War Injuries of Major Extremity Arteries

Abstract During the period 1991–1994, 99 patients (all males, median age 35 years) with combat-related injuries of major limb arteries were managed. Mechanism: mine fragments (40%), high-velocity projectiles (35%), and shotgun pellets (25%). Patients were admitted 1 hour to 16 hours (median 8 hours) after injury; 39% were in severe hemorrhagic shock. Arterial injury was diagnosed by clinical findings. Preoperative angiography was usually not necessary. Of 99 injured patients, 50 (51%) showed signs of distal ischemia and required arterial reconstruction. No primary amputation was performed. Reconstruction was always necessary in cases of injury of axillary or popliteal arteries, but not of superficial femoral or brachial arteries. Ligation of injured single forearm or crural arteries was well tolerated. End-to-end anastomosis by reconstruction was possible only in 38% of cases. In 56% of patients, autologous venous bypass was performed. Uncontrolled wound infection developed in 22% of cases, leading to a secondary hemorrhage compelling arterial ligature (8%), and thrombosis (6%). The secondary amputation rate after arterial reconstruction was 10%. Injury of major vessels was associated with limb bone fractures, nerve damage, or major vein injuries in 68% of cases, frequently on the forearm, the popliteal region, and the crural region. When limb ischemia was present, vascular reconstruction had priority over orthopedic immobilization. Arterial injury was almost always associated with the venous damage in the forearm, the popliteal region, and the crural region. Injured veins of the upper limb were ligated; venous repair was more often indicated in lower limb injury (52%). The method of choice was lateral suture/patch. Gunshot damage to peripheral nerves was rarely treated with primary repair.     

Civilian arterial injuries.

During 1968-1973, 122 patients with 126 arterial injuries were treated. In 94 instances (90 patients), these injuries involved extremities. Systolic blood pressure was below 90 mm Hg upon admission in 55.6% of all patients and 37.7% of those with injuries to arteries of the extremities. The decision for operative exploration and repair of arteries of extremities was based largely on clinical grounds (shock, loss of pulse). Preoperative arteriography was needed infrequently, while operative angiography was nearly routine. Although several cases of late revascularization or traumatic thrombosis of renal artery have been reported, hypertension complicates the postoperative period, and early, aggressive approach is essential. Mortality was 10.6%, from aortic injuries. There were no deaths among patients with arterial injuries distal to inguinal ligament or thoracic outlet. The amputation rate from reconstruction failure was 1.1%, none occurring in the last 3 years of the series. The high patency rate and lack of evidence of pulmonary embolization suggest that associated venous injuries be repaired routinely. Arterial injuries represent ideal lesions (normal arterial wall with excellent run-in and run-off). Prompt treatment of shock and early, proper management of patients' mechanical disruptions will salvage many lives and most limbs.     

Elective vascular reconstruction after trauma

Elective vascular reconstruction was performed to correct 135 vascular lesions at Walter Reed Army Medical Center in patients who had sustained earlier vascular trauma. This represents approximately 7 per cent of the operations performed from 1967 to 1974. Approximately three fourths of the lesions resulted from combat wounds and the remaining one fourth from civilian trauma. Of the 135 lesions, fifty-two were arteriovenous fistulas, thirty-five were false aneurysms, and the remaining forty-eight lesions involved thrombosis or stenosis. The popliteal artery was involved most frequently (nineteen lesions), closely followed by eighteen injuries to the superficial femoral artery and fourteen injuries to the brachial artery. In managing both false aneurysms and arteriovenous fistulas, repair of the arterial injury was the major objective. However, particular effort was made to repair larger veins in the arteriovenous fistula category. Patients with arterial thrombosis and stenosis who had symptoms interfering with their daily activity have had successful vascular reconstruction utilizing a variety of technics. No operative or related postoperative deaths occurred in this group of patients. There was only one early postoperative graft occlusion, (0.7 per cent of the operations) and two late graft occlusions (1.5 per cent). Subsequently, additional vascular reconstruction was successful.     

Early experience with the retrievable OptEase vena cava filter in high-risk trauma patients.

OBJECTIVES: Prophylactic vena cava filters (VCF) are efficient in preventing pulmonary embolism. Filter retrieval avoids the potential long-term complications of permanent VCF. Clinical evaluation was focused on filter-related complications and feasibility of retrieval in high-risk trauma patients. METHODS: Analysis of single-institution consecutive case series of patients who received a prophylactic OptEase VCF after multiple trauma between 08/2003 and 12/2004. Data were collected prospectively. RESULTS: A total of 37 OptEase filters were inserted prophylactically after multiple trauma (median patient age 35 years, range, 17-73 years, median ISS 41, range, 17-59). All patients had contraindications for pharmacological prophylaxis for thromboembolic events. 32 filters (86%) were retrieved after 16 days (range, 7-25 days). 12 of 33 filters (36%) demonstrated trapped clots/thrombosis within the filter structure on pre-retrieval cavography. Two patients received anticoagulation before filter retrieval due to filter thrombosis (6%). Symptomatic PE was observed in 1 patient (3%) 5 days after VCF retrieval. Minor caudal filter migration was observed in 1 patient (3%). Overall mortality was 3%. CONCLUSIONS: Retrieval of the OptEase filter is safe and feasible. Temporary filter placement avoids possible long-term complications of permanent VCF. It is an efficient form of PE prophylaxis when temporary contraindications to anticoagulation are present.     

The nature of arterial healing following dextran treatment of experimental small artery trauma.

Vascular thrombosis is a major cause of morbidity and death. Because of the many variables involved with thrombosis in patients, major advances in treatment often depend upon design and study of adequate experimental models which provide a degree of control of the variables. Arterial trauma was produced in small femoral arteries 3 mm. or less in diameter by a standardized intimectomy technique. One group of animals was treated with an equal volume of saline and served as controls. Serial sections of blood vessels at graded time intervals from one hour to 90 days were studied. The damaged blood vessels of dextran-treated animals did not thrombose and provided an opportunity for studying the mechanism of healing in traumatized blood vessels which remained patent. The damaged blood vessels of saline-treated animals uniformly thrombosed and eventually healed for scar formation with evidences of attempts at recanalization. The blood vessels of dextran-treated animals remained open for as long as 90 days and were re-endothelialized and healed. What appears to be beginning re-endothelialization of blood vessels of dextran-treated animals was observed as early as 48 hours. In a model experimental setting, dextran has been shown to prevent thrombosis and permit healing in small arteries subjected to a standardized surgical trauma.     

膝部超时限腘动脉损伤的治疗

目的 总结超时限胭动脉损伤的诊治经验和教训。方法 1995年2月～2006年1月，收治28例胭动脉损伤时间超过8h的患者。其中男25例，女3例；年龄3～53岁。车祸伤12例，高处坠落伤3例，火器伤2例，锐器伤3例，绞扎伤2例，其他6例。20例未扪及动脉搏动，8例动脉搏动减弱。2例见裸露胭动脉和／或活动性喷血，8例直接手术探查，18例彩色多普勒检查示胭动脉及分支有彩色血流信号通过。7例胭动脉缺损〈5cm，9例缺损〉5cm。损伤至血管再通时间8～150h，平均31．8h。采用端端吻合、大隐静脉移植修复16例，截肢12例。结果 行动-静脉吻合或桥接术的16例患者，15例血管再通，肢体存活，其中12例1年内下肢功能基本恢复，3例遗留不同程度足下垂和踝关节挛缩，另1例枪伤患者因吻合血管术后1d再次栓塞，行二期截肢；血管吻合术后肢体存活率94％（15／16）。28例患者均获随访6个月～11年，平均4．2年。无死亡患者，截肢率43％，病残率54％。结论 胭动脉损伤的预后主要取决于血管再通时间和侧支循环的血氧代偿能力；延误诊断和治疗是严重胭动脉损伤截肢率居高不下的主要原因。     

Robotic-enhanced arterial revascularization for multivessel coronary artery disease

BACKGROUND: A tendency to reduce operative trauma is determining the evolution of cardiac surgical techniques lately. The introduction of robotic-enhanced endoscopic systems enables surgeons to perform arterial revascularization for multivessel disease without sternotomy. METHODS: From May 1999,17 (4 women, 13 men; median age 63+/-7.4 years) patients with multivessel coronary artery disease were treated surgically using arterial revascularization by means of bilateral internal mammary arteries. Both arteries were harvested endoscopically using the da Vinci system (Intuitive Surgical, Mountain View, CA). These vessels were anastomosed using the "Dresden technique." RESULTS: Survival was 100%. Mean duration of the operation was 255+/-40.4 minutes. Bilateral internal mammary artery harvesting took 88.5+/-15.9 minutes; cross-clamp time was 36+/-8.7 minutes. An average of 2.06 anastomoses were performed per operation. Postoperatively, patients remained in the intensive care unit for 21+/-13 hours. One patient (5.8%) needed reexploration due to bleeding. CONCLUSIONS: The robotic surgical system introduces a new treatment of coronary artery disease to surgical practice, and enables arterial revascularization with distinctly reduced surgical trauma.     

The current surgical management of carotid body paragangliomas.

To determine if recent trends in evaluation and therapy have contributed to the successful surgical management of carotid body paragangliomas, we reviewed our experience over the past decade. Nineteen carotid body paragangliomas were identified in 17 patients. Eleven patients underwent complete, preoperative embolization of their afferent arteries with one complication. Calculated carotid body paragangliomas surface areas did not differ between the embolized 64.6 +/- 43.3 cm2 and nonembolized 63.0 +/- 57.9 cm2 lesions. Intraoperative blood loss was lower (p = 0.02) in the patients treated with embolization (372 +/- 213 ml) compared with their cohorts (609 +/- 564 ml). However, the operative times were equivalent 4.1 hours versus 4.5 hours in both groups. Intraoperative electroencephalographic (EEG) monitoring was used in 10 patients; in one patient the EEG indicated intraoperative thrombosis of the carotid artery, which was successfully treated by thrombectomy without complications. Two patients required carotid bifurcation resection and vascular reconstruction to remove the entire tumor; a late stroke manifested by contralateral hand weakness developed in one of these patients. The incidence of cranial nerve injury was low at 16%, with one transient ramus mandibularis paresis and two instances of vocal cord dysfunction. Two additional patients had a postoperative Horner's syndrome. We conclude that by diminishing intraoperative blood loss through complete and careful preoperative embolization and use of intraoperative EEG monitoring along with careful surgical technique, the complications associated with this challenging operation are facilitated and diminished.     

Experiences in the use of eight cutaneous and osteocutaneous superficial and deep circumflex iliac free flaps

Eight patients underwent free tissue transfers involving groin cutaneous or osteocutaneous flaps using the superficial and deep circumflex iliac arteries and veins. Four were used for head and neck reconstruction, two for severe neck scar contractures, and two for composite skin and mandibular reconstruction. Three were used in lower extremity reconstructions, all in situations requiring bone and skin reconstruction. One was used for skin cover alone in an upper extremity reconstruction for wrist cover. One of the head and neck cases sustained vascular thrombosis requiring a second successful free flap coverage for a 12.5% failure rate. One required re-exploration with successful salvage. The average operating time was 12 hours. The anatomy and surgical techniques are discussed. The main values of the procedure are the presence of a double vascular supply of both arteries and veins for complex reconstructions, and the fact that a large area of skin and subcutaneous tissue can be procured, with a relatively inconspicuous donor site.     

Extrathoracic Approach for Reconstruction of Subclavian and Vertebral Arteries

One hundred extrathoracic arterial reconstructions were performed on 98 patients with occlusions or stenoses of the subclavian or vertebral arteries: 52 bypasses, 18 transpositions of the subclavian artery to the common carotid artery, 13 endarterectomies and 17 operations involving two or more simultaneous reconstructions. The operative mortality was 1% (one patient). In 2 patients hemiplegia occurred as a complication of carotidsubclavian bypass operation. Six patients had a nerve injury as an operative complication: 1 lesion of the brachial plexus, 3 lesions of the recurrent nerve, and two lesions of the phrenic nerve (one patient also had Horner's syndrome). Immediate thrombosis of the operated arteries developed in 7 patients, 2 of whom were re-operated on. During the follow-up period (mean 4.5 years), six additional operations were performed because of failure of the first operation: the bypass graft was thrombosed in 5 of these cases and in one case a venous bypass graft with insufficient flow was replaced by a prosthesis. One patient underwent reconstruction of the contralateral side because of residual symptoms. In addition, 1 carotid endarterectomy, 2 thoracic sympathectomies, 4 coronary artery reconstructions and 8 lower limb arterial reconstructions were performed during the follow-up period. There were 17 late deaths, 9 of which were due to coronary artery disease. Of the 80 survivors 79% were satisfied with the operative result. The bypass was considered patent in 68%.     

Surgical treatment of renovascular hypertension and respective late results. A twenty years experience.

This paper presents the long term results following operative reconstruction for renovascular hypertension in 115 patients operated upon over a period of 20 years. There were 71 (61.7%) males and 44 (38.3%) females with a median age of 46 years (range 16-67). Renal revascularization was unilateral in 96 (83.4%) cases and bilateral in 19 (16.6%). Dacron knitted bypass grafts, were used in 51 and PTFE in 33 instances. Saphenous vein grafts were used in 11 patients. In 15 cases treatment was by local endarterectomy with concomitant angioplasty (12 unilateral and 3 bilateral). Simultaneous aortorenal reconstruction was undertaken in 38 (33%) patients. There were no deaths in the group with isolated renal artery reconstruction. In the group of aortorenal reconstructions, two deaths were encountered (5.7%). Postoperatively, blood pressure was either normal or improved in 83 (72%) patients at a mean follow-up period of 48.3 months (range 1-195 months). The best results were obtained in younger individuals with segmental renal artery lesions. Linear progression analysis, showed age to be a major determinant in the postoperative response to hypertension. There was a greater degree of long term success in patients with fibromuscular dysplasia, as compared to individuals with atherosclerosis. Crude survival probabilities, were 78% and 61% at 5 and 10 years respectively. Late deaths encountered in the present series, were mostly attributable to myocardial infarction (7.8%). In this series, the best results were obtained in individuals younger than 50 years of age, with segmental renal artery lesions.     

Primary utilization of stents in angioplasty of superficial femoral artery

Percutaneous transluminal angioplasty (PTA) of infrainguinal arteries has been frequently reported in the literature. Independent of the technical feasibility, the results, in short-and long-term follow-up differ among published series. The objective of this article was to assess the long-term results of angioplasty in small, (<3 cm) segmental lesions of the superficial femoral artery treated with primary stenting. Eighteen patients (12 men, 6 women) with lesions of the superficial femoral artery smaller than 3 cm were selected for endovascular treatment and follow-up. The median patient age was 65 years (range, 54 to 84). The indication for treatment was intermittent claudication in 7 patients and critical ischemia (ischemic pain associated with trophic lesions) in 11 patients (62%). Of these, 13 lesions were stenoses and 5 total occlusions. The run-off was good in 15 patients who had more than 2 distal arteries and 3 had only 1 patent artery. During follow-up, all patients were observed with physical examination, progressive exercise treadmill test; pulse volume was measured with Doppler and duplex scan after 1, 3, and 6 months, and then twice a year. There was only 1 primary failure; the initial success rate was 94%. During follow-up of 40 months (6 to 70 months), only 1 patient presented with thrombosis of the stent 6 months after the procedure. There was no symptomatic restenosis in our study. One patient suffered an acute myocardial infraction after 45 months and died. The primary patency after 1 and 3 years was 88%. No patient was lost to follow-up. Primary stenting of segmental lesions (less than 3 cm) of the superficial femoral artery produced satisfactory results immediately and during long-term follow-up.     

Antegrade palliation for diminutive pulmonary arteries in Tetralogy of Fallot.

OBJECTIVES: The purpose of this study was to evaluate the outcome following palliative reconstruction of right ventricular outflow tract in Tetralogy of Fallot (TOF) with diminutive pulmonary arteries with central and peripheral stenosis. METHODS: Between 1986 and 1999 in 15 children with the diagnosis of TOF palliative reconstruction of the right ventricular outflow tract without closure of the ventricular septal defect (VSD) was performed. All patients were not suitable for an AP-Shunt because of a diminutive pulmonary vascular bed. Six patients were younger than 1 year at operation. RESULTS: There was one hospital death (6.7%) in a child with additional aortic valve insufficiency in multi-organ failure. Although the postoperative course was prolonged (median duration on ICU: 8 days) and complicated by congestive heart failure, clinically the 14 patients discharged improved significantly. The arterial oxygen saturation increased from 67 to 93% (P<0.001), the hemoglobin decreased from 16.1 to 13.3g/l (P=0.02) and hematocrit from 0.52 to 0.40 (P=0.06). In control angiography, the McGoon Index increased in the average from 1.01 to 1.95 (P<0.001). VSD closure was performed in 12 patients (median: 2.5 years after initial operation) with one perioperative death. A homograft had to be implanted in seven patients and a mechanical prosthesis in the right ventricular outflow tract in one. One late death occurred due to ventricular arrhythmia 12 years after antegrade palliation (11 years after corrective operation). CONCLUSIONS: The antegrade palliation seems to be an adequate strategy for the treatment of selected children with diminutive pulmonary arteries in TOF, who were not candidates for primary correction or an AP-Shunt.     

Application of xenogeneic bioprostheses in reconstruction of the arteries of infrainguinal localization

The application of 37 xenogenous bioprostheses was carried out in reconstruction of the arteries of infrainguinal localization in 37 patients (34 men and 3 women). Patients older than 60 years made up 67.2%. Most of the patients had occlusion of the femoral artery and lesions of the tibial arteries: one artery in 26 (70.2%), two arteries in 3 (8.1%) patients. The femoro-proximal-popliteal shunt was performed in 15 (40.5%) patients, in 22 (59.5%) patients long shunts were implanted (in 9--femoro-proximal-popliteal shunting, in 13--femoral-tibial). During the shunting operations a reconstruction of the inflow pathways was carried on (aorto-femoral shunting, endarterectomy from the iliac-femoral segment). The results of the reconstructive operations on the lower extremities with the application of xenoprostheses were estimated as good in 28 (75.6%) patients, in 6 (16.2%) patients--as satisfactory, in 3 (8.2%)--as bad. There were no lethal outcomes.     

Reconstructive options in the treatment of osteoradionecrosis of the craniomaxillofacial skeleton.

Osteoradionecrosis (ORN) of the craniomaxillofacial skeleton is a serious and debilitating complication that can occur following radiation therapy in the head and neck. Patients require effective treatment, which eradicates diseased tissue and restores function with minimal additional morbidity in a single stage, a requirement fulfilled in many cases by free tissue transfer. In a 6-year period from 1994 to 1999, 21 patients with ORN were treated by wide resection and free-flap reconstruction. The median interval between radiation therapy and ORN was 4 years (range: 1-33 years). The median radiation dose was 6000cGy. The affected areas were the mandible (15 patients), the temporal bone (three patients), the maxilla (one patient), the cervical vertebrae (one patient) and the frontal bone (one patient). Clinical symptoms included pain, ulceration, a persistent draining fistula, exposure of bone or hardware, and pathological fracture or non-union of bone. Six patients had had previous unsuccessful attempts at conservative surgical resection. Ten patients had preoperative hyperbaric oxygen (HBO) therapy. A number of different flaps were used for reconstruction in these patients. These included free fibula flaps (13 patients), iliac crest flaps (two patients), scapula flaps (three patients) and rectus abdominis flaps (three patients). All patients achieved relief from their presenting symptoms and primary bone or wound healing. One flap (4.8%) was lost. This was successfully reconstructed in a subsequent procedure. There were three flap re-explorations, two for arterial thrombosis and one for venous thrombosis. Conservative measures, such as limited debridement and HBO therapy, may be effective in preventing the progression of ORN. However, they fail to eradicate established ORN, which requires radical surgical resection followed by functional reconstruction with well-vascularised tissue.     

Patency of radial arteries reconstructed after radial forearm flap harvest

Poor patency is cited as a reason to not perform radial artery reconstruction after the harvest of the radial forearm flap. The need for a long vein graft and the presence of a patent ulnar artery are offered as explanations for thrombosis of the reconstruction in this setting. Similar arguments have been made regarding radial artery reconstruction in the trauma setting. In this study, the patency rate for patients undergoing radial forearm flap harvest with immediate reconstruction with reversed interposition vein grafting was evaluated. The mean follow-up time was 24 months, and all seven patients had patent reconstructions. Ultrasound examination revealed slightly larger diameters of the vein grafts compared with native arteries. No areas of stenosis were detected. No complications resulted from harvest of the vein. From these data, we conclude that radial artery reconstruction can be performed with the expectation of patency.     

Is combined partial hepatectomy with segmental resection of inferior vena cava justified for malignancy?

HYPOTHESIS: En bloc partial hepatectomy with inferior vena cava (IVC) resection may be the only curative strategy for patients with hepatic malignancies involving the IVC. DESIGN: Retrospective study. SETTING: Tertiary referral center. PATIENTS: All consecutive patients undergoing combined partial hepatectomy with segmental IVC resection and reconstruction between 1990 and 2002. Patients with tangential excision of the IVC were excluded. Follow-up was completed by outpatient clinic visits and mail correspondence. MAIN OUTCOME MEASURES: Perioperative outcomes; overall and recurrence-free survival. RESULTS: Nineteen patients (7 men and 12 women) underwent partial hepatectomy and segmental IVC resection and reconstruction. Median age was 59 years (range, 24-74 years). Diagnoses consisted of cholangiocarcinoma (9 patients), metastatic tumor (5 patients), sarcoma (3 patients), and hepatocellular carcinoma (2 patients). Major hepatectomies (>/=3 segments) were performed in 15 patients; the caudate lobe was resected in 13. Hepatic vascular isolation was used in 13 patients. Ringed polytef grafts were used for IVC reconstruction in all but 1 patient. Transfusion was necessary in 18 patients (median requirement, 5 U). Median operative time was 6.3 hours (range, 3.7-9.0 hours), and hospitalization was 10.5 days (range, 6-41 days). Negative margins of resection were achieved in 16 patients. Complications occurred in 8 patients (42%), including 1 perioperative death (5%). There was evidence of mural thrombosis of the graft in 2 patients (both nonocclusive); warfarin sodium was used postoperatively in 14. Late graft thrombosis was evident in 2 patients. Median overall survival was 38 months (5-year survival, 21%), and recurrence-free survival was 11.5 months (5-year survival, 0%). CONCLUSIONS: Patients with large tumors involving both the liver and the IVC are candidates for partial hepatectomy and segmental IVC resection. Resection affords the possibility of negative margins, acceptable perioperative morbidity and mortality, long-term graft patency, and prolonged survival.     

Combined infrarenal aorta and carotid artery reconstruction: Early and late outcome in 152 patients

Between January 1, 1985 and December 31, 1998, we performed combined infrarenal aorta and carotid artery reconstruction in 152 consecutive patients. The mean age of these patients was 65.4 ± 8.6 years (range, 43-88 years). Infrarenal aortic disease involved abdominal aortic aneurysm in 78 patients (44.7%) and occlusive aortoiliac lesions in 84 (55.3%). Carotid artery disease was detected by performing routine Doppler ultrasonography prior to aortic reconstruction. A total of 121 carotid lesions were asymptomatic (79.6%). A total of 32 patients (21%) had a history of contralateral carotid repair. Eighty-one patients (53.2%) presented with coronary artery disease diagnosed on the basis of clinical and/or laboratory testing. Concurrent lesions were diagnosed in the renal arteries of 43 patients (28.3%) and in the visceral arteries of 16 (10.5%). Based on the results of cardiac evaluation, eight patients underwent coronary revascularization before combined reconstruction. Renal or visceral artery reconstruction was carried out during the same procedure in 30 (19.7%) and 10 (6.6%) patients, respectively. Univariate analysis demonstrated six factors that were significantly associated with perioperative mortality and morbidity: age, coronary artery disease, chronic obstructive pulmonary disease, procedure time, intraoperative blood loss, and creatinemia over 140 mmol/L. Multivariate analysis showed that only the first four of these factors were independent. Actuarial survival in the overall population, including the patients who died during the perioperative period, was 73.9 ± 7.1% at 5 years and 50.9 ± 10% at 10 years. From our experience, we conclude that combined infrarenal aorta and carotid artery reconstruction can be performed with no additional operative risks and consequently is the strategy of choice. In our series neither procedure had any effect on the early or late outcome of the other. Our experience suggests that combined surgery is a safe alternative to staged surgery in patients with concurrent lesions involving the infrarenal aorta and carotid artery bifurcation.     

True aneurysmal disease in the hand and upper extremity

Ten patients with true aneurysmal disease of the hand and forearm vessels were treated at our institution between 1981 and 1990. Pseudoaneurysms resulting from penetrating trauma or mycotic aneurysms were specifically excluded. Eight patients were male, two were female; mean patient age was 38 years (range 26 to 72 years). A history of repetitive occupational or recreational trauma was elicited in five patients. All patients presented with painful masses or neurologic symptoms due to nerve compression. Ischemic changes were evident in five patients due to thrombosis or distal embolization. Arteriography and transcutaneous Doppler ultrasound aided in documentation of flow characteristics and planning for operative intervention. Three patients underwent excision and ligation once collateral flow was demonstrated to be adequate and reconstruction was not felt to be feasible. Seven patients underwent resection with vein graft reconstruction. Immediate postoperative and interval patency rates were 100%. No digital amputations were required even in those patients presenting with severe distal ischemia.