A diagnosis of paradoxical cerebral embolus (PCE) was made in five patients aged 31 to 62 years who sustained eight cerebral ischemic events. No patient had evidence of primary carotid system or left heart disease. A probe-patent foramen ovale was the presumed mechanism in four patients, and an unsuspected congenital atrial septal defect was found in the fifth patient. Clinically apparent pulmonary emboli or venous thrombosis preceded the cerebral event in only one instance. Review of the literature reveals a high mortality with PCE. However, careful clinical search for this lesion may be rewarding: four of our five patients survived. One should consider PCE in any patient with cerebral embolus in whom there is no demonstrable left-sided circulatory source. This principle applies particularly if there is concomitant venous thrombosis, pulmonary embolism, or enhanced potential for venous thrombosis due to, for example, morbid obesity, use of hormonal birth control pills, prolonged bed rest (especially postoperatively), or systemic carcinoma.

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A total of 97 patients underwent 107 renal revascularization procedures for restoration and preservation of renal function. Of the 4 groups of high risk surgical patients that emerged an overall successful outcome was achieved in 83%, with a 6% mortality rate and an 11% morbidity rate. Renal revascularization for restoration and preservation of renal function can be performed safely with good results. The preoperative serum creatinine level was not predictive of the surgical outcome. Alternative bypass procedures are preferred.

Infrequently, when the aorta cannot be used for a standard renal bypass operation because of a previous aortic operation, severe degenerative atherosclerosis or complete aortic thrombosis, a unilateral (hepatic) or bilateral (hepatic and splenic) visceral bypass should be contemplated. Patients with abdominal aortic aneurysms extending above the renal arteries might benefit from concomitant bilateral visceral bypass procedures followed by aortic replacement during the same operative session. The hepatic circulation with its common anatomic variations, indications, surgical technique and effects of hepatorenal artery bypass on the renal and hepatic circulation are discussed.