Nd:YAG iliac and femoropopliteal laser angioplasty: results with large probes as "sole therapy".

Laser assisted balloon angioplasty with a laser heated metallic capped fiberoptic catheter may be effective in the treatment of femoral and iliac artery occlusive disease. In order to avoid the inherent trauma of balloon angioplasty, yet at the same time "debulk" atheroma, 75 patients underwent laser angioplasty of the superficial femoral and iliac arteries as "sole therapy". Laser angioplasty was performed using an Nd:YAG laser coupled to a 600 micron fiber and a 3.5 mm probe (22-28 watts), 4.2 mm or 5.0 probe (32-40 watts). Fifty-nine patients had laser angioplasty for claudication and 16 for limb salvage. The initial angiographic success rate was 84% (41/49) (lesion length 2-14 cm) for the superficial femoral and 69% (18/26) (lesion length 2-14 cm) for the iliac arteries. In follow-up extending to 21 months (mean 14.4 months) 73% (30/41) of the superficial femoral artery and 76% (14/18) of the initially recanalized iliac arteries remain patent. When initial failures are included, this represents an overall intermediate-term patency rate of 52% (32/49) for superficial femoral and 49% (14/26) for iliac arteries respectively. By avoiding the disruptive effect on the arterial wall architecture caused by balloon angioplasty, while at the same time ablating and vaporizing more atheromatous material with larger laser probes, the long-term patency rates of laser angioplasty as "sole therapy" may prove to be superior to those of laser assisted balloon angioplasty.

Isolated hypogastric artery revascularization after previous bypass for aortoiliac occlusive disease.

Patients with recurrent buttock claudication and/or impotence occurring after aortoiliac reconstruction, whose resting and postexercise vascular laboratory values are normal, represent an uncommon and poorly recognized problem resulting from occlusion of the bypassed iliac segments and ischemia isolated to the distribution of the hypogastric artery. This paradox and its solution are exemplified by two patients reported herein. In each instance flow was reestablished after thromboendarterectomy of the proximal hypogastric artery by connecting the artery to the functioning bypass.

Net protein catabolic rate after kidney transplantation: impact of corticosteroid immunosuppression.

Protein catabolic rate (PCR) was measured during the first 3 to 7 weeks after kidney transplantation in nine nondiabetic patients (16-52 yr old) who were receiving azathioprine and corticosteroid immunosuppression. Five of the patients received additional amounts of corticosteroids to treat rejection episodes. The PCR paralleled the amounts of corticosteroids administered initially as prophylactic immunosuppression and later as treatment for rejection episodes. In spite of a diet containing 1.2 g of protein per kg ideal body weight, net urea generation reflected severe lean body mass breakdown, roughly equivalent in magnitude to a 50% body surface area full-thickness burn. This catabolism was accompanied by a fall in serum albumin without significant weight loss. Hypercatabolism in the early posttransplant period is severe. After transplantation diet should be modified to try to satisfy these nitrogen demands.

Nonresectional management of major hepatic trauma. An evolving concept.

Over a 6 year period, 319 acute liver injuries were identified at laparotomy. Fifty-three patients (17 percent) sustained major hepatic trauma that necessitated complex operative techniques: lobectomy in 21, segmentectomy in 6, selective hepatic artery ligation in 3, and temporary packing in 7. Throughout the study period, there has been a progressive shift to nonresectional therapy. Lobectomy for parenchymal injuries has continued to have a prohibitive mortality rate of 64 percent, whereas alternative procedures, such as hepatotomy, selective hepatic artery ligation, and packing, have had lower mortality rates from hemorrhage without an increase in delayed death from sepsis. Hepatotomy has also proved useful to gain access to retrohepatic vena caval tears. Our present experience supports the national trend of surgical restraint in the operative treatment of complex liver trauma and suggests that hepatic lobectomy is rarely justified.

Near-drowning complicated by brain abscess due to Petriellidium boydii.

Extracutaneous infection from Petriellidium boydii is an unusual occurrence despite the ubiquity of the organism in nature. Central nervous system infection by this organism is extremely rare, only seven previous reports having been found. The rarity of this manifestation prompted the report of a brain abscess occurring in a previously healthy youth after a near-drowning. The source of the infection was likely to have been the river water at the accident site, from which P boydii was isolated. Although previous in vitro susceptibility data and failure of amphotericin B therapy in a similar infection suggested miconazole treatment might be beneficial, the organism causing the brain abscess was resistant to miconazole and amphotericin B. This report emphasizes the urgent need for safer and more predictably effective alternatives to currently available antifungal agents.