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Paten cy of the intern al carotid artery in cas e of common carotid arter y occlusion is usually maintain ed by a flow of blood from th e external caroti d into the intern al carotid artery. A cas e whe re a reversed flow of blood was established from the cerebral circ ulation into the internal carotid artery and eventua lly into the external carotid artery is pr esent ed. Car eful read ing of the cerebral views of th e standard carotid angiogram allowed detection of a retr ograd e flow into the internal carotid artery. Sur gical exploration confirmed the patency of th e internal carotid art ery ; th e occluded common carotid artery was bypassed by a pro sth esis, which resto re d an antegrade flow into the intern al carotid artery.

We report a patient with Marfan's syndrome and pectus excavatum who underwent open heart surgery with simultaneous correction of the sternal malformation. Permanent internal stabilization, achieved by bilateral overlapping of the bevelled ends of the lowest ribs and reinforced with sternal closure wires offered a maintained postoperative chest wall stability, avoided the potential postoperative complications of cardiac compression, and improved the aesthetic appearance of the anterior chest wall. The increased risk of bleeding due to extensive dissection was minimized by postponing the repair of pectus excavatum to when protamin is administered after termination of cardiopulmonary bypass.

A retrospective analysis of blunt trauma to the lower extremity with injury to the popliteal vessels was undertaken in an attempt to determine the major predictors of outcome and to expose the shortcomings of our management. Thirty-one patients with lower extremity trauma including a popliteal artery injury were admitted to our clinic between 1979 and 1993. Two patients died of hemorrhagic shock or from associated lesions. Amputation of the leg was performed primarily in one patient because of massive tissue damage and secondarily in five patients because of uncontrolled local infection (two patients), excessive tissue damage (two patients), and persistent ischemia (one patient who later died). A peripheral neurologic deficit resulted in 12 of 24 non-amputated extremities. Three additional patients suffered sequelae from bone and joint damage. In all, nine patients recovered completely from their limb injury. Severe ischemia of the leg was found to be an indicator of major limb damage and was a strong determinant of poor outcome. Of 18 patients with severe ischemia, two died (one after amputation), five were amputated, and eight were left with a peripheral neuropathy. Only two patients recovered completely. Of 13 patients with relative ischemia, five recovered completely and four sustained a peripheral neuropathy. The deleterious effects of delayed revascularization were evident in four patients who developed a peripheral neuropathy secondarily. Morbidity from the ischemic insult could have been reduced in seven patients: the diagnosis was missed in two, its seriousness not realized in one, and a non-optimal management led to an excessive ischemic time in four. The magnitude of skeletal and soft tissue injury, alone or in combination, was also strongly associated with an increased morbidity. Most patients with blunt lower limb trauma and popliteal vascular injury are left with serious sequelae from associated neuro-musculo-skeletal damage and from ischemia. Although the magnitude of the first variable is determined by initial trauma and cannot be altered, a constant awareness of possible arterial injury in lower limb trauma, and adherence to a plan of management according to the ischemic state of the leg, should help avoid the additional deleterious effects of prolonged ischemia.

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