Reconstruction for Symptomatic Vertebral Artery Lesion Using Vertebral Artery to Carotid Artery Transposition: A Retrospective Study.

BACKGROUND: A posterior circulation infarction is caused by a vertebral artery (VA) lesion (stenosis or occlusion). The purpose of this study is to assess early and long-term outcomes after open surgery for a VA lesion at the origin. METHODS: In a retrospective study conducted from January 1, 2000 through March 31, 2020 in a single center, patients were treated with vertebral artery to carotid artery transposition (VCT). RESULTS: A total of 28 patients, with a mean age of 65.29 ± 9.81 years (range 45-84), were screened, including 22 patients with VA stenosis and 6 patients with VA occlusion. The complication rate was 21.4% (n = 6), including Horner syndrome (n = 2), lymphocele (n = 1), respiratory failure (n = 1), embolism of a subclavian artery stenosis (n = 1), and vocal cord paralysis (n = 1). The 30-day mortality rate was 0%. Primary patency was 100%. Overall, improvement in symptoms was 85.7% (n = 24) after surgery and 96.4% after 30 days. In the long-term results, primary patency was 100%, and the cumulative patency rate after 60 months was 85.7%, with 1 occlusion of the VA. Cumulative survival rates were 94%, 87%, 69%, and 59% after 12, 24, 60, and 72 months (n = 5). One of the 3 patients died after 60 months because of VA occlusion and posterior circulation infarction. CONCLUSIONS: VCT is a safe, effective, and durable procedure. It provides good stroke protection, symptomatic relief, and perioperative risk at acceptable levels, in experienced hands.

Reconstruction for renal artery aneurysms using the tailoring technique.

OBJECTIVE: Renal artery (RA) aneurysm (RAA) is a rare and complex disease. Treatment options for a RAA include endovascular surgery and open surgery with ex vivo repair or in situ reconstruction. This study evaluated the long-term outcome after vascular reconstruction of RAAs using the tailoring technique. Tailoring or aneurysmorrhaphy means a partial resection of the aneurysm with direct suture of the remaining arterial wall. METHODS: A single-center retrospective study was conducted between January 1990 and December 2015. The tailoring technique was used to surgically repair 88 RAAs in 80 patients (52 women) with a mean age of 52.9 years. Patients' demographic data, vascular therapy, and renal function during follow-up were retrospectively evaluated. RESULTS: The localization of the RAA was at the right kidney in 58 patients. The mean size of the aneurysm was 21.4 ± 9.7 mm (range, 8-67 mm). Hypertension was diagnosed in 56 patients, and 23 were asymptomatic. One RAA was ruptured. The overall morbidity rate was 16.3%, including bleeding (n = 4), RA stenosis (n = 3), RA occlusion (n = 4), RA dissection (n = 1), and myocardial infarction (n = 1). One patient died of myocardial infarction for a 30-day mortality rate of 1.3%. The 30-day primary patency rate was 90.0%. The 30-day secondary patency rate was 95.0%. Follow-up data were obtained from 71 patients who underwent tailoring in 78 RAAs. The mean follow-up period was 60.7 months (range 2-229 months). In 76.4% of patients with RAA and hypertension, RAA reconstruction contributed to the cure or improvement of hypertension. The long-term patency after RAA reconstruction was demonstrated in a Kaplan-Meier curve, with cumulative patency rates of 98.7%, 97.4%, 94.8%, and 92.3% after 18, 24, 36, and 48 months, respectively. Estimated survival rates were 98.8%, 97.5%, and 96.3% after 12, 48, and 60 months, with an estimated mean time of 216.5 ± 7.2 months. CONCLUSIONS: The tailoring technique is a safe and effective procedure with good long-term outcomes. RAA reconstruction contributed to the cure or improvement of renovascular hypertension.

Open Repair for Abdominal Aortic Aneurysm in a Young Boy with Tuberous Sclerosis and Review of the Literature.

BACKGROUND: Abdominal aortic aneurysms (AAAs) are very rare in pediatric patients and can rarely be associated with tuberous sclerosis (TS). Open surgery is the first-line therapy. We report our experience added by a review on current literature. CASE REPORT: A 9-year-old boy with TS and history of 2 earlier open repairs for AAA presented to our department with a recurrent juxtarenal aortic aneurysm. We performed a polytetraflourethylene patch plasty. Postoperative course was uneventful. After 8 months, reconstruction was stable, and no recurrent aneurysm developed. CONCLUSIONS: Recurrent aneurysms may develop after open surgery for TS-associated AAA. However, open surgery is the recommended therapy but requires special techniques and experience in pediatric patients.

High-urgency kidney transplantation in the Eurotransplant Kidney Allocation System: success or waste of organs? The Eurotransplant 15-year all-centre survey.

BACKGROUND: In the Eurotransplant Kidney Allocation System (ETKAS), transplant candidates can be considered for high-urgency (HU) status in case of life-threatening inability to undergo renal replacement therapy. Data on the outcomes of HU transplantation are sparse and the benefit is controversial. METHODS: We systematically analysed data from 898 ET HU kidney transplant recipients from 61 transplant centres between 1996 and 2010 and investigated the 5-year patient and graft outcomes and differences between relevant subgroups. RESULTS: Kidney recipients with an HU status were younger (median 43 versus 55 years) and spent less time on the waiting list compared with non-HU recipients (34 versus 54 months). They received grafts with significantly more mismatches (mean 3.79 versus 2.42; P < 0.001) and the percentage of retransplantations was remarkably higher (37.5 versus 16.7%). Patient survival (P = 0.0053) and death with a functioning graft (DwFG; P < 0.0001) after HU transplantation were significantly worse than in non-HU recipients, whereas graft outcome was comparable (P = 0.094). Analysis according to the different HU indications revealed that recipients listed HU because of an imminent lack of access for dialysis had a significantly worse patient survival (P = 0.0053) and DwFG (P = 0.0462) compared with recipients with psychological problems and suicidality because of dialysis. In addition, retransplantation had a negative impact on patient and graft outcome. CONCLUSIONS: Facing organ shortages, increasing wait times and considerable mortality on dialysis, we question the current policy of HU allocation and propose more restrictive criteria with regard to individuals with vascular complications or repeated retransplantations in order to support patients on the non-HU waiting list with a much better long-term prognosis.

Subclavian carotid transposition: immediate and long-term outcomes of 126 surgical reconstructions.

BACKGROUND: Subclavian carotid transposition (SCT) is a safe, effective, and durable treatment in atherosclerotic disease of the proximal subclavian artery. We report about our experience in SCT in a retrospective study with a long-term outcome in 126 cases and discuss our results with the current literature. METHODS: From January 1995 to December 2013, we treated 126 patients (51 men, 75 women; mean age, 60.9 years; range, 25-80 years) for proximal subclavian atherosclerotic lesions. Preoperative angiography revealed 58 stenoses (46.0%) and 68 occlusions (54.0%). We performed 126 SCTs. The following parameters were documented through a retrospective chart review: demographic data, occlusion site, preoperative symptoms, cardiovascular risk profile, coexisting cerebrovascular disease, and postoperative outcome. Continuous variables are summarized as mean. Categoric variables are expressed as frequency and percentage. Survival and patency rates were estimated using Kaplan-Meier analysis. RESULTS: Four immediate occlusions and 1 hemodynamic relevant stenosis (4.0%) occurred postoperatively. Thrombectomy was successful in 2 and a carotid axillary bypass was performed in 3 cases. Three strokes occurred, one during concomitant carotid endarterectomy. The 30-day mortality was 0%. Follow-up data were obtained on 106 of 126 patients (84.0%). The mean follow-up period was 53.8 months (range, 3-159 months). Twenty-three (18.3%) late deaths occurred. Estimated survival was 121.48 ± 6.86 months (range, 3-112 months). Ninety-five percent reported continuous resolution of symptoms. Primary patency rate was 96.0% and secondary patency rate was 100% at 30 days. The long-term patency rate was 96.3% at a mean follow-up of 53.8 months. CONCLUSIONS: SCT is safe, effective, and durable in the long term. SCT is a standard procedure for occlusion and stenosis. Vessel occlusions, ineffective angioplasty, and preparation for thoracic stent grafting make SCT an important procedure in the surgeon's repertoire.

Long-term graft outcome after renal arterial reconstruction during living related kidney transplantation.

BACKGROUND/OBJECTIVES: The aim of this retrospective study was to evaluate the repair of vascular variations/pathologies in living donor kidney transplantations in a single centre over a 15-year period. METHODS: Between 01/1997 and 05/2012, 338 living donor renal transplantations were performed in the Department for Endovascular and Vascular Surgery, University of Düsseldorf, Germany. Twenty-four of them showed disorders, like multiple renal arteries (MRA), atherosclerotic stenosis or fibromuscular dysplasia (FMD) needing vascular repair before transplantation. RESULTS: Mean age of donors was 51 ± 11.2, in recipient's 44 ± 13.9 years. In seven transplantations, renal artery (RA) repair was performed because of MRA. Atherosclerotic stenosis of the RA was apparent in 12 cases needing a repair with disobliteration. FMD was the reason in five transplantations for vascular repair. Complications like renal vessel thrombosis, lymphocele, heamorrhage, distal urinary leakage and ureteral obstruction was not significantly associated with RA reconstruction. Comparison of renal function in kidneys with reconstructed RA compared with kidneys without vascular repair showed no significant difference in primary function and serum creatinine up to the first year after transplantation. Mean follow-up was 75.6 ± 48.1 months. The 5-year graft survival rate for kidneys with RA repair was 88.5 vs. 93.4 % without reconstruction. CONCLUSIONS: We could show that RA pathologies, suitable repaired, are not a contraindication for transplantation with acceptable 5-year-graft-survival rates.

Time is brain?--Surgical revascularization of acute symptomatic occlusion of the internal carotid artery up to one week.

BACKGROUND: Clinical outcome and surgical success rate of open surgical reconstruction for acute symptomatic internal carotid artery (ICA) occlusion up to 1 week after stroke onset were analyzed to determine a cutoff time, after which risk exceeds clinical benefit. METHODS: From November 1997 to March 2007, a total of 5369 patients were examined at the authors' stroke unit; 502 from this cohort underwent ICA reconstruction. A subgroup of 49 patients underwent surgical revascularization of acute ICA occlusion within 168 hr at a mean of 42.5±38.7 hr after stroke onset. Preoperative diagnostic measures consisted of extracranial/intracranial duplex sonography (n=49), cerebral computed tomography (n=31), magnetic resonance imaging and angiography (n=37), and digital subtraction angiography (n=24). All 49 patients experienced a complete ICA occlusion and an ipsilateral recent ischemic infarction. Modified Rankin scale score (mRS) before surgery was 0 to 3 in 20 patients (41%) and 4 to 5 in 29 patients (49%). RESULTS: ICA patency could be restored in 38 patients (78%). The following clinical outcomes were noted: clinical improvement in mRS by at least 1 point in 23 of 49 of patients (47%), no change in 14 of 49 (28%), deterioration in mRS by at least 1 point in 6 of 49 (12%), and death within 30 days in 6 of 49 (12%). A total of 21 patients (43%) experienced perioperative cerebral events (new infarction, new intracranial hemorrhage or enlargement, or hemorrhagic transformation of the preexisting infarction). Univariate analysis showed that clinical improvement correlated significantly with success of recanalization and with early recanalization within 72 hr. Age, gender, and preoperative Rankin stage did not have influence. Clinical deterioration or death was only associated with perioperative cerebral events and seemed to be time-independent. Multivariate analysis did not have enough statistical power to analyze the impact of different risk factors on outcome after urgent revascularization. CONCLUSIONS: In patients who undergo surgery after 72 hr from symptom onset, the risk seems to outweigh the benefit.

Long-term dilatation of polyester and expanded polytetrafluoroethylene tube grafts after open repair of infrarenal abdominal aortic aneurysms.

OBJECTIVES: Since 1995, expanded polytetrafluoroethylene (ePTFE) grafts have been implemented in open surgical repair (OSR) of abdominal aortic aneurysms (AAA) and are supposed to show less dilatation than polyester grafts. This study examined differences in graft dilatation and clinical outcome. METHODS: This single-center long-term, prospective randomized study monitored 99 consecutive patients after OSR of AAA. Implanted were 90 tube ePTFE Gore-Tex Stretch grafts, 56 tube Dacron grafts (Uni-Graft KDV, polyester, B. Braun, knitted), and 51 tube Dacron grafts (Gelseal Plus, polyester, Vascutek, triaxial knitted). Follow-up with ultrasound examination was performed at discharge, at 12 months, and at 6 years. RESULTS: Patients were a mean age of 67 years. Thirty-day mortality was 2.5% (n = 5 of 199), without significant differences among the groups. The Kaplan-Meier analysis showed 5-year survivals of 0.82 (ePTFE/Gore), 0.81 (polyester/Braun), and 0.83 (polyester/Vascutek). Mean ± standard deviation dilatation of the midgraft segment was 1% ± 5% (ePTFE/Gore), 10% ± 9% (polyester/Braun), and 7% ± 8% (polyester/Vascutek) (P ≤ .001) at discharge; 8% ± 11% (ePTFE/Gore), 24% ± 7% (polyester/Braun), and 20% ± 13% (polyester/Vascutek; P ≤ .001) after 12 months; and 19% ± 21% (ePTFE/Gore), 33% ± 22% (polyester/Braun), and 23% ± 19% (polyester/Vascutek; (P ≤ .001) after 6 years. No graft failure or rupture occurred. Graft patency was 100%. CONCLUSIONS: After a mean implantation of 6 years, the ePTFE/Gore, polyester/Braun, and polyester/Vascutek tube grafts presented with significant differences. The ePTFE grafts showed a stronger resistance against dilatation than the two types of polyester grafts. Owing to similar perioperative and postoperative courses, no advantage could be identified in any group concerning the overall outcome. Vascular implants for OSR of AAA made of ePTFE and polyester are safe, even after a long implantation time. Therefore, the choice of the suitable graft does not depend on its postimplantation dilative characteristics. The outcome is not likely to be connected with dilatation of the implanted graft, because a causal connection between graft dilatation and death cannot be made. The study does not offer a basis for the preference of one of the three graft types. Nevertheless, continuous ultrasound examinations should be performed after implantation of an aortic tube graft to identify possible problems arising from changes in the graft and the residual vascular branches over time.

Single-center experience with open surgical treatment of 36 infected aneurysms of the thoracic, thoracoabdominal, and abdominal aorta.

BACKGROUND: To describe a single-center experience with open surgical treatment of infected aortic aneurysms. We analyzed risk factors for 90-day mortality. METHODS: Between 1983 and 2008, 4,410 patients underwent open surgery for thoracic, thoracoabdominal, or abdominal aneurysm at our institution. Primary infection of the aneurysm was suspected because of clinical signs of infection in combination with typical radiological and morphological aspects in 66 patients (1.5%). In all, 36 patients displayed 10 different kinds of organisms in cultures of blood and/or intraoperative specimens and were further analyzed. RESULTS: The group consisted of 23 men and 13 women, with a mean age of 66.8 ± 8 (50-84) years. Location of the aneurysm was thoracic in five patients (14%), thoracoabdominal in 13 patients (36%), and abdominal in 18 patients (50%). Eleven patients (28%) were treated before and 25 (72%) after 1995. We found free rupture in three cases; contained rupture into surrounding tissue in 23 cases (64%); penetration into lung, bronchus, esophagus, or inferior vena cava in five cases; and an intact aneurysm in another five cases. Kinds of surgery were as follows: extra-anatomic revascularization in four patients (11%), Dacron patch plasty in four patients (11%), in situ revascularization in 24 patients (66%), and four patients died during surgery before reconstruction (11%). In all, 13 patients died during hospital stay (36%). In 25 patients treated after 1995, 90-day mortality was 24% and was significantly better (p < 0.05) than the rate of 64% in 11 patients treated before 1995. Outcome depended on status of rupture: all patients with free rupture, three of five patients (60%) with rupture into an organ, seven of 23 patients (30%) with contained rupture into the surrounding tissue, but no patient with intact aneurysm died. Age, gender, bacterium, location of the aneurysm, and method of surgical treatment did not influence 90-day mortality. During follow-up, 18 patients died after a mean of 56 ± 49 months. One patient died because of an infected aortic prosthesis. CONCLUSIONS: Outcome of patients with infected aortic aneurysms has improved during the last 15 years and depends on the status of rupture at time of surgery. Therefore, only early diagnosis and early treatment can further improve the prognosis.

Surgical management of iliofemoral vein thrombosis during pregnancy and the puerperium.

BACKGROUND: The risk of deep venous thrombosis is elevated during pregnancy and the puerperium. Therapy is usually limited to conservative measures as invasive thrombus removal is feared because of possible complications. However, leg- or life-threatening situations require fast thrombus removal, and the long-term rate of post-thrombotic syndrome (PTS) may be reduced by venous recanalization. Our center's experience may give support to surgical venous thrombectomy (VT). METHODS: Between 1996 and 2016, all women who received VT for pregnancy-related deep venous thrombosis in our department were included. Retrospective data were combined with a current follow-up. RESULTS: The study included 82 women with a mean age of 29 years (17-38 years). An additional arteriovenous fistula was performed in 79 and planned simultaneous cesarean section in 13 patients. Neither pulmonary emboli nor fetal complications occurred during surgery, and perioperative and postoperative mortality was 0%. Operative revision was required in 38% mainly for rethrombosis (24%) and bleeding (12%). One fetus died 2 months after VT of unrelated causes. After a mean of 83 months, complete venous recanalization was seen in 88%, venous valve sufficiency in 90%, and PTS in 31% without any ulcers. At 10 years, PTS incidence rose to reach 50% with limited statistical significance because of the number of patients reaching long-term follow-up. CONCLUSIONS: Iliofemoral venous recanalization during pregnancy can be performed safely in a specialized center, with lower PTS rates than in historical controls.

Elevated risk of thrombophilia in agenesis of the vena cava as a factor for deep vein thrombosis.

BACKGROUND: Congenital absence of the inferior vena cava (AIVC) is a rare malformation which may be associated with an increased risk for deep vein thrombosis (DVT). However, the role of thrombophilia in AIVC and DVT is unknown. METHODS: Between 1982 and 2013 41 patients (12 female, 29 male, mean age 28 S.D. 11 years) were detected at the University of Düsseldorf, Germany, with AIVC. Based on medical history, clinical examination, imaging and coagulation studies, we performed on this collective a risk characterisation. Extensive literature research added further 123 published cases during 1993 and 2013. AIVC-patients were compared with iliocaval DVT-patients without AIVC (n = 168) treated during the same period in our clinic (90 female, 78 male, mean age 38 S.D. 17 years). RESULTS: In contrast to classical DVT younger men were more often affected. Factor-V-Leiden-mutation, 5,10-methylenetetrahydrofolate reductase (MTHFR) polymorphism and hyperhomocysteinemia individually are associated with an increased risk of DVT in patients with AIVC. Aplasia/hypoplasia of the right or left kidney is also associated with IVCA. CONCLUSIONS: AIVC should be considered in young patients who present with DVT involving the vena cava. Analysis of publications with AIVC and our patients yielded a typical spectrum of AIVC-associated DVT characteristics: AIVC occurs in young male adults, is revealed by proximal DVT, not necessarily accused by precipitating factors like immobilisation, and is mostly located bilateral. Hereditary coagulation abnormalities seem to be more often a contributing factor for DVT in AIVC.

Vascular challenges in renal transplantation.

BACKGROUND: The increasing demand for transplantable organs, especially kidneys, has led to expanded criteria for renal transplant donors. As a result of the expanded criteria, more organs with vascular anomalies and/or pathologies are available for transplant. This retrospective study evaluated the impact of vascular repair on the outcome in kidney transplantation in a single center over a 15-year period. MATERIAL AND METHODS: Between January 1997 and May 2012, 1134 deceased donor renal transplantations were performed in the Department for Vascular and Endovascular Surgery of the University of Düsseldorf, Germany. RESULTS: A vascular reconstruction of some type was necessary to repair renal vessels or to prepare the recipient site for transplantation in 374 of 1134 (33.0%) renal transplantations. The iliac artery in 12.3% (139/1134) of cases and the renal artery in 10.1% (115/1134) of cases showed severe atherosclerosis and a thrombo-endarterectomy was required. Organ loss occurred in 13 cases (1.1%) due to vascular failure. The 5-year graft survival for kidneys with reconstructed renal arteries was 84.3% in deceased donor renal transplantations (86.1% without arterial reconstruction). CONCLUSIONS: The demand for renal transplants has led to more marginal-quality organs and older donors and/or recipients waiting for a second or third transplantation. Thus, the expertise of a vascular surgeon is extremely helpful in a transplantation center because it allows for marginal organ transplantation with acceptable 5-year graft survival rates.

Retrograde balloon dilation >10 weeks after renal transplantation for transplant ureter stenosis - our experience and review of the literature.

OBJECTIVE: Despite many efforts to prevent ureteric stenosis in a transplanted kidney, this complication occurs in 3-5% of renal transplant recipients. Balloon dilatation (BD) is a possible minimally invasive approach for treatment, but reports to date refer only to the antegrade approach; we analysed our experience with retrograde BD (RBD) and reviewed previous reports. PATIENTS AND METHODS: From October 2008 to February 2011, eight patients after renal transplantation (RTX) underwent RBD for transplant ureteric stenosis at our hospital. We retrospectively analysed the outcome and reviewed previous reports. RESULTS: The eight recipients (five men and three women; median age 55 years, range 38-69) were treated with one or two RBDs for transplant ureteric stenosis. There were no complications. The median (range) time after RTX was 4.5 (2.5-11) months. Long-term success was only achieved in one recipient, while five patients were re-operated on (three with a new implant, two by replacement of transplanted ureter with ileum) after a median (range) of 2.8 (0.7-7.0) months after unsuccessful RBD(s). For two recipients the success remained unclear (one graft loss due to other reasons, one result pending). When the first RBD was unsuccessful there was no improvement with a second. CONCLUSION: RBD is technically feasible, but our findings and the review of previous reports on antegrade ureteric dilatation suggest that the success rate is low when the ureter is dilated at ⩾10 weeks after RTX. From our results we cannot recommend RBD for transplant ureteric stenosis at ⩾10 weeks after RTX, while previous reports show favourable results of antegrade BD in the initial 3 months after RTX.

Spontaneous rupture of collateral venous aneurysm in a patient with agenesis of the inferior vena cava: a case report.

We present a case of rupture of collateral venous vessels in the presence of agenesis of the inferior vena cava in a young woman. The embryologic development, pitfalls in diagnosis, and options for treatment in cases with agenesis of the inferior vena cava are discussed.

Reconstruction for renal artery aneurysm: operative techniques and long-term results.

BACKGROUND: Ninety-four patients (37 male, 57 female; mean age, 51.0 years) underwent reconstruction for renal artery aneurysm (RAA) between 1980 and 2001. RAAs were present in 52 patients in the right kidney, in 29 patients in the left kidney, and in 13 patients in both kidneys. Eighty-three aneurysms were located in the mainstem, 49 in a branch artery, and four in an accessory artery. Additional ipsilateral renal artery stenoses (RAS) occurred in 26 patients, bilateral RAS in 18, and contralateral RAS in six. The causes of RAA were fibromuscular dysplasia (n = 48), atherosclerosis (n = 28), dissection (n = 7), aortic coarctation (n = 5), arteritis (n = 3), giant cell arteritis (n = 1), Marfan's syndrome (n = 1), and trauma (n = 1). Seventy-five patients had hypertension, 14 were asymptomatic, and five had rupture. Indications for RAA repair concerned aneurysms with 1 cm or more diameter in combination with risk factors of hypertension, ipsilateral and contralateral stenosis, and childbearing age in women. Without risk factors, aneurysm size eligible for reconstruction was limited to 2 cm or more. METHODS: Methods applied for reconstruction in 107 kidneys and 136 aneurysms included aneurysm resection with tailoring (n = 37), saphenous vein graft interposition (n = 40), tailoring and saphenous vein graft interposition (n = 7), resection and reanastomosis (n = 14), saphenous vein graft interposition and resection and reanastomosis (n = 3), polytetrafluoroethylene bypass (n = 5), and homologous vein graft interposition (n = 1). Four reconstructions had to be performed ex situ because of multiple branch involvement in three patients and rupture in one. In all patients, the concerned kidney was protected with hypothermic flush perfusion with addition of heparin and prostaglandin E1. RESULTS: The overall morbidity rate was 17%, including one early graft occlusion, one partial thrombosis of the renal artery that necessitated fibrinolytic therapy, and a branch artery stenosis after tailoring managed with aortorenal bypass. The mortality in elective cases was null; one patient died of myocardial infarction 2 days after an emergency operation for ruptured RAA. The technical primary success rate was 96.8%; the secondary success rate was 98.9%. After a follow-up period from 1 to 143 months (mean, 46 months) in 83 patients (88%), 67 (81%) had patent renal arteries free of stenoses. Among six patients with RAS, four underwent successful reoperation, five had mainstem occlusions, three had segmental artery occlusions, and two underwent nephrectomy. Concerning the patients who underwent reoperation, percutaneous transluminal angioplasty was considered seriously but assessed as inappropriate because of long extension of stenosis or involvement of branch arteries. Hypertension was cured in 19 patients (25%) and improved in 17 (22%). CONCLUSION: Surgical reconstruction of RAA is a safe procedure that provides good long-term results, prevents aneurysm rupture, cures or improves hypertension in about half of the cases, and can be achieved with autogenous reconstruction in 96%.

Kidney transplantation from related and unrelated living donors in a single German centre.

BACKGROUND: Organ transplantation began in 1954 with living related donation (LRD). Because of organ shortage from cadavers, unrelated kidney donation (LURD) has been proposed and shown to have good results despite complete HLA mismatching. This study aims to look at differences and similarities comparing LRD and LURD performed in our centre since the implementation of the German transplant law in 1997. METHODS: Between January 1997 and July 2001, 62 out of 112 potential living donors and their recipients were accepted. Immunosuppression consisted of triple therapy (steroids, cyclosporin, mycophenolate) in patients with three or fewer mismatches, or quadruple therapy including mono- or polyclonal antibody treatment in patients with four or more mismatches or cytotoxic antibodies. LRD and LURD groups were compared for number and type of rejections, complications and kidney function at the end of observation (median 15.5 months, range 1-50 months). RESULTS: Out of 112 pairs presenting, transplantation was performed in only 62 cases (55.4%). Reasons to deny transplantation were medical problems of the potential donors in 19, psychological problems in 13, recipient problems in seven and other reasons in 11 pairs. In 38 cases LRD transplantation and in 24 cases LURD transplantation was carried out. Recipient age was significantly lower in the LRD group (37.7+/-12.1 years) compared with the LURD group (53.6+/-7.8 years). Mean donor age was 49.7+/-9.2 years in the LRD group and 50.3+/-9.1 years in the LURD group (ns). The number of mismatches was lower in LRD (2.1+/-1) than in LURD (4.4+/-0.9) (P=0.001) transplantation. The acute rejection rate was similar in both groups (52.2 vs 54.2%). OKT3 and tacrolimus rescue therapy for more severe rejections was more often applied in the LRD group but the difference did not reach the level of significance. There were more infectious complications in LURD transplantation (66.7 vs 36.4%, P=0.036) and a trend towards more surgical complications in LRD transplantation (28.9 vs 8.3%, P=0.062). One graft was lost due to transplant artery thrombosis and one recipient died 4 months after transplantation subsequent to cerebral ischaemia. Both patients belonged to the LRD group. Creatinine values at the end of observation time were 1.76+/-0.6 mg/dl in the LRD group and 1.62+/-0.5 mg/dl in the LURD group (ns). CONCLUSION: Although kidney transplantation from unrelated donors was performed with a lower HLA match and although the recipients were older, the results are equivalent to living related transplantation. Therefore, kidney transplantation from emotionally related living donors represents a valuable option for patients with end-stage renal disease. Careful selection of donors and recipients is a prerequisite of success.

Aneurismas micóticos de la aorta torácica, abdominal y de las arterias ilíacas: experiencia con reparaciones anatómicas y extra-anatómicas en 33 casos / Mycotic aneurysms of the thoracic, abdominal aorta and iliac arteries: experience with anatomic and extra-anatomic repair in 33 cases

Introducción: Un aneurisma micótico de la aorta y sus arterias adyacentes es una condición terrible, queamenaza la vida, los órganos y las extremidades. Dependiendo de los segmentos aórticos comprometidos, lareparación con reconstrucciones in situ o bien con reconstruccón extra-anatómicas puede ser un desafío mayor. Aún cuando la cirugía se haya realizado con éxito, el pronóstico es muy pobre, debido al mal estado de salud de los pacientes que han desarrollado este tipo de aneurismas. El objetivo de nuestro estudiofue el intentar determinar si a través del uso combinado de técnicas quirúrgicas y antisépticas en un solo centro, se puede lograr, en un período largo de tiempo(18 años), algún progreso en el manejo de esta condición. Materiales y Métodos: de enero de 1983 a diciembre de 1999, un total de 2520 pacientes con aneurismas de la aorta torácica o abdominal o de las arterias ilíacas fueron sometidos a cirugía de reemplazo aórtico o ilíaco en nuestro centro. Durante este período, 33 (1.31 por ciento) de estos pacientes (promedio de edad 64.3 años) fueron tratados por aneurismas micóticos de la aorta descendente y aorta toraco-abdominal(n = 13), suprarrenal (n = 4), infrarrenal (n = 10) y de las arterias ilíacas (n = 6). Veinte (61 por ciento) de éstos 33 pacientes tenían historia de varios procesos sépticos, en los 13 restantes (39 por ciento), la etiología fue incierta. Se encontraron signos de infección como leucocitosis y elevación de la proteína C-reactica pre-operatoriamente en el 79 por ciento de los pacientes, 48 por ciento presentaron fiebre y el 76 por ciento se quejaban de dolor. Al momento de la cirugía, ocho (24 por ciento) de los aneurismas micóticos se habían roto y 20 (61 por ciento) habían penetrado hacia los tejidos peri-aórticos formando una ruptura encapsulada. Cinco (15 por ciento) aneurismas estaban intactos. Los microorganismos predominantemente encontrados en el saco fueron especies de staphylococcus aureus y salmonella. Fue necesario el desbridamiento cuidadoso de los todos los tejidos infectados. En la trama vascular aórtica infrarrenal e ilíaca, se realizaron reconstrucción in situ sólo en aquellos casos en los cuales se anticipaba encontrar infecciones de bajo grado. Se realizaron revascularizaciones alternas con procedimientos extra-anatómicos (bypasses axilobifemorales y femorofemorales con material protésico) en ocho de los dieciséis casos