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Objective: An evaluation of the treatment of patients with venous angiodysplasia and severe chronic insufficiency. Design: The clinical series of patients with venous angiodysplasia of Klippel-Trenaunay (K-T) and Servelle-Martorell (S-M) type. Setting: Primary care teaching hospital. Patients: Eighty-three patients with angiodysplasia type K-T characterized by the triad of local giantism, varicose veins and naevus flammeus. Malformations of the deep venous system were present in 96%. The predominant vascular lesion in patients with the S-M syndrome ( n=34) was a haemangiomatosis, involving both the skeleton and soft tissues, causing growth retardation in the affected extremity. A malformation of the deep venous system could be seen in all patients. Main outcome measures: Healing of skin ulcers and varicose bleeding of the lower extremities. Interventions: Conservative treatments included external compression bandages or stockings. In 14 patients, surgical extirpation of superficial veins was used. Results: All the ulcers were treated successfully, and no haemorrhage reoccurred. Haemodynamic studies showed an improvement of the venous reflux disease in 86% of patients. Conclusion: Venous angiodysplasia of the lower extremity is nearly always associated with malformation of the deep venous system. Surgery is indicated for the elimination of a pathological short circuit flow in atypical drainage veins of the affected leg, especially when skin lesions are present. For any type of surgery, a careful preoperative angiographic and haemodynamic evaluation is mandatory.

Carotid artery insufficiency is caused by an abnormal kinked or coiled internal carotid artery in 15-20 per cent of symptomatic patients. Surgical correction should be considered if other causes for the neurological signs are excluded, a pronounced kinked or coiled area is demonstrated and if there is not a severe neurological deficit. As well as eliminating the elongation, surgical correction should include intraluminal inspection of the artery as, in 38-5 per cent of cases, a concomitant arteriosclerotic stenosis requires simultaneous correction.

1) Traumatic rupture of the thoracic aorta is most frequently caused by a traffic accident with deceleration. Approximately 80% of these patients die immediately. In 29 patients (1973-1986) reaching surgical treatment, all aortic lesions were located at the aortic isthmus (28 covered and 1 free rupture). 25 (86%) of them had serious associated injuries of the head, other thoracic or intraabdominal organs and/or the extremities. A seat belt could not prevent the deceleration injury of the aorta but reduced associated injuries of the head and the intraabdominal organs. 2) The widely accepted surgical rule that every diagnosed traumatic aortic rupture should have an immediate surgical repair is no longer acceptable. In all patients with a clinically and angiographically stable covered rupture of the aorta with serious associated injuries and symptoms of shock the surgical treatment of the aortic lesion should be undertaken with delayed emergency after some hours or several days. This changed surgical concept is based both on the rarity of secondary free rupture of the aortic lesion and on the chance to stabilize the circulatory condition by a primary shock treatment including the surgical elimination of other sources of blood loss. The group with such a delayed aortic vascular repair (n = 12) showed a remarkably improved outcome with reduced operative mortality and reduced risk of paraplegia (47% vs. 25% respectively 35% vs. ca. 10%). None of these patients with a delay up to 17 days for vascular repair developed a secondary free aortic rupture. Up to recently this risk has been obviously overestimated on the basis of earlier studies in the sixties. 3) The immediate repair of the aortic rupture with its high operative mortality and high rate of ischemic paraplegia can be restricted to a few exceptional cases with a secondary free rupture in the hospital. The transvenous DSA is the best approach for an early diagnosis and for the surgical decision to perform vascular repair immediately or with delay.