Expansion of the kidney donor pool by using cardiac death donors with prolonged time to cardiorespiratory arrest.

Donation after Cardiac Death (DCD) is an increasingly important source of kidney transplants, but because of concerns of ischemic injury during the agonal phase, many centers abandon donation if cardiorespiratory arrest has not occurred within 1 h of controlled withdrawal of life-supporting treatment (WLST). We report the impact on donor numbers and transplant function using instead a minimum 'cut-off' time of 4 h. The agonal phase of 173 potential DCD donors was characterized according to the presence or absence of: acidemia; lactic acidosis; prolonged (>30 min) hypotension, hypoxia or oliguria, and the impact of these characteristics on 3- and 12-month transplant outcome evaluated by multivariable regression analysis. Of the 117 referrals who became donors, 27 (23.1%) arrested more than 1 h after WLST. Longer agonal-phase times were associated with greater donor instability, but surprisingly neither agonal-phase instability nor its duration influenced transplant outcome. In contrast, 3- and 12-month eGFR in the 190 transplanted kidneys was influenced independently by donor age, and 3-month eGFR by cold ischemic time. DCD kidney numbers are increased by 30%, without compromising transplant outcome, by lengthening the minimum waiting time after WLST from 1 to 4 h.

An international comparison of reimbursement for DIEAP flap breast reconstruction.

INTRODUCTION: The deep inferior epigastric artery perforator (DIEAP) flap is currently considered the gold standard for autologous breast reconstruction. With the current economic climate and health cutbacks, we decided to survey reimbursement for DIEAP flaps performed at the main international centres in order to assess whether they are funded consistently. METHODS: Data were collected confidentially from the main international centres by an anonymous questionnaire. RESULTS: Our results illustrate the wide disparity in international DIEAP flap breast reconstruction reimbursement: a unilateral DIEAP flap performed in New York, USA, attracts €20,759, whereas the same operation in Madrid, Spain, will only be reimbursed for €300. Only 35.7% of the surgeons can set up their own fee. Moreover, 85.7% of the participants estimated that the current fees are insufficient, and most of them feel that we are evolving towards an even lower reimbursement rate. In 55.8% of the countries represented, there is no DIEAP-specific coding; in comparison, 74.4% of the represented countries have a specific coding for transverse rectus abdominis (TRAM) flaps. Finally, despite the fact that DIEAP flaps have become the gold standard for breast reconstruction, they comprise only a small percentage of all the total number of breast reconstruction procedures performed (7-15%), with the only exception being Belgium (40%). CONCLUSION: Our results demonstrate that DIEAP flap breast reconstruction is inconsistently funded. Unfortunately though, it appears that the current reimbursement offered by many countries may dissuade institutions and surgeons from offering this procedure. However, substantial evidence exists supporting the cost-effectiveness of perforator flaps for breast reconstruction, and, in our opinion, the long-term clinical benefits for our patients are so important that this investment of time and money is absolutely essential.

Thrombocytopenia, antithrombin deficiency and extensive thromboembolism in pregnancy: treatment with low-molecular-weight heparin.

Pregnancy limits the therapeutic options for managing thrombocytopenia which occurs in 5% of patients on heparin. We describe a case of extensive thromboembolism associated with antithrombin (AT) deficiency complicated by thrombocytopenia which resolved when low-molecular-weight heparin was instituted. A primigravid woman presented at 11 weeks gestation with bilateral femoral occlusive thrombi extending above the renal veins. Investigations revealed AT deficiency, thrombocytopenia and renal infarction. After low-molecular-weight heparin was substituted for unfractionated heparin, the thrombocytopenia resolved and although the pregnancy was lost, the patient made a full recovery.

The value of light reflection rheography as a screening tool for deep venous thrombosis.

Deep venous thrombosis (DVT) is a common condition in which the clinical diagnosis is notoriously inaccurate. The diagnosis is usually made in the Radiology Department by either Doppler ultrasound or conventional venography. The high clinical suspicion for DVT and the availability of these imaging modalities places an ever increasing burden on radiology departments. Light reflection rheography (LRR) is a non-invasive technique for assessing venous disorders. It is easy and quick and can be performed at the bedside or in the Radiology Department. LRR was prospectively compared with conventional venography in 50 consecutive patients undergoing investigation for possible DVT. LRR was entirely normal in 24 patients and this was confirmed on venography in each case. In practice it was not always possible to differentiate between DVT and venous insufficiency in the 26 abnormal tracings but all 15 cases of venography-proven DVT were within this group. There were no false negative diagnoses of DVT. LRR is a simple and quick method of screening for DVT with significant cost saving implications. A normal tracing reliably excludes the diagnosis, whilst all abnormal tracings should undergo Doppler ultrasound or venography.

Digital subtraction angiography.

Digital Subtraction is a computerised radiological technique to demonstrate the vascular tree by removing unwanted background information and enhancing dilute contrast medium within the blood vessels. Contrast may be introduced intravenously or intra-arterially. The relative merits of these two methods, together with the advantages and limitations of the technique are discussed.

Breast ductography--its role in the diagnosis of breast disease.

Breast ductography is a safe and simple technique to outline the duct system of the breast with contrast medium in patients with nipple discharge. The results of 60 successful ductograms are presented and an assessment of its clinical usefulness is made.

Early experience with intra-arterial thrombolytic therapy for peripheral arterial occlusion.

The authors present their early experience with local intra-arterial thrombolytic therapy for peripheral arterial occlusions causing limb threatening ischaemia, using streptokinase or urokinase. Ten patients were treated in a period of one year. Five patients had successful recanalisation, two patients had partial success and three patients required major amputation. The indications, contraindications and results of this treatment are reviewed.

Management of renal stab wounds by arteriographic embolisation.

A 26 year old man was admitted with multiple stab wounds to his chest, abdomen and right loin. He was noted to have a large haemothorax, a tender abdomen and frank haematuria. At laparotomy, there was a small non expanding retroperitoneal haematoma that was not explored, and no visceral damage. Post operatively he continued to have haematuria. IVP and ultrasound showed perirenal haematoma and clot in the upper pole calyces but was otherwise normal. Renal arteriography demonstrated a pseudo-aneurysm in the right mid region, feeding an arteriovenous fistula (Figure 1). Selective renal artery embolisation with spring occlusion coils was performed which occluded the branch supplying the false aneurysm and fistula (Figure 2). He had no further haematuria. At six month follow up he remained well, normotensive and with no haematuria. Isotope renogram showed 30% loss of function at the upper pole.

Leaking false aneurysm of right coronary saphenous vein graft; successful treatment by percutaneous coil embolisation.

An unusual complication after aortocoronary bypass grafting (CABG) is described in which a false aneurysm of the saphenous vein graft to the right coronary artery (RCA) developed and caused profuse intermittent bleeding through the sternotomy wound. The aetiology of this condition is uncertain but it could occur whenever a suture line is present especially in the presence of infection. The diagnosis was made non-invasively by a contrast enhanced computed tomogram and was subsequently confirmed by selective coronary bypass angiography. The pseudoaneurysm was successfully obliterated by coil embolisation of the right coronary graft, which stopped the bleeding immediately and was followed by rapid wound healing.

Management of a pregnant patient with airway obstruction secondary to goitre.

A case of airway obstruction in advanced pregnancy is presented. The patient was successfully managed with an awake fibreoptic intubation performed orally followed by a caesarean section and thyroidectomy as a combined procedure. On resection, a thyroid gland weighing 370 g was removed. The patient made an uneventful recovery.

Management of thrombosis in peripheral arterial disease.

There is accumulating evidence that thrombosis contributes to peripheral arterial disease, and that antithrombotic therapy should be considered at all symptomatic stages. In claudication, antiplatelet therapy is indicated in addition to lifestyle advice and sometimes surgery or angioplasty; the place of thrombolysis is unproven. In chronic critical limb ischaemia, prophylaxis of venous thromboembolism by low-dose heparin is indicated during hospitalisation, as is long-term antiplatelet therapy; local thrombolysis or systemic prostanoid infusions are increasingly used. In acute critical limb ischaemia, full dose heparinisation is followed by thromboembolectomy, local thrombolysis, angioplasty and surgery as appropriate. Antiplatelet therapy and/or anticoagulation are employed following such procedures, according to risk factors in the individual patient. Collaboration between vascular surgeons, radiologists and physicians is important in comprehensive patient care.