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Because of the unacceptably high mortality rate associated with aortoenteric fistula, we have constantly re-evaluated our experience with this lesion. A study of 31 cases of aortoenteric fistula proven at operation has provided a better understanding of the prevention and management of aortoenteric fistula. Prevention remains the primary goal, as the treatment of this complication even with the adoption of recommendations made in our paper can be expected to continue to carry a significant late mortality rate. The most important point in prevention is to provide adequate protection between gut and graft, using tissue, prosthetic cuff and correct reperitonealization techniques. Systemic or groin infection should be followed by prompt total removal of the graft before the onset of aortoenteric fistula. Once aortoenteric fistula is present, early operation with removal of the graft, proper closure of the aortic and enteric openings, and sump drainage of the area is indicated. Blood supply to the extremities is supplied by extra-anatomic bypass or endarterectomy if the underlying problem is arterial occlusive disease. Paraprosthetic aortoenteric fistulas may be diagnosed early by the presence of fever, blood culture, and a high degree of suspicion. CAT and gallium 67 scanning can be helpful in identifying this early type of fistula.

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Two hundred ninety patients undergoing carotid endarterectomy were reviewed. From 1968 to 1972, 188 patients had carotid endarterectomy under general anesthesia with use of a shunt and hypercarbia. Stump pressures were not recorded in this group. There were three deaths, three postoperative hemiplegias and two complications of transient limb weakness. From 1973 to 1975, 102 patients were operated on under local anesthesia with systemic Innovar and Sublimaze, normocarbia and intra-operative assessment of stump pressure. In this group there was one death, no hemiplegia, and no complications of transient limb weakness. Twenty of the 102 were shunted either on the basis of stump pressure or the loss of motor ability or consciousness on carotid clamping. Those shunted had stump pressures ranging from 10 to 70 mm Hg with a mean of 20 while those not shunted had stump pressures ranging from 20 to 85 mm Hg with a mean of 53 mm Hg. Five patients lapsed into unconsciousness despite internal carotid stump pressures of 30, 30, 34, 36 and 70 mm Hg respectively, thus requiring intraoperative shunting. This experience seriously questions the reliability of carotid stump pressure as the sole determinant to identify those patients who require intraoperative shunting. We have come full circle, back to operation under local anesthesia, since intraoperative assessment of the patient's motor ability and consciousness alone provide the only absolute criteria for assessing the need for intraoperative shunting. Since the operation can be performed with greater technical efficiency without a shunt and without the potential complications of shunting itself, it behooves the surgeon to have a reliable method of knowing when it is not required.

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