Acute Mesenteric Ischemia Remains a Highly Morbid Diagnosis after Initial Hospitalization Survival.

Acute mesenteric ischemia (AMI) remains a vascular emergency. Our aim was to explore readmission for AMI. We identified all patients admitted for AMI from the state of California through the Healthcare and Utilization Project from 2005 to 2011. Our primary end point was the rate and etiology for readmission. Our secondary end points were the length of hospitalization and in-hospital mortality. Cox proportional hazard regression was utilized to assess risk of 30-day readmission. There were 534 (9.9%) readmissions at 30 days. The mean age was 67 ± 17 years and 209 (39.1%) were male. The five most common etiologies for readmission were AMI (7.6%), cardiac events (5.3%), severe sepsis (1.2%), dehydration (1.1%), and acute kidney failure (1.1%). Once readmitted, these patients were most likely to experience cardiac catheterizations (25.4%), red blood cell transfusions (23.6%), intubation and mechanical ventilation (17.6%), biopsy of the large intestine (13.9%), reoperation for small bowel resection (10.9%), administration of total parenteral nutrition (10.5%), and transfusion of other blood products (6.9%). This hospitalization was 8.8 ± 12.7 days long. In-hospital mortality was 36 patients (6.7%). On multivariable Cox-regression analysis, severe (hazard ratio [HR]: 2.1 [1.4-3.2], p = 0.0005) and moderate (HR: 1.5 [1.03-2.13], p = 0.04) Elixhauser Comorbidity Group, complications (HR: 1.5 [1.2-1.9], p = 0.0007), and longer index hospitalization (HR: 1.02 [1.01-1.02], p < 0.0001) were predictors of readmission. Conclusion AMI remains a vascular emergency. Readmissions have a significant rate of morbid invasive procedures and can lead to an in-hospital mortality of 6.7%. The adoption of guidelines similar to the European Society for Trauma and Emergency Surgery should be considered.

Prevalence of Previously Undiagnosed Abdominal Aortic Aneurysms in Patients with Intracranial Aneurysms: From the Brain and Aortic Aneurysms Study (BAAS).

BACKGROUND: A relationship between intracranial and abdominal aortic aneurysms (AAA) has been appreciated through genome-wide association studies suggesting a shared pathophysiology. However, the actual prevalence of AAA in patients presenting with ruptured intracranial aneurysms is not known. Our aim was to estimate the prevalence of previously undiagnosed AAA in patients presenting with aneurysmal subarachnoid hemorrhage (aSAH) to see if it may be high enough to justify formally testing the utility of screening. METHODS: A prospective, observational inception cohort study of 81 consecutive patients presenting to Mayo Clinic Florida with aSAH was performed from August 14, 2011 to February 10, 2014. These individuals were then screened using an abdominal ultrasound technique for an AAA. Our primary end point was detection of AAA. Our secondary end points were 30-day good-to-fair functional status (modified Rankin scale < 4) and all-cause mortality. RESULTS: We detected an AAA in 10 patients (rate: 12%; 95% CI 6-22%) with aSAH. The mean diameter of these AAA was 3.4 ± 1.0 cm. Among these 10 patients, there was one death within the first month of aSAH hospitalization. There were no significant differences in demographic or clinical characteristics based on AAA detection status. Mean follow-up time was 4.7 years. The rate of good-to-fair functional status at 30-days was 79%. All-cause mortality during follow-up at 1-year was higher for patients with AAA (36%; 95% CI 0-61%) compared to patients without AAA (7%; 95% CI 1-14%) (log-rank p = 0.045). CONCLUSIONS: The co-prevalence of AAA in patients presenting with ruptured brain aneurysms may be sufficiently high such that screening for AAA among likely survivors of aSAH might be appropriate. Larger studies would be needed to establish a net clinical benefit from screening AAA and then treating newly identified large AAAs in this morbid population.

Midterm outcome of endovascular abdominal aortic aneurysm repair in octogenarians: a single institution's experience.

OBJECTIVES: We analyzed midterm durability of endovascular abdominal aortic aneurysm repair (EVAR) in octogenarians compared with younger patients. METHODS: Data for 182 consecutive patients who underwent elective EVAR between 1999 and 2003 were retrospectively reviewed. Forty-nine patients (27%) were 80 years or older (study group [SG]; mean age, 84 years; range, 80-89 years), and 133 patients (73%) were younger (control group [CG]; mean age, 72 years; range, 53-79 years). Chi2 analysis, Fisher exact test, Student t test, and Mann-Whitney U test were used as appropriate to test for intergroup differences. Kaplan-Meier curves, log-rank tests, and multivariate Cox models were used for time-to-event analysis, with P < or =.05 considered significant. RESULTS: Mean follow-up was 16 months (range, 1-43 months). Body weight was higher (P <.001), and elevated plasma lipid levels (59% vs 43%; P =.042) and use of nicotine (47% vs 29%; P =.015) more frequent in the octogenarians. Baseline aneurysm size, procedure-related data, and hospital stay were comparable between groups. Aneurysm-related mortality was 0% in the study group and 0.7% in the control group (P =.740). Systemic complications occurred in 22% (SG) versus 11% (CG) (P =.035), owing to a rise in serum creatinine concentration greater than 30% of baseline in 14% in the octogenarian group (vs 5% in the CG; P =.048). Groin lymphoceles developed in 12% (SG) versus 2% (CG; P =.013). Technical success was 96% (SG) versus 98% (CG; P =.408), and clinical success was 86% versus 90% (P =.269). No aneurysm rupture occurred during follow-up, and aneurysm-related adverse events were comparable between groups. The estimated risk for any type of endoleak (2.2; 95% confidence interval [CI], 1.1-4.2; P =.023) or type II endoleak (2.1; 95% CI, 1.0-4.3; P = 0.51) was higher in the study group versus the control group; however, this did not affect secondary procedure rates (SG 16% vs CG 12%; estimated risk, SG vs CG,: 1.5; 95% CI, 0.6-3.6; P = 0.420) or aneurysm remodeling (97.2% combined aneurysm sac stabilization or decrease in both groups; P =.592). Aneurysm enlargement occurred in 2.8% (SG 1 vs CG 4; P =.592). CONCLUSION: Elective EVAR in octogenarians appears safe and effective over midterm follow-up, with a temporary decrease in renal function (14%) and postoperative lymphoceles (12%) being the most common postoperative adverse events. Advanced chronologic age is not associated with diminished procedural outcome, clinical success, or postoperative survival, compared with younger age. Because of low perioperative mortality and high procedural success, EVAR may be the preferred approach to abdominal aortic aneurysm treatment in selected elderly patients.

Selective type III phosphodiesterase inhibition prevents elevated compartment pressure after ischemia/reperfusion injury.

BACKGROUND: A new synthetic cyclic adenosine monophosphate phosphodiesterase inhibitor, cilostazol, has been shown to inhibit platelet aggregation and act synergistically with endogenous prostaglandin I2 to enhance smooth-muscle cell vasodilitation. The effect of cilostazol in ischemia/reperfusion injury-induced compartment syndrome was investigated. METHODS: Sixteen rabbits underwent femoral artery occlusion after ligation of branches from the terminal aorta to the femoral artery. After 7 hours of ischemia, reperfusion was established with heparinized polyethylene shunts. Experimental animals (n = 8) received cilostazol (3.0 mg/kg) and control animals (n = 8) received normal saline as an intravenous infusion 10 minutes before shunt placement. During reperfusion, anterior compartment pressure was continuously monitored in the left lower extremity, and femoral artery blood flow was measured by laser Doppler fluorometry. To quantitate skeletal muscle oxidative metabolism and viability, triphenyltetrazolium chloride (TTC) reduction (micrograms of TTC per milligram of protein) of tibialis anterior muscle from the right lower extremity was measured at femoral artery occlusion, 7 hours of ischemia, and 2 hours of reperfusion. To assess tissue edema, dry/wet weight ratios were also determined at these intervals. Data were expressed as means +/- SE. Comparisons within groups were performed by analysis of variance, and comparisons between groups with two-tailed unpaired t tests. RESULTS: At 2 hours of reperfusion, the difference between controls and cilostazol-treated animals was extremely significant (p = 0.0008). Preischemia and 2-hour reperfusion TTC and dry/wet weight ratios were not significantly different within or between experimental groups, nor was femoral artery blood flow during reperfusion. CONCLUSION: Cilostazol inhibits the increase in compartment pressure central to the development of the compartment syndrome. The mechanism appears to be independent of altered tissue permeability or oxidative metabolism.

Endovascular repair of abdominal aortic aneurysms: where do we stand?

Endovascular repair of abdominal aortic aneurysms has evolved dramatically within the past few years. In light of the potential to reduce morbidity and mortality associated with open surgical repair, endoluminal grafting offers therapeutic options to patients who are not surgical candidates because of comorbidities. With the development of bifurcated devices, more complex aneurysms may be treated by endovascular grafting. Although successful placement of endovascular grafts requires a pronounced learning curve, including appropriate patient selection, midterm results seem consistent with those of traditional open repair of aneurysms. This review describes the current indications, minimal requirements, different devices and associated techniques, and potential complications of endoluminal repair of abdominal aortic aneurysms. Future aspects of endoluminal grafting are also discussed.

Early outcome of in situ femorotibial reconstruction among patients with diabetes alone versus diabetes and end-stage renal failure: analysis of 83 limbs.

PURPOSE: Both end-stage renal disease and diabetes have been demonstrated to have a negative effect on the outcome of infrainguinal arterial reconstruction, primarily because of increased perioperative morbidity and wound complications. This study was undertaken to determine whether the combination of these comorbid factors affects the outcome of distal arterial reconstruction. METHODS: Eighty-three distal lower extremity arterial bypasses originating from the femoral artery and terminating at the peroneal, anterior, or posterior tibial artery were performed on 76 patients over a 5-year period at a tertiary care medical center. Autogenous greater saphenous vein was used as the bypass conduit in all instances. Combined inflow and composite vein procedures were excluded. RESULTS: There was one perioperative death, for a mortality rate of 1.2%. The diabetes mellitus (DM) plus end-stage renal disease (DM+ESRD) cohort displayed a significantly lower 1-year primary patency rate compared with the diabetes mellitus cohort, 53% versus 82% (p < 0.02). However, the limb salvage rate for the DM+ESRD and DM cohorts during the same time interval were not significantly different, 63% versus 84% (p < 0.06). The 52% 1-year survival rate for the DM+ESRD cohort was strikingly lower than the 90% 1-year survival rate for the DM cohort (p < 0.002). CONCLUSION: Despite the use of the optimal autogenous conduit, the combination of diabetes and end-stage renal disease can be expected to significantly decrease primary graft patency without affecting limb salvage. The greatest effect of these comorbid factors is on patient survival.

Superior maturation and patency of primary brachiocephalic and transposed basilic vein arteriovenous fistulae in patients with diabetes.

PURPOSE: Primary radiocephalic arteriovenous fistulas (RCAVFs) have classically been used for the initiation of dialysis. If a suitable forearm cephalic vein can be demonstrated, it is used to construct such a fistula. However, we have noted a tendency for RCAVF in patients with a history of diabetes mellitus (type I and type II) to remain patent but not mature to the point of cannulation. Therefore, the present study was undertaken. METHODS: Fifty-eight consecutive patients with diabetes who required initial access for hemodialysis at an urban medical center and tertiary Veterans Medical Center underwent creation of an RCAVF (n = 10), brachiocephalic arteriovenous fistula (BCAVF; n = 22), or transposed basilic vein arteriovenous fistula (TBAVF; n = 26). The vein used was determined by physical examination with tourniquet compression. If neither forearm or upper-arm cephalic veins were 2 mm in diameter, a TBAVF was created after venography. Patency was determined by Kaplan-Meier estimate; differences between groups were assessed by Fisher's exact test. RESULTS: The 70% rate of nonmaturation of RCAVFs was significantly greater than the 27% rate for BCAVFs and 0% for TBAVFs (p < 0.05). The 33% cumulative primary patency rate at 18 months for RCAVFs was significantly less than 78% for BCAVFs and 79% for TBAVFs (p < 0.001). Within and between groups, there were no significant differences in age, gender, aspirin use, history of congestive heart failure, erythropoietin use, hematocrit level, history of peripheral vascular disease, or mortality rate. CONCLUSIONS: In patients with renal failure and a history of diabetes, both primary BCAVFs and TBAVFs demonstrate significantly greater maturation and increased primary cumulative patency rates compared with RCAVFs; therefore, these autogenous conduits are considered to be optimal in this group of patients. Whether the discrepancy in lower-arm vein maturation is a result of a lack of compensatory increase in radial arterial flow or an intrinsic defect in the lower-arm cephalic vein is currently under investigation.

Durability of early prosthetic dialysis graft cannulation: results of a prospective, nonrandomized clinical trial.

PURPOSE: Initiation of hemodialysis frequently requires temporary central venous catheterization, which leads to subsequent venous stenosis in 50% of patients. These lesions severely limit upper extremity dialysis fistula creation. The present study was undertaken to determine whether early cannulation (EC) allowed omission of temporary venous catheterization without affecting perioperative morbidity and long-term graft patency. METHODS: Seventy-nine prosthetic grafts for hemodialysis were placed in 76 patients over a 40-month period. Patients who required hemodialysis between 24 and 72 hours after surgery were assigned to EC. The remaining grafts underwent late cannulation (LC) after postoperative day 14. All grafts were constructed with a 6 mm stretch-expanded polytetrafluoroethylene conduit in the brachial artery-to-axillary vein position. Statistical analysis of cumulative primary patency estimates and patient survival data were determined by Kaplan-Meier analysis and log-rank test, patient variables were compared using chi 2 and Fisher's exact test, and multivariate analysis was performed using Cox's proportional hazard model. RESULTS: Forty-eight patients underwent EC and 31 underwent LC. There were no significant differences regarding age (mean, 61.5 years), history of diabetes, congestive heart failure, hematocrit level (mean, 30%), or presence of peripheral vascular disease. Thrombosis occurred before cannulation in one of 48 ECs (2.0%) and one of 31 LCs (3.2%). There were no episodes of cannulation hemorrhage or wound infection in either group. Cumulative primary patency estimates for EC were 0.89, 0.82, and 0.70 at 3, 6, and 12 months, respectively. These were not significantly different from the LC estimates of 0.86, 0.78, and 0.74 at 3, 6, and 12 months, respectively. Overall, patients who had a history of peripheral vascular disease had a significantly decreased 12-month patency rate (60% vs 74%; p = 0.05). Central venous catheters were omitted in 47 of 48 EC patients. CONCLUSION: EC of prosthetic dialysis grafts does not increase perioperative morbidity rates or decrease 12-month cumulative primary patency rates.

Magnetic resonance angiography in the evaluation of living-related renal donors.

Live-donor kidney donation requires an accurate determination of renal arterial anatomy. Traditionally, conventional angiography has supplied this information. The present study was undertaken to determine the accuracy of magnetic resonance angiography (MRA) compared with conventional angiography (CA) in the evaluation of potential living renal donors. Fifteen potential living renal donors underwent both conventional angiography (midstream aortic injection) and three-dimensional phase contrast MRA. Two overlapping volumes of 64 slices (slice thickness 1.5 mm) were obtained in the axial plane to allow coverage from the celiac trunk to the aortic bifurcation. Conventional angiography demonstrated single renal arteries in 24 kidneys and multiple renal arteries in 6 kidneys. Magnetic resonance angiography demonstrated multiple renal arteries in 5 of the 6 kidneys. The sensitivity of MRA in determining kidneys with multiple renal arteries was 83% (5/6). One kidney with an accessory 2-mm polar artery was incorrectly identified as having a single renal artery by MRA. The overall accuracy of MRA in identifying the number of renal arteries was 97% (29/30). Fibromuscular dysplasia was demonstrated in 2 patients by CA, but was not visualized prospectively by MRA. Based on standard physician and hospital fees for each procedure, use of MRA alone would represent a cost savings of approximately $1900 over CA. Despite its minimally invasive and economic attractions, MRA does not achieve the level of accuracy required to replace CA in the evaluation of potential living kidney donors.

Prevention of renal cortical ischemia during aortic clamping with prostaglandin E1.

OBJECTIVES: To investigate the effects of aortic clamping and prostaglandin E1 on systemic hemodynamics and renal cortical and medullary blood flow by means of continuous intraparenchymal laser Doppler fluorometry. DESIGN: Experimental animal study in a porcine model. With the animal under general anesthesia after hemodynamic monitoring was instituted, surgical exposure was obtained through a small left retroperitoneal incision. The kidney was left undisturbed. Intraparenchymal laser Doppler probes (0.44 mm in diameter) were inserted in the renal cortex and medulla. In the first group of six animals, systemic hemodynamic variables, urine output and renal cortical and medullary flow were measured at baseline after 60 minutes of equilibration, and after 15 minutes of aortic clamping and unclamping. Data are given as mean +/- SE. INTERVENTION: In another six animals, prostaglandin E1 (20-micrograms intravenous bolus given over 1 minute) was given before clamping, and the same variables were recorded. RESULTS: In the first group, aortic clamping caused no change in cardiac output or filling pressures. Cortical blood flow decreased from 40.4 +/- 3.7 to 33.3 +/- 2.7 mL/100 g per minute (P < .0004) after clamping, and to 27 +/- 2.3 mL/100 g per minute (P < .0001) after unclamping, and was associated with a decrease in urine output from 3.2 +/- 0.5 to 2 +/- 0.2 mL/min (P < .0013). Medullary flow remained the same at 9.2 +/- 0.8, 10 +/- 0.3, and 9.8 +/- 0.6 mL/100 g per minute, respectively. These adverse effects were prevented when prostaglandin E1 was given before clamping. There was an initial drop in blood pressure (100 +/- 4 to 89 +/- 5 mm Hg, P < .0004), but cardiac output (43.3 +/- 5.8 L/min) and filling pressures (6 +/- 1 mm Hg) were unchanged. Cortical flow was preserved during the entire period of clamping and unclamping (43.3 +/- 5.8 mL/100 g per minute). Medullary flow remained unchanged (10 +/- 0.8 mL/100 g per minute). Urine output increased from 2 +/- 0.3 to 3.4 +/- 0.6 mL/min (P < .006). CONCLUSIONS: In this animal model, infrarenal aortic clamping causes a significant decrease in renal cortical flow and urine output with no significant changes in filling pressures, cardiac output, or medullary blood flow. These adverse effects are prevented by pretreatment with prostaglandin E1, which prevents cortical ischemia and maintains brisk diuresis.

The pentafraction of hydroxyethyl starch inhibits ischemia-induced compartment syndrome.

Pentafraction (PF), a solution of biodegradable hydroxyethyl starch macromolecules with molecular weights of 10 to 100 x 10(4) daltons, has been shown to minimize tissue edema by sealing interendothelial clefts at the capillary level. The effect of PF on ischemia-reperfusion-induced compartment syndrome was studied. Ten rabbits underwent bilateral femoral artery occlusion following ligation of branches from the terminal aorta to the popliteal artery. After 7 hours of ischemia, reperfusion was established with heparinized polyethylene shunts. Experimental animals (n = 5) received PF and control animals (n = 5) received normal saline (NS) as an intravenous infusion (30 mL/kg) for 1 hour, beginning 10 minutes after shunt placement. During reperfusion, anterior compartment pressure was continuously monitored in the left lower extremity. To quantitate oxidative metabolism, triphenyltetrazolium chloride (TTC) reduction (micrograms of TTC per milligram of protein) of tibialis anterior muscle from the right lower extremity was measured at femoral artery occlusion, 7 hours of ischemia, and 2 hours of reperfusion. In the NS group, anterior compartment pressure significantly increased from the end of the ischemic interval, 10.8 +/- 4.14 to 36.4 +/- 9.9 mmHg and 44.6 +/- 15.4 mmHg, after 1 and 2 hours of reperfusion (p < 0.007) compared with the PF group, which did not change significantly, 10.6 +/- 2.6 to 11.4 +/- 12.9 mmHg and 7.4 +/- 2.8 mmHg, after 1 and 2 hours of reperfusion (p < 0.67).(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term results of the surgical management of chronic pancreatitis.

To investigate the long-term results of surgical management of chronic pancreatitis, we reviewed the hospital records of 50 consecutive patients who underwent surgery for chronic pancreatitis between 1975 and 1985. The principal indications for surgery were abdominal pain (100%), pseudocyst (24%), and biliary obstruction (42%). Surgeries included pancreatic duct drainage (56%), distal pancreatic resection (20%), and drainage of a pancreatic pseudocyst (24%). Follow-up averaged 5.2 years (range 5 to 11 years). Reoperation was required in 31 patients during the extended follow-up period. Principal indications for reoperation were abdominal pain (93%), recurrent pancreatic pseudocyst (32%), and uncertainty of the diagnosis of chronic pancreatitis (26%). Subsequent operations included cholecystectomy (35%), pseudocyst drainage (32%), splanchnicectomy (16%), and pancreatic biopsy (16%); and eliminated abdominal pain in 24 patients (83%). The diagnosis of chronic pancreatitis was not revised in any case. At most recent follow-up, 30 patients (60%) were well and without abdominal pain, 12 (24%) experienced intermittent abdominal pain, and one (2%) had continued abdominal pain that required narcotics. Five patients (10%) died of other causes, and two (4%) were lost to follow-up. We conclude that pain, the principal symptom of chronic pancreatitis, can be eliminated or reduced in the majority of patients by appropriate surgical therapy.

Autogenous vein grafts for femorofemoral revascularization in contaminated or infected fields.

PURPOSE: The purpose of this study was to determine the indications and the long-term results for femorofemoral revascularization with autogenous vein grafts (AVG) rather than conventional synthetic materials. METHODS: A consecutive series of 13 men and 12 women (mean age 64 years) receiving femorofemoral AVG was collected during a retrospective review of our experience from 1979 to 1992. Sixteen of these 25 patients required revascularization for acute ischemia in the presence of potential groin contamination (group 1), and the remaining nine had frank infections involving previous synthetic grafts (group 2). New grafts were constructed with the greater saphenous vein in 23 patients (92%) and with the cephalic vein in two. RESULTS: One patient in each group (8%) died after operation with patent grafts. Preoperative and postoperative ankle/brachial indexes (ABI) were available for 12 patients in group 1 and for seven patients in group 2. There was significant improvement in the ABI among 11 patients with ischemia in group 1 (mean 0.33 +/- 0.13; p = 0.0001), whereas no change in the ABI occurred in conjunction with the replacement of patent infected grafts among six patients in group 2 (mean 0.04 +/- 0.17; p = NS). One patient from each group sustained a reduction in postoperative ABI for the recipient limb despite a patent AVG. Cumulative 3-year survival and primary patency estimates for all 23 operative survivors were 63% and 75%, respectively. Late results seemed to be comparable in group 1 and group 2, but each contained too few patients for adequate analysis. CONCLUSIONS: Despite their infrequent use, AVG seem to represent a reasonable alternative to synthetic bypass for femorofemoral revascularization in patients having either contaminated wounds or established graft infections.

Parathyroid carcinoma: 50-year experience at The Cleveland Clinic Foundation.

BACKGROUND: Parathyroid carcinoma is rare, with a reported prevalence of 0.6% to 4.0% in patients presumed to have primary hyperparathyroidism. This study examines the long-term results of surgical therapy and combination chemotherapy. PATIENTS: From 1938 to 1988, 1260 operations for primary hyperparathyroidism were performed; only six patients (0.47%) were subsequently found to have parathyroid carcinoma. A seventh patient was referred to our institution after the diagnosis of parathyroid carcinoma had been made. RESULTS: All patients had excessive hypercalcemia (serum calcium concentration > 12.0 mg/dL) with a range of 12.3 to 18.3 mg/dL. Locally recurrent tumors causing recurrent hypercalcemia were managed by repeated neck exploration and tumor resection. Six of the seven patients (85%) survived 5 years, while four patients (57%) survived 10 years. CONCLUSIONS: Diagnosis of parathyroid carcinoma rests upon postoperative surveillance of patients who have undergone previous neck exploration and resection of apparently benign adenomas. Long-term survival is possible with repeated resection of locally recurrent tumors.

Surgical management of aortic aneurysm and coexistent horseshoe kidney: review of a 31-year experience.

PURPOSE: The coexistence of horseshoe kidney and aortic aneurysm poses a technical challenge to the vascular surgeon at the time of aneurysm repair. Clinical experience with this problem was reviewed to assess the results of treatment and to develop guidelines for the treatment of patients with horseshoe kidney and aortic aneurysm. METHODS: From 1960 through 1991, 19 patients with associated horseshoe kidney (HSK) required repair of abdominal aortic aneurysm at the Cleveland Clinic. Seventeen men and two women, with a mean age of 67 years, underwent 16 elective and three urgent operations. The HSK was found before operation in 16 patients (84%), whereas the remaining three were discovered at operation. Computed tomography and intravenous pyelography were the most reliable means of preoperative diagnosis, whereas ultrasonography and aortography were less dependable. Mean size of abdominal aortic aneurysm was 6.1 cm. The mean preoperative creatinine level was 1.5 mg/dl. The surgical approach was transperitoneal in 16 patients and retroperitoneal in three. Division of the renal isthmus was avoided in all patients. RESULTS: Renal artery anomalies were encountered in 14 patients (74%). Renal arterial continuity was established by a variety of techniques, including branch grafts or reimplantation into the aortic graft. Abnormal preoperative renal function was associated with a significantly increased risk for early postoperative hemodialysis (p = 0.02). There were three postoperative deaths, and the mortality rate for patients who required dialysis (67%) was significantly higher (p = 0.05) than that for patients who did not (6.3%). There were six late deaths at a mean follow-up interval of 57 months. CONCLUSIONS: The most important aspect of HSK, therefore, is the appropriate surgical management of frequent renal artery anomalies. We currently believe this is best achieved with retroperitoneal exposure.

Laparoscopic cholecystectomy in a renal transplant recipient.

Laparoscopic cholecystectomy is a viable and safe alternative for the treatment of symptomatic gallstones and biliary colic. As surgeons gain more experience with this procedure, contraindications become fewer and indications increase. Well-documented advantages of this approach include less patient discomfort, less surgical scarring, and earlier return to employment. Not previously discussed in the literature, however, are the additional advantages that this procedure holds for a specific subset of patients--namely, those patients that have undergone successful organ transplantation and are receiving immunosuppressive drugs. We report a case of a laparoscopic cholecystectomy in such a patient.

Successful renal transplantation in a patient with systemic sarcoidosis and renal failure due to focal glomerulosclerosis.

In 1987, a patient presented with pulmonary sarcoidosis and progressive renal failure. Percutaneous renal biopsy showed focal glomerular sclerosis (FGS). Over the subsequent 4-year period, her renal failure progressed to require hemodialysis. During this time, her pulmonary sarcoidosis was treated with daily corticosteroid therapy and she remained in clinical remission. The patient received a one-haplotype-identical living-related renal transplant from her mother. The patient is now 25 months posttransplant with a serum creatinine of 106 mumol/L (1.2 mg/dL). Her sarcoidosis continues to be in clinical remission. In this report, we review the rare association of a primary glomerular lesion causing renal failure in patients with sarcoidosis. In addition, we detail the first successful renal transplant in such a patient.