False aneurysm of the thyrocervical trunk.

False aneurysm of the thyrocervical trunk as a complication of central venous catheterization is rare. We report a case of this complication in a 63-year-old white man and review the history, diagnosis, pathophysiology, and treatment of these aneurysms.

Left gastric artery as an alternative for arterial reconstruction in orthotopic liver transplantation.

The hepatic arterial blood supply is indispensable for the survival of the graft during liver transplantation. Inadequacies in the recipient hepatic artery mandate arterial reconstruction different from the preferred method of direct anastomosis. We report the use of the left gastric artery as an attractive alternative for reconstructing the arterial blood supply of a transplanted liver.

Nodular regenerative hyperplasia: a controversial indication for orthotopic liver transplantation.

Nodular regenerative hyperplasia of the liver is an uncommon cause of portal hypertension. Patients with nodular regenerative hyperplasia have signs and symptoms of portal hypertension, without evidence of hepatocellular failure or encephalopathy. We report the case of a 44-year-old woman with recurrent esophageal bleeding and refractory ascites who had a history of hemosiderosis, hepatitis C, and chronic renal allograft rejection. Our preoperative diagnosis was cirrhotic end-stage liver disease and end-stage renal disease for which the patient underwent combined hepatic and renal transplantation. Her portal hypertension symptoms resolved, and her renal function has been normal for 18 months of follow-up. Histologic examination of the liver revealed nodular regenerative hyperplasia, and a review of the literature regarding the surgical management of patients with nodular regenerative hyperplasia revealed that various shunting procedures are generally recommended. After the failure of medical management in patients with nodular regenerative hyperplasia, portosystemic shunting may be indicated before proceeding to hepatic transplantation.

Protocol Doppler color flow imaging immediately after kidney transplantation.

Doppler color flow imaging has been used to identify obstruction, rejection, and nonfunctioning renal allografts. When done in the immediate posttransplant period on poorly functioning kidneys, it allows early and accurate detection of surgically correctable changes such as arterial or venous thrombosis or early obstruction by blood, urine, or lymph. Further, it determines changes in intrarenal flow patterns that may indicate early transplant dysfunction, such as acute tubular necrosis and/or acute rejection as well as obstruction. Additionally, baseline values can be obtained in uncomplicated cases for serial follow-up. Between July 1980 and February 1991, 20 transplant patients had Doppler color flow imaging in the immediate posttransplant period. The kidney contour, perirenal collections, vessel flow patterns, and resistive indexes were assessed. In two patients, immediate surgical intervention salvaged the allograft. In several other patients with primary nonfunctioning kidneys, the study distinguished between acute tubular necrosis and obstruction due to external compression. We concluded that protocol Doppler color flow imaging is valuable in the immediate posttransplant period for determining surgically correctable complications.

Modified vascular reconstruction for pancreaticoduodenal allograft.

The simultaneous recovery of the cadaveric liver and pancreaticoduodenal allograft is well established. The current technique for procurement enables the retrieval of both organs in most multiorgan donor operations. Vascular complications may account for 45 percent of pancreatic graft failures, most of which are thromboses of the portal vein caused by low flow in the entire pancreatic vasculature, a twisted venous anastomosis or an acutely angled arterial reconstruction that can contribute to the thrombosis and, thereby, to graft failure. Because a diabetic recipient may have severely atherosclerotic vessels, an interposition autograft of the internal iliac artery of the recipient is not recommended. Our modified vascular reconstruction prevents compromised arterial blood supply when donor arterial grafts (iliac, carotid or femoral) are not available and when direct splenic to SMA reconstruction is not feasible.

Liver transplantation in patients with situs inversus.

Situs inversus has been considered an absolute contraindication to liver transplantation due to technical difficulties. Associated vascular malformation and distorted anatomy may make the procedure even more complicated or impossible. Only three cases of patients with abdominal situs inversus who underwent successful liver transplantation have been reported in the English literature. We describe two additional patients with situs inversus who suffered from biliary atresia and underwent successful liver transplantation. The preoperative evaluation and the operative procedure are presented, and technical difficulties are discussed. Since biliary atresia is associated with polysplenia syndrome, including vascular malformation and visceral malposition, we suggest that each case be extensively evaluated preoperatively to determine the size requirement for the donor liver and the feasibility of reconstruction.

Salvage of hemodialysis access in infected arteriovenous fistulas.

Infection combined with additional complications of arteriovenous fistulas is a serious threat to access in patients with upper-extremity polytef (polytetrafluoroethylene) grafts. We present three cases of infected access grafts that were treated with systemic antibiotics, excision of the grafts, and primary anastomosis of the arterialized vein to artery for access salvage. The new arteriovenous fistulas were used immediately, preventing interruptions in hemodialysis regimens. This technique of immediate reconstruction allows the surgeon to utilize the arterialized outflow vein and save other sites of access for future use.

Effects of theophylline on erythropoietin production in normal subjects and in patients with erythrocytosis after renal transplantation.

BACKGROUND: Erythrocytosis occurs in 10 to 15 percent of renal-transplant recipients, and there is in vitro evidence that the production of erythropoietin is modulated by adenosine. METHODS: We prospectively evaluated the effects of theophylline, a nonselective adenosine antagonist, in eight patients with erythrocytosis after renal transplantation and in five normal controls. RESULTS: After an eight-week course of theophylline treatment, the mean (+/- SEM) serum erythropoietin levels were significantly reduced in both the renal-transplant recipients (from 60 +/- 14 units per liter at base line to 9 +/- 7 units after treatment; P less than 0.05) and the normal subjects (from 6.9 +/- 0.8 units per liter at base line to 4.7 +/- 0.5 units per liter after treatment; P less than 0.05). Similarly, the hematocrits were reduced in both the transplant recipients (from 0.58 +/- 0.04 at base line to 0.46 +/- 0.03 after treatment; P less than 0.05) and the normal subjects (from 0.43 +/- 0.01 at base line to 0.39 +/- 0.01; P less than 0.05). In the renal-transplant recipients, red-cell mass was also reduced after eight weeks of theophylline (from 3197 +/- 82 ml at base line to 2273 +/- 69 ml after treatment; P less than 0.05). The previous requirement of weekly phlebotomy was eliminated in all recipients. Plasma and urinary cyclic AMP levels were not increased. These effects were reproducible when the subjects were rechallenged with theophylline after a recovery period. CONCLUSIONS: Theophylline attenuates the production of erythropoietin in both normal subjects and patients with erythrocytosis after renal transplantation and may be useful in the treatment of the latter condition.

Renal transplantation in a developing country: anesthesia and other considerations.

The Renal Transplant Team at Tulane University Medical Center has been involved in training a multispecialty group of Guatemalan physicians to perform renal transplantations in Guatemala. The purpose is to train the physicians in their own country, using available equipment and personnel so that they can perform successful operations in our absence. This paper is a review of the considerations involved in the initial renal transplantation done in Guatemala by the Tulane Renal Transplant Team. The need for a preliminary site visit was paramount. Personnel, facilities, and both surgical and anesthesia equipment and supplies were carefully evaluated. The recipient was a 22-year-old man with end-stage renal disease due to chronic glomerulonephritis. The donor was a healthy 33-year-old brother. This article is not intended to review renal transplantation in the United States, but to show what is feasible in a developing country where many drugs and equipment are not available.

Conduit placement for hemodialysis.

The complications of infection and clotting are frequent enough as to make vascular access sites and their preservation a prime consideration in the management of patients who require long-term maintenance hemodialysis for support of end-stage renal disease. Utilization of the described technique during placement of subcutaneous conduits on the volar surface of the forearm for hemodialysis purposes tends to minimize the complications of infection and clotting and prolong the usable life of the conduit fistulas.

Modulation of prostacyclin synthetase and unmasking of PGE2 isomerase in bovine coronary arterial microsomes.

Prostacyclin (PGI2), a major product of prostaglandin endoperoxide (PGH2) metabolism in blood vessels, has potent vasodilator and platelet activity. Therefore, modulation of PGI2 synthetase activity is of prime physiological importance in the regulation of blood vessel function. In this study, PGI2 synthetase activity of bovine coronary arterial microsomes could be altered over a 2-3 fold range by GSH or dithiothreitol in a concentration-dependent manner and over a microsomal protein range of 10-200 micrograms. Modulation of coronary artery PGI2 synthetase activity was also seen in vessels from sheep, dog and man. These data suggest that coronary artery PGI2 synthetase activity is unusually sensitive to the redox state or sulfhydryl oxidation of the enzyme. The present data also unmask an active PGE2 isomerase, previously reported to be absent in bovine coronary arterial microsomes.

Effect of dialysis on serum carnitine, free fatty acids, and triglyceride levels in man and the rat.

Serum free carnitine, free fatty acid and triglyceride values were followed in patients with end-stage renal disease on maintenance dialysis therapy. During dialysis a decrease in serum carnitine was documented. Whereas the elevated triglyceride concentration remained constant, there was a sharp rise in free fatty acids during the dialysis procedure. This pattern occurred whether patients were subjected to hemodialysis or intermittent peritoneal dialysis. Peritoneal dialysis was performed in a rat model and produced results similar to those observed in human subjects. Furthermore, it could be demonstrated that peritoneal dialysis initiated the hypertriglyceridemia in the otherwise normal animal within a short time period. Whereas the abnormalities observed in carnitine and fatty acid metabolism may or may not be causally related in rat or man, they both seem to result from dialysis therapy.

Quantitative renal scintillation camera studies in renal transplantation.

Renal transplant recipients and donors were studied serially with quantitative renal scintillation camera studies utilizing 131I-Hippuran and 99mTc-Iron ascorbate. This study allows for determination of effective renal plasma flow (ERPF), glomerular filtration rate (GFR), filtration fraction (FF), and predicted return in ten minutes. A drop in FF occurred with, or preceded clinical rejection; whereas, an increase in FF occurred with acute tubular necorsis (ATN) caused by preservation injury, aminoglycosides, and following acute rejection. Combined with the other parameters of renal function determined by this technique, FF alterations proved useful in the differentiation of ATN from rejection and in predicting the prognosis of renal homografts.

Perturbation of serum carnitine levels in human adults by chronic renal disease and dialysis therapy.

Serum carnitine levels in nondialyzed and dialyzed patients with chronic renal disease were compared against a group of normal control subjects. The concentration of serum carnitine was directly correlated with that of serum creatinine (r = +0.734; p less than 0.001). In nondialyzed uremic patients the serum free carnitine levels in males rose 218% (p less than 0.001) and in females rose 186% (p less than 0.001) above normal control values. During dialysis there was a sharp decline in serum carnitine to levels reaching 20% of the zero time control value (p less than 0.001). The decrease in serum carnitine could be accounted for by an almost quantitatively accumulation of carnitine in the dialysate fluid. After termination of dialysis there was a hyperbolic rise in serum carnitine which reached the high values again within 44 to 48 h. It is postulated that frequent perturbations in serum carnitine as a result of chronic dialysis therapy over a prolonged time period could potentially lead to a tissue deficiency in carnitine with its resultant complications.