Renal artery aneurysm endovascular repair.

A 68-year-old woman with a left renal artery aneurysm underwent successful endovascular repair with the use of a commercial type self-expanding stent-graft. Complete aneurysm exclusion was achieved after stent-graft expansion. A side branch vessel was occluded after stent-placement, resulting in a small upper lobe renal perfusion defect. There were no other complications. The aneurysm remained excluded and its greatest diameter has been reduced from 2.6 cm to 1.95 cm, 10 months after treatment. Renal function remained normal.

Expanding ulnar artery aneurysm presenting with signs of threatened rupture.

The case of a 25-year-old man admitted with an ulnar artery aneurysm of the wrist is presented. The size of the aneurysm (1.5 x 2.7 cm) and progressive pain gave the impression of a threatened rupture. Radiologic examinations confirmed the existence of a non-thrombosed ulnar artery aneurysm with occlusion of the 4th and 5th digital arteries. During an urgent surgical exploration a pseudo-aneurysm was found and resected and the artery was repaired. Thrombolysis of the digital arteries was performed with a good result. The combination of a large-sized pseudo-aneurysm, lack of a history of penetrating trauma and presentation of threatened rupture are unique and not reported previously in the literature.

Treatment of non-small cell lung cancer with gefitinib ('Iressa', ZD1839): the Greek experience with a compassionate-use program.

This is a retrospective analysis of 150 patients with advanced non-small cell lung cancer who had failed prior treatment or were unfit for chemotherapy and were treated with oral gefitinib ('Iressa', ZD1839; AstraZeneca) 250 mg/day. Thirty-two patients who received gefitinib for 3 weeks or less were not included in the analysis. For the remaining 118 evaluable patients, the mean age was 63.1 years; most patients had received prior chemotherapy (97.5%), Eastern Cooperative Oncology Group performance status scores 0-2 (97.4%) and stage IV disease (64.4%). The majority were symptomatic (84.6%). Disease control was observed in 30 patients (25.4%), of whom five had a partial response and 25 had stable disease; 18 (15.3%) were not evaluable. Median duration of treatment was 29.9 weeks in responding patients and 11.5 in patients with progressive disease (p<0.0001). Median overall survival was 7.3 months (15.2 months for disease control) and median progression-free survival was 3.2 months. Gefitinib was well tolerated, with grade 3/4 skin rash and diarrhea seen in 2.5 and 4.2% of patients, respectively. Clinical benefit was evaluated using questionnaires before and following treatment with gefitinib. In 82 patients with completed questionnaires, evaluation revealed symptom improvement in 40.1% and improvement in general feeling in 31.4%. Epidermal growth factor receptor (EGFR) analysis found that efficacy did not correlate with tumor EGFR overexpression. Therefore, in this retrospective analysis, gefitinib treatment provided disease control in 25% of patients who derived significant palliative benefit.

Lower extremity bypass procedures in diabetic patients with end-stage renal disease: is it worthwhile?

BACKGROUND/AIMS: Limb-threatening ischemia in patients with end-stage renal disease (ESRD) represents a challenging therapeutic problem. Furthermore, diabetes mellitus is frequently associated with ischemic gangrene, persistent infection and impaired wound healing. The present study was undertaken to examine graft patency, limb salvage and survival in patients with ESRD and diabetes following bypass grafting to treat lower limb critical ischemia. METHODS: A retrospective analysis of 56 arterial reconstructions performed in 39 patients with diabetes mellitus and ESRD during a period of 8 years. The indications for bypass grafting were: ischemic rest pain (n = 13), non-healing ulcer (n = 18) or foot gangrene (n = 25). Risk factors in association with surgical morbidity and mortality, limb loss and graft patency were evaluated. RESULTS: Thirty-four patients were on hemodialysis and 5 on peritoneal dialysis. Forty-nine infrainguinal reconstructions were performed; the site of distal anastomosis was the below knee popliteal artery (n = 22), the anterior tibial artery (n = 12), the posterior tibial artery (n = 8), and the peroneal artery (n = 7). Seven axillofemoral reconstructions were also performed; the site of distal anastomosis was the common femoral artery (n = 5) and the above knee popliteal artery (n = 2). The 30-day operative mortality rate was 18% (7 patients). The mean follow-up was 11.5 (range 1-93) months. Patient survival rate at 1 and 2 years was 63 and 45%, respectively. Primary patency rate was 64% at 1 year and 58% at 2 years. The limb salvage rate was 65% in the first year. CONCLUSION: Limb salvage rate in patients with ESRD and diabetes justifies an aggressive policy of revascularization, despite decreased survival of this population.

Selective use of the intensive care unit after elective infrarenal abdominal aortic aneurysm repair.

AIM: Abdominal aortic aneurysm (AAA) repair has traditionally involved admission to the intensive care unit (ICU). This paper reports on an experience of using preoperative medical criteria and a list of intraoperative factors for selective use of the ICU. These criteria were evaluated in relation to their impact on the safety and short term results after open AAA repair. METHODS: All elective open infrarenal AAA repairs during a 9 year period (1994-2003), following a specific algorithm towards selective use of the ICU, were retrospectively evaluated. Patients were clinically evaluated, before the operative procedures, and divided into categories according to their medical risk (cardiac and pulmonary status). Patients with an ejection fraction <30% and a FVC or FEV1 <50% of the predicted value were transferred immediately from the operating room to the ICU. A list of intraoperative factors: 1) prolonged operative time; 2) prolonged aortic clamping time; 3) suprarenal clamping; 4) quantity of blood transfusion; 5) intraoperative acute renal failure; 6) intraoperative hemodynamic instability; 7) intraoperative cardiac dysfunction were also considered criteria for transfer from the operating room to the ICU. Patients who did not meet any of the above criteria were extubated and transferred to the surgical floor. RESULTS: Elective AAA repair was performed on 602 patients, among whom, 551 (91.5%) were extubated in the operating room and thereafter treated in the surgical floor and 51 (8.5%) were transferred from the operating room to the ICU. However, later transfer from the floor to the ICU was required in 7 more patients (1.1%), increasing the total percentage of patients treated in the ICU to 9.6%. (51 patients initially and 7 later on). The total postoperative 30 days mortality rate was 0.7% (4 patients) and the morbidity rate was 18.8% in this series. The mean length of in-hospital stay was 9.9 days and the mean ICU length of stay was 4.2 days. CONCLUSION: Elective AAA repair with selective use of the ICU can be a considerable safe policy in a single high volume hospital. It can reduce resource use without a negative impact on the quality of care.

Docetaxel and cisplatin combination chemotherapy in advanced carcinoma of the urothelium: a multicenter phase II study of the Hellenic Cooperative Oncology Group.

PURPOSE: Both docetaxel and cisplatin have moderate activity in patients with advanced urothelial cancer. We performed a multicenter phase II study in order to assess the efficacy and toxicity of the combination of these two agents in patients with advanced carcinoma of the urothelium. PATIENTS AND METHODS: Sixty-six patients not amenable to curative surgery or irradiation were enrolled onto this cooperative group study and treated on an outpatient basis with docetaxel 75 mg/m2 followed by cisplatin 75 mg/m2, both administered intravenously. Granulocyte-colony stimulating factor was administered subcutaneously at a dose of 5 micrograms/kg daily from day 5 until resolution of neutropenia. The chemotherapy was administered every three weeks for a maximum of six courses in patients without evidence of progressive disease. RESULTS: Thirty-four of sixty-six patients (52%, 95% confidence interval 40%-64%) demonstrated objective responses, with eight achieving clinical complete responses and twenty-six partial responses. A multivariate logistic regression analysis indicated that the patients most likely to respond were those without lung metastasis and without weight loss before treatment. The median duration of response was 6.1 months and the median times to progression and survival for all patients were 5 and 8 months, respectively. Absence of anemia, of liver metastases and of weight loss correlated with longer survival. Grade > or = 3 toxicities included granulocytopenia in 33% of patients, anemia in 14%, diarrhea in 13% and emesis in 7% of patients. CONCLUSION: The combination of docetaxel and cisplatin appeared relatively well tolerated and moderately active in patients with advanced urothelial cancer. The patients most likely to benefit were those without weight loss and without lung or liver metastases.