis obliterans; 379, 423,

428, 429

in vasomotor disorders, post-traumatic;

406, 408, 409, 410-421

in vasospasm; 137-139, 332, 333, 344

in vasospastic disorders: 390, 391, 392,

393, 423, 429, 430

in Volkmann’s ischemic contracture:

145

incidence, Zone of Interior: 423

indications for, Zone of Interior: 422-

423, 424

lumbar

indications for, and results

causalgia and pain: 423, 430, 431

Raynaud’s disease and like disorders: 423, 429, 430

thromboangiitis obliterans: 423, 428,

429

thrombophlebitis: 423, 435

trenchfoot and frostbite: 423, 427,

428

vascular insufficiency; 423, 431, 432
INDEX 459

Sympathectomy—Continued

lumbar—continued

technique of operation; 321, 348, 410,

411, 426

tests, preoperative: 423-426, 427, 428,

429, 430, 431

thoracic

indications for, and results

causalgia and pain; 423, 430, 431

Raynaud’s disease and like disorders: 423, 429, 430

thromboangiitis obliterans: 423, 428,

429

vascular insufficiency; 423, 431, 432

technique of operation; 321, 348, 411,

426, 427

tests, preoperative: 423-426, 428, 429,

430, 431

thrombosis, intrasaccular, as result:

339-341, 345

spontaneous cure

of aneurysms following: 324, 335, 339,

345, 362, 373, 434

case reports: 363, 364

of arteriovenous fistulas following:

331, 340, 345, 367, 373, 434

case report: 368, 369

Sympathetic block

amputation following, in comparable

arterial wounds: 137

in battle casualties: 72, 74, 137-139

in concussion, arterial: 82

in vasomotor disorders: 398, 409, 410,

419, 420

Technical Bulletin, TB Med 147, Mar

1945: 81, 127

Teleoroentgenography, in measuring cardiac size: 55, 182, 190, 207

Telford, E. D.; 427

Tests of vascular status in patients. See

Vascular status, methods of evaluation.

Thompson, Maj. W. D., Jr.: 130

Thoracic artery, lateral

aneurysm of, treated Zone of Interior:

156, 161

Thoracic sympathectomy. See Sympathectomy, thoracic.

Thoracoacromial artery

aneurysm of, treated Zone of Interior: 156, 161

Thoracoacromial artery—Continued

arteriovenous fistula of, treated Zone of

Interior; 156, 162

Thorax, surgical procedures for exposure

and management of vessels in: 242-256

Thromboangiitis obliterans: 375-380, 386,

423, 428, 429

amputation in: 380, 429

incidence; 375

racial distribution in patients: 19, 375

symptoms and signs; 21, 375, 376

tests and diagnostic aids: 376, 377, 428

therapy

Buerger’s postural exercises and physical therapy: 379

crushing peripheral nerves: 380

pancreatic tissue extracts: 379

smoking, abstinence from: 377-379,

429

sympathectomy: 379, 423, 428, 429

typhoid vaccine, fever therapy; 379

Thrombophlebitis

diagnostic aids; 29, 40, 41

sympathectomy as treatment: 423, 435

Thrombosis

amputation following: 80, 81

anticoagulants as preventives; 310-317

arterial, following

ligation: 315, 316

repair of artery: 112, 288, 300, 310,

311, 312, 313

case report: 134

dicumarol as preventive: 310-317

heparin as preventive: 310-317

intrasaccular in aneurysms and arteriovenous fistulas: 339-341, 345

management in overseas theaters: 80, 81

spontaneous, incidence: 382

venous, diagnostic aids: 30, 31, 38, 42

Thrombus, extension, in arterial repair:

300-301, 315

following sympathectomy: 340

case report: 341

Thyrocervical trunk artery

surgical procedures for exposure; 238-241

Tibial artery, anterior and posterior

aneurysms of

spontaneous cure, case reports: 364,

365

treated Zone of Interior: 155, 161
460 VASCULAR SURGERY IN WORLD WAR II

Tibial artery—Continued

arteriovenous fistulas of

case report: 177-180

treated Zone of Interior: 155, 162

injury, frequency of: 68-70

comparative British World War I,

American World War II: 69

comparative British World War I,

American World Wars and 11:68

surgical procedures for exposure: 228-

231

resection of fibula: 230, 231

sympathectomy

as postoperative measure: 353

as preoperative measure: 335

vasospasm of, case reports: 136

wounds of, effect

on incidence of amputation: 78, 79

Timelag between wounding and treatment;

73, 74

case report: 111

effect on incidence of amputation: 75

Tobacco smoking

abstinence, special ward for: 5, 379

in Raynaud’s disease: 390

in Raynaud-like disorders: 392

in thromboangiitis obliterans: 377-379,

429

Torney General Hospital Vascular Center:

2, 3, 11, 14, 15. See also DeWitt

General Hospital Vascular Center.

Tourniquets, use of in battle casualties;

86-92

application, principles of: 91, 92

release and removal: 89-91

case reports: 90, 91

types

pneumatic: 87

rubber tubing: 87

strap and buckle: 86, 87

wounds requiring, and management of

patients: 88, 89

case reports; 89-91

Touroff, A. S. W.: 165

Training: 12, 13

Transection, arterial; 81, 82

Trauma, as indication for amputation;

66, 67

Trenchfoot: 5, 11, 19, 397

amputation in: 427

diagnostic aids: 30, 51

sympathectomy as treatment: 423, 427,

428

Trendelenburg test. See Brodie-Trendel- enburg test.

Trent, J. C.: 243, 247

Trophoneurosis, peripheral: 395

Tuffier: 37, 115, 116, 130

Tuffier tube: 116

Tunisian campaign: 62

Turovets, I. G.; 84

Tycos oscillometers: 14, 40

Typhoid vaccine

in thromboangiitis obliterans: 379

in vasomotor index: 47

Ulcers

chronic in vascular insufficiency, sympathectomy as treatment: 431, 432

in thromboangiitis obliterans; 376

in vasomotor disorders, sympathectomy

as treatment: 399, 411, 416, 417

Ulmer, J. L.: 145

Ulnar artery

aneurysm of

spontaneous cure, case report; 366, 367

treated Zone of Interior: 155, 161

arteriovenous fistulas of, treated Zone of

Interior: 155, 162

injury, frequency of, comparative British

World War I, American World

War II; 69

occlusion of, test for; 29

surgical procedures for exposure: 233-236

wounds, effect

on incidence of amputation: 78, 79

Ungerleider and Gubner, method of measuring cardiac frontal area: 169, 207,

222

Van Kend: 104

Van Slyke blood gas apparatus: 14

Varicosities, tests for: 37, 38

Vascular

centers, Zone of Interior: 1-16. See also

Ashford General Hospital, DeWitt

General Hospital, and Mayo General

Hospital,

clinical research in: 16

equipment: 13-15, 17, 18

establishment: 1-3

organization: 3-5

patient loads: 5-11

personnel: 11, 12

records, forms: 15, 19, 20

training programs: 12, 13
INDEX 461

Vascular Continued

insufficiency. See Gangrene, ischemic;

Sympathectomy, lumbar and theracic.

status, methods of evaluation in patients:

17-59

clinical history

general: 20, 21

vascular; 21-23

physical examination

general; 23

vascular: 23-28

auscultation: 27

inspection; 24, 25

mensuration: 27

nerve and muscle for injury

sequelae: 28

palpation: 25, 26

percussion: 27

retinal vessels: 28

vital signs: 23, 24

status, methods of evaluation in patients,

etc.

clinical history, etc.

physical examination, etc.

tests, and methods of determination

Allen; 29

arteriography: 51, 52

axillary vein thrombosis: 38

blanching: 29

blood

clinical laboratory tests: 28

pressure: 23, 24, 58, 59

volume; 42, 43, 192-194, 195-197

Branham’s sign: 31

capillary dilatability, typhoid vaccine injection: 47

cardiac

output: 185-187

size: 207-222

circulation time: 42

Coenen-Henle phenomenon: 56

collateral circulation

claudication time: 33

Delbet’s; 31, 32, 33

occlusive compression: 32, 33

reactive hyperemia: 33-36

dorsiflexion: 30, 31

electrodiagnosis: 50

exercise tests

lower extremities; 29

upper extremities: 29

Gunderman’s sign: 31

heparin tolerance test: 28

Vascular—Continued

status, methods of evaluation in patients—contin ued

tests, and methods of determina- tion—contin ued

Homans’: 30, 31

Kerr’s: 47

laboratory, clinical: 28

Matas’: 33-36

nerve conduction interruption

peripheral nerve block: 48

spinal analgesia: 48, 49

sympathetic ganglion block: 47, 48

oscillometry: 40, 41

pain, ischemic: 30

Perthes: 37

phlebography; 52-54

plantar: 29

plethysmography: 43, 44

occlusion

Branham’s sign; 31

Gunderman’s sign: 31

temporary, during operative procedure: 55

Ochsner-Mahorner: 37

ophthalmoscopy: 28

reflex vasodilatation: 46, 47

roentgenography: 50-55

aorthography: 54

arteriography: 51, 52

phlebography: 52-54

soft tissue techniques: 54

teleoroentgenography: 55

Samuels; 29

Scalenus anticus syndrome: 38

Schecter and Ragan: 30

skin resistance: 43

temperature: 38, 39

sweating: 42

Trendelenburg: 37

varicosities: 37

vascular tone, basal

Naide’s: 49, 425

modification: 49, 50

vasodilatation, reflex; 46

vasomotor index: 47

vasomotor tone and lability or

reactivity: 45-47

body cooling: 46, 47

capillary dilatability: 47

cold shower: 47

heat application; 47

ice water immersion: 47
462 VASCULAR SURGERY IN WORLD WAR II

Vascular—Continued

status, methods of evaluation in patients—continued

tests, and methods of determination—continued

vasomotor tone and lability or

reactivity—continued

Kerr’s trigger reflex: 47

venous filling time: 36, 37

Tuffier and Hallion: 37

venous pressure: 42

wheal test, fluorescin: 44, 45

histamine: 44

intradermal saline: 44

tests, and method of determination at

operation: 55-59

auscultation: 57, 58

blood pressure, intravascular, intrasaccular: 58, 59

inspection: 56, 57

intrasaccular: 58

occlusion, temporary: 55

palpation; 57

temperature: 58

Vasomotor disorders, post-traumatic: 395-421

etiology: 397

general discussion: 395, 396, 418-421

incidence: 397

symptoms and signs: 397, 398, 399-401

therapy: 398, 401-421

bed rest with elevation of limb; 402

exercise and physical therapy; 398,

402-405, 410, 419

case report: 404

neuropsychiatric measures: 405-409

case reports: 407-409, 413, 414

procaine infiltration, local: 419

sympathectomy, indications and results: 410-417

edema: 399, 400, 402, 406, 411,

412-414

case reports: 412, 413, 414

osteoporosis: 396, 402, 417, 418

pain on weight-bearing and rest

pain: 399, 408, 409, 411, 414, 415

sympathetic over-activity: 399, 400,

401, 411, 415, 416

ulcers, chronic: 399, 411, 416, 417

sympathetic block: 398, 409, 410, 419,

420

tests: 400, 401

preoperative for sympathectomy: 411

Vasospasm

as indication for sympathectomy in

vascular surgery; 332, 333, 344

in battle casualties: 135-139

case reports: 136

incidence of amputation following: 81

therapy: 136-139

sympathetic block and sympathectomy; 137-139

Vasospastic disorders: 383-394. See also

Raynaud’s disease and like disorders.

Vein grafts, sutured: 113-115, 294-297

Venous

filling time test: 36, 37

pressure determinations: 42

thrombosis, diagnostic aids: 30, 31, 38, 42

Vertebral artery

arteriovenous fistulas of

case reports: 261-263

treated Zone of Interior: 155, 162

injury, frequency of, comparative British

World War I, American World War

II: 69

surgical procedures for exposure; 257-

260

Volkmann’s ischemic contracture; 142-145

therapy

fasciotomy: 144, 145

case report: 144, 145

sympathectomy: 145

Von Oppel, W. A.: 103

Wallace, C.: 64

Ward rounds, coordinated in vascular

centers:

Warren, J. V.: 189, 198, 199, 204

Warthmuller, H: 115

Waugh, W. Grant; 130, 131, 133, 275

Weens, H. S.: 198

Weiss, S.: 192, 203

Welch, C. S.: 95

Wheal tests

fluorescin: 44, 45

histamine: 44

intradermal saline: 44

White, J. C.: 424, 425, 428, 436, 437

White, P. O.: 311

Wilson, W. C.; 106

Winslow, N.: 361

Wolff, Maj. Luther H.; 86-92

Women’s Army Corps: 12, 19

World War I; 77, 85, 266

incidence of amputations: 107
INDEX 463

World War —Continued

incidence of arterial injuries: 60, 64, 68,

69

ligation of arteries: 102

ligation of concomitant vein: 102-105

nonsuture anastomosis, not employed:

119

results of acute occlusion: 83, 84

secondary hemorrhage: 129, 130, 133

sutured vein grafts: 109-111, 115

sympathectomy: 146, 422

vasospasm: 135

Wounds, arterial, acute battle-incurred:

60-148

amputation following. See also Amputation,

incidence of: 66-70

by cause: 66, 67

comparative American, German, Russian; 66, 67

by management, methods of: 112,

125, 137

by repair, arterial, types of: 112

complications following: 126-148

aneurysms and arteriovenous fistulas:

139-142

case reports: 140-142

causalgia: 145

circulatory insufficiency: 146-148

sympathectomy as treatment: 146-148

case reports: 146-148

gangrene

gas: 66, 67, 84, 85

ischemic: 83-85

hematoma, pulsating: 127-129

case reports: 128, 129, 134

hemorrhage

methods of control: 70, 71, 85-92

secondary: 129-135

case reports: 131, 132, 134

infection as antecedent; 127, 130

therapy: 133-135

infection: 66, 67, 82, 83, 84, 85,127,130 ischemia: 126, 127

occlusion, acute: 83-85

gangrene, gas, and infections as

result: 84, 85

gangrene, ischemic, as result: 83-85

vasospasm: 81, 135-139

case reports: 136

Volkmann’s ischemic contracture:

142-145

case report: 144, 145

Wounds, arterial, acute battle-incurred—Continued directives on management: 61, 62, 70-

72, 156

amputation, primary: 108, 109

debridement: 70, 101

ligation of concomitant vein: 72, 107

posture of extremity: 97

thrombosis; 80, 81

distribution of: 67-70

according to anatomic location in

wounds of extremities

comparative British World War I,

American World Wars and

II: 68

by artery, giving results, comparative

British World War I, American

World War II: 69

incidence: 62-66

American casualties World War II:

64, 65

casualties in various wars: 63, 64

wounds, among wounds of extremities:

65, 66

management

directives on: 61, 62, 70-72, 80, 81,

97, 101, 108, 109, 156

methods of

conservative (nonsurgical): 95

expectant treatment; 92-95

case report: 93, 94

supplemental measures; 97-101

anticoagulant therapy: 74, 98, 99

heat: 72, 101

oxygen therapy; 98

posture of extremity; 97, 98

refrigeration: 73, 74, 99-101

sympathectomy and sympathetic

block:72, 74,137-139, 146-149

surgical measures; 101-126

amputation, primary: 108,109

debridement: 70, 85, 95, 101, 130

fasciotomy: 144, 145

case reports: 119-122, 144, 145

ligation: 71, 72, 102, 111, 112, 125

with concomitant vein: 71,

102-108

repair: 74, 109-126

by anastomosis, end-to-end; 111

case report: 96

by nonsuture; 119-126

case reports; 116, 117, 119-

121, 122
464 VASCULAR SURGERY IN WORLD WAR II

Wounds, arterial, acute battle-incurred—Continued

management—continued

methods of—continued surgical measures- -continued

repair—continued

by prosthetic devices: 115-118

by suture: 109-113

case reports: 111, 113

by sutured vein graft: 113-115

sympathectomy: 74, 137-139,

146-148

problems of, medicomilitary: 72-83

associated wounds; 76, 77

infection; 82, 83, 84, 85, 111, 130

site of wound: 77-80

status of casualty: 75, 76

surgeons, lack of experienced vascular:

74, 75

Wounds, arterial, acute battle-incurred—Continued

problems of—continued

timelag: 73, 74, 75

case report: 111

type of wound: 80-82

compression: 81, 82

concussion: 82

case report: 136

laceration and transection: 81, 82

spasm; 81, 82

thrombosis: 80, 81

Wounds, soft tissue

associated injuries in aneurysms and

arteriovenous fistulas: 165, 166, 167

vasomotor disorders, following: 397, 406, 408, 415
VASCULAR SURGERY IN WORLD WAR II 465

Distribution:

Active Army:

Gen Staff, DA (1)

SS, DA (1)

Tec Svc, DA (1) except TSG (350)

AFF (3)

OS Maj Comd (10)

OS Base Comd (2)

Log Comd (1)

MDW (2)

Armies (2)

Div (2)

Tng Div (2)

Brig (1)

Ft Cps (2)

Disp (2)

Gen Br Svc Sch (2)

Army Hosp (3)

US Army Hosp (2)

Med RTC (1)

Med Lab (1)

Mil Dist (1)

MAAG (1)

ARMA (1)

TOE 8-22A, Hq Hq Det, Med Gp (1):

8-5I0A, Fid Hosp (1)

8-551 A, GH (1000 bed, Comz) (1)

8-553A, GH (2000 bed, Comz) (2)

8-563A, Sta Hosp (100 bed, Comz)

(1)

8-564A, Sta Hosp (200 bed, Comz)

(1)

8-565A, Sta Hosp (300 bed, Comz)

(1)

8-566A, Sta Hosp (500 bed, Comz)

(1)

8-567A, Sta Hosp (750 bed, Comz)

(1)

8-571A, Mobl Surg Hosp (60

bed) (1)

8-581A, Evac Hosp Smbl (1)

8-590A, Convalescent Gen A, Comz

(1)

NG USAR: None.

Unless otherwise noted, distribution applies to ConUS and overseas.

For explanation of abbreviations used, see SR 320-50-1.

U. S. GOVERNMENT PRINTING OFFICE: 1955 330323