The influence of anticoagulant treatment on the probability of function in femoropopliteal vein bypass surgery: analysis of a clinical series (1970 to 1985) and interim evaluation of a controlled clinical trial.

During the years 1970 to 1985, 463 patients with obliterative atherosclerosis at the femoropopliteal level underwent elective surgery. The operation performed was an autologous saphenous vein bypass using the reversed technique. The vascular surgical treatment was documented in reasonable detail (both baseline and follow-up) in accordance with the documentation system of the Austrian Society of Vascular Surgery. On-line data entry with use of SAS data-base management software was used. The patency curves were estimated in accordance with the Kaplan-Meier method; possible differences were checked by means Breslow's and Mantel's tests. The preoperative clinical status (claudicants, n = 200; limb salvage, n = 263) influenced the postoperative results in a statistically significant manner (Breslow p less than 0.01; Mantel p less than 0.03). All the other risk factors analyzed (site of distal anastomosis above versus below the knee, n = 231, and n = 232, respectively; Breslow p less than 0.58, Mantel p less than 0.58. Presence [n = 122] or nonpresence [n = 341], of diabetes mellitus [Breslow p less than 0.77, Mantel p less than 0.68]; smoking habits [nonsmokers, n = 93, smokers n = 370, Breslow p less than 0.68, Mantel p less than 0.69;]) did not reach statistical significance. Anticoagulant treatment (n = 101) had no effect (Breslow p less than 0.93, Mantel p less than 0.72), even when the therapy was restricted to cases with disease at advanced clinical stages (stages III, IV; n = 50; Breslow p less than 0.55, Mantel p less than 0.95). On the basis of these analyses, a prospective trial was initiated in 1979. Eighty-eight patients were studied; those in group I (n = 42) received dicumarol, and those in group II (n = 46) were controls who did not receive anticoagulant treatment. At present, the median follow-up time is at 30 months. Treatment with dicumarol favorably influenced graft patency (Breslow, p less than 0.03, Mantel p less than 0.07; one-tailed tests). The patients' preoperative clinical status affected the results of surgery (Breslow p less than 0.03, Mantel p less than 0.02; one-tailed tests). In relation to the preoperative clinical status, a therapeutic effect was observed in stages III and IV (n = 45; Breslow p less than 0.03, Mantel p less than 0.07; one-tailed tests), while no effect of therapy was demonstrable in claudicants (n = 43; Breslow p less than 0.3, Mantel p less than 0.4; one-tailed tests).(ABSTRACT TRUNCATED AT 400 WORDS)

Failure of cimetidine to prevent gastroduodenal ulceration and bleeding after renal transplantation.

Treatment of renal transplant patients with the H2-antagonist cimetidine has previously been assumed to be of reasonable prophylactic value in controlling the incidence of the postoperative complications of gastric or duodenal ulceration. We attempted to evaluate the performance of the drug in a controlled trial by treating transplant patients with either cimetidine or a placebo. Of the 59 patients accepted for the trial, four had to be excluded eventually because of irregularities in the administration of the drug and, in on case, nonfatal respiratory failure. Six of 27 from the cimetidine group had erosions or ulcers by the third day after surgery and two more had them by the end of the fourth week. Three of 28 placebo patients developed lesions after 3 days and three more developed them after 7 weeks. In the months after transplantation, one cimetidine and two placebo patients developed ulcers. Bleeding occurred three times with cimetidine and twice with the placebo. Renal function was similar in both groups as was the necessity of transplantectomy because of irreversible rejection. We conclude that cimetidine does not lower the incidence of gastroduodenal mucosal lesions and upper gastrointestinal bleeding after renal transplantation, nor does it influence rejection of the allograft.

Primary hepatic cancer--the role of limited resection and total hepatectomy with orthotopic liver replacement.

Between 1977 and 1986, 172 patients with primary hepatic cancer were treated at the Department of Surgery I, University of Vienna Medical School. In 76 cases (80%) males, 20% females), cirrhosis of the liver was also present. Ninety patients underwent curative surgery (hepatic resection in 64, and liver transplantation in 26 cases). There were no early tumor stages. Forty-five large tumors were confined to one lobe, 42 involved both lobes, 3 even invaded adjacent structures, the majority (74%) being hepatocellular carcinomas. Forty-four of the 64 liver resections were performed in patients with otherwise normal livers (mortality 18%), while 20 patients had associated liver cirrhosis. In view of the extremely high mortality rates after extended liver resection, only limited local resections have been performed in cirrhotic malignancies since 1982 (mortality 25%). Perioperative mortality (25% overall) was due mainly to hepatic failure and sepsis; non-fatal complications occurred in 12 patients (26%). Seventeen of the 26 liver transplants were cirrhotic hepatomas. Nine deaths (34%) were caused by technical problems (graft failure, clotting disorder after massive transfusion) and systemic infections. The outcome for the patient after the immediate postoperative period was determined by tumor regrowth (residual liver tissue, graft, distant metastases) in both groups (median life expectancy 18.4 months after radical liver resection and 18.6 months after liver transplantation). Surgery is the only alternative for these patients (50% survival of untreated hepatoma: 2.6 months), improving both their quality of life and survival. We believe that in carefully selected candidates with non-resectable tumors liver replacement may be a useful alternative.

The PTFE Y-graft: one year experience in 21 patients. A preliminary report.

21 patients had aortoiliac reconstructions for aortic aneurysms or occlusive disease with the new PTFE Y-graft during the past 12 months. 2 patients in the aneurysm group with additional renal artery reconstruction suffered postoperative myocardial infarction and subsequently died. 2 patients older than 80 years died after aneurysm repair in cause of graft infection, respectively respiratory insufficiency. All grafts (n=17) are functioning well or did so until death of the patient (n=4). The obvious advantage of the PTFE Y-graft is the fact, that there is no need of preclotting. Suture line--even using 4-0 material at the proximal anastomosis--and graft body is absolutely tight and no blood loss has to be expected from this site. However positioning of the left limb of the y-graft can be difficult in patients with right sided extraperitoneal approach and proximal side end anastomosis. Performing an end-end anastomosis can overcome this problem. For occlusion of the prosthesis limbs two vascular clamps on each side are needed to control blood flow within the rather stiff graft. Immediate and short term function is excellent. There was no material specific complication noted until now. Further longterm experience is necessary to evaluate the definitive quality of this new prosthetic material after some years.

[Intraoperative diagnosis in vascular surgery (author's transl)]. / Die intraoperative Diagnostik in der Gefässchirurgie.

The different methods of intraoperative diagnosis in vascular reconstructive surgery are described. Intraoperative angiography is of importance in the morphological assessment of reconstructive procedures, whilst functional assessment is based on pressure difference and basic and peak flow determination. The peripheral resistance can be calculated from these parameters. With intraoperative diagnosis the immediate postoperative occlusion rate is lowered and the haemodynamic state in the reconstructed part can be better judged, which is of prognostic value in long-term functional terms.

[Multiple transplantation of the kidney as a risk factor]. / Die Mehrfachtransplantation der Niere als Risikofaktor.

The influence of match, immunological therapy, age of the recipient and sex has been analysed by graft survival in 91 patients receiving a second kidney graft. Effects of these risk factors in first kidney grafts are not demonstrable in second grafts with the exception of cyclosporin which also produces better second graft survival. The main active risk factor for second transplants is endurance of function of the first graft. Function of the first graft over a period exceeding 1 year gives a significantly better second graft survival rate than function lasting less than one year.

[Free intestinal grafts for oesophageal reconstruction: indications, technics and results]. / Die freie Transplantation von Darmsegmenten zum Osophagusersatz: Indikation, Technik und Ergebnisse.

Autotransplantation of intestinal segments for oesophageal reconstruction using microsurgical techniques has been reported in the literature in 137 patients. In 8 patients (5.8%) arterial thrombosis occurred, necessitating removal of the transplant in 6 patients (4.4%); two of them (1.5%) died of sepsis. Altogether 6 patients (4.4%) died postoperatively. Salivary fistulae are reported in 15 patients (10.9%) and these usually resolved spontaneously. This technique seems satisfactory for the reconstruction of oesophageal defects in patients with recurrent cancer in whom the classical procedures are no longer feasible.

[Effect of risk factors on early and long-term regional results following kidney transplantation]. / Der Einfluss von Risikofaktoren auf regionale Früh- und Langzeitergebnisse nach Nierentransplantation.

An observational study by multifactorial statistical analysis was undertaken on 785 kidney transplants. Risk factors in first transplants for primary non-function are cold ischaemic time, donor centre and acute rejection, with a non-function rate of 8% and a delayed function of 37%. Risk factors for transplant survival are bad match, no preoperative transfusions, age of recipient below 40 years, male sex, diabetes, conventional immunosuppressive therapy and cadaver donors. Donor centre and delayed primary function have no influence on long-term kidney function. The analysis revealed additive effects of various risk factors. This has to be taken into account in recipient-selecting policy.

[Liver transplantation--indications and postoperative course]. / Lebertransplantation--Indikation und postoperativer Verlauf.

54 liver transplantations on 53 patients are analysed. Tumor disease was found in 57%, cirrhotic liver disease in 43%. 9 patients had metastatic liver tumors after distal colon surgery. The fatal technical failure rate was 3%, the postoperative mortality for the first 3 month and for 1 year 40% and 52% respectively. Very often jaundice and rejection in the graft were found, independent from the crossmatch (pos. in 16%). There is only one child with 3 years. The main reason for postoperative death are lung and heart diseases, which were not diagnosed preoperatively in 10 patients. We conclude that the postoperative complication rate is to be lowered by applying rigorous selection criteria, raising the replantation rate and improving the donor organisation.

[The PTFE plastic prosthesis as an arterial replacement: experiences over a 5-year period]. / Die PTFE-Kunststoffprothese als arterieller Gefässersatz: Erfahrung über 5 Jahre.

Unilateral iliac femoral reconstructions with PTFE are yielding good results-similar to those with Dacron, with patency rates of 75, 67, and 65% at 1, 2 and 3 years, respectively (Kaplan-Meier). PTFE has additional advantages compared with other materials: a) no need of preclotting; b) smooth inner surface-easy thrombectomy in case of thrombosis and c) good handling characteristics. In view of the above-mentioned facts PTFE can be recommended without restriction for unilateral pelvic reconstructions. The functional early results of bilateral aorto-femoral Goretex-Y bifurcation grafts in 50 cases after 2 years are encouraging. Long-term results are still pending. Reports of other groups using this material as aorto-bifemoral substitute are not yet available. The functional results with PTFE for femoro-popliteal grafts are not satisfactory: 35% after 2.5 years. Extra-anatomical bypasses yielded 70% one-year functioning rate. Especially the ring-or spiral-armoured PTFE grafts seem to be suitable for these reconstruction procedures.

[Professional organ procurement as a prerequisite for attaining the necessary transplantation frequency: experiences with organ distribution at the transplantation center in Vienna]. / Professionelle Organgewinnung als Voraussetzung zum Erreichen der notwendigen Transplantationsfrequenz: Erfahrungen mit der Organspende am Transplantationszentrum Wien.

In the years 1965 to 1988 one or more organs were harvested for the purpose of transplantation from 649 brain dead organ donors reported to the Vienna transplantation centre. Based on a 1982 law regulating organ donation a large number of initiatives aiming at the improvement of the organ procurement system have taken place. In particular, the introduction of a decentralized donor guidance and organ retrieval system, a few information campaigns, as well as the introduction of full-time transplantation coordinators have significantly increased the number of organ donors. This development has made the Vienna transplantation centre one of the largest centres in Europe and has recently resulted in the achievement of a virtual balance between the increase of patients on the waiting list and the growth of the rate of transplantations performed. If this organ procurement policy is consistently continued in the years to come, there is a good chance of ensuring sufficient supply of organs for all patients on waiting lists, at least within the Viennese area.

[Problems arising in connection with surgical management of renovascular hypertension (author's transl)]. / Zur problematik der chirurgischen therapie der renovaskulären Hypertonie.

65 consecutive renal artery stenosis reconstructions for the treatment of severe renovascular hypertension are reported. 63% of the cases were males, 37% females. The disease was caused by arteriosclerosis in 66% of cases and in 23% by fibromuscular dysplasia or other pathological changes of the renal artery; the mean age was 47 in the former. and 31 years in the latter group. An aortorenal saphenous vein bypass was performed in 35% cases, a dacron graft was used in 29% and thrombendarteriectomy was carried out in 23% cases. Positive results were achieved in 68.8% of the patients. 63% of the females became normotensive. Operative mortality due to faulty technique was 4.9% initially. The operative mortality has been zero since 1973. nor have there been any therapeutic failures on a technical basis. No significant correlation was established between age of the patients and result of operation.

[Autologous venous bypass in the therapy of arterial occlusive disease of the femoropopliteal area: long-term results]. / Der autologe Venenbypass in der Therapie der arteriellen Verschlusskrankheit der femoro-poplitealen Etage: Langzeitresultate.

The outcome of 532 femoro-popliteal vein grafts performed electively during the years 1970 to 1985 for obliterative arterial disease, was analyzed using the documentation-system of the Austrian Society for Vascular Surgery, as well as SAS and BMDP-software on an IBM 4381 computer of the Medical Faculty. The probability of function was estimated according to the Kaplan-Meier method, statistical differences were checked with Breslow's and Mantel's test, the proportional hazards regression model (Cox) was used to elucidate the influence of different risk factors on each own and in combination of each other. In the univariate analysis, the preoperative clinical status was found to be of prognostic significance, but technical details such as intraoperative as well as postoperative arteriography or site of the distal anastomosis were not important. A postoperative coumarine treatment had no demonstrable impact on graft function, but positively influenced the probability of patient survival. Taking into account the factors found to be of significance in the univariate analysis (e.g. set of factors: site of distal anastomosis, diabetic state and smoking habits) were analyzed using the proportional hazards regression model but were found of no major influence. The factors preoperative clinical status, patients age, and coumarine therapy significantly influenced the probability of patient survival, but diabetes mellitus and smoking were found to be not important.

[Spontaneous rupture of renal allografts (author's transl)]. / Spontane Parenchymruptur allotransplantierter Nieren.

Spontaneous rupture of an allografted kidney is not such a rare complication of kidney transplantation. In our series 5.2% of the transplanted kidneys ruptured spontaneously. The condition is an acute emergency characterized by the triad, acute abdomen, swelling in the region of the transplant and haemorrhagic shock. The aetiology of transplant rupture seems to be multifactorial, but the superimposition of an acute rejection episode on ischaemic tubular damage with acute renal failure was found to be the most important combination of events leading to transplant rupture in our patients. Exceptionally precise immunological monitoring in the early phases following transplantation and early aggressive therapy of an acute rejection crisis associated with acute renal failure should prevent allograft rupture.

[Prolonged renal graft survival after repeated blood transfusions (author's transl)]. / Verlängerte Funktionsdauer von Nierentransplantaten nach Mehrfachtransfusionen.

In order to investigate the influence of pretransplant blood transfusions on renal graft survival, the results in 43 recipients with 10 or more transfusion (group A) were compared with those in 48 recipients with less than 10 or no transfusions (group B). In both groups cadaveric kidneys with mainly 3 or more mismatched histocompatibility antigens were transplanted. The incidence of preformed cytotoxic antibodies was similar in both groups (25.6% and 22.9%, respectively). The cumulative renal graft survival rate was significantly higher in the poly-transfused group: 85.6% +/- 6.1% and 73.4 +/- 7.9% after 1 and 2 years, respectively, in group A in comparison with 73.9 +/- 6.6% and 63.3 +/- 8.1% after 1 and 2 years respectively, in group B (Wilcoxon rank sum test: p less than 0.05). Severe renal rejection with a serum creatinine above 3 mg/100 ml was more frequently observed in group B than in group A. Enhancement due to blocking antibodies must be assumed as a possible explanation for the favourable effect of repeated pretransplant transfusions on graft survival rates.

[Renal transplantation in children (author's transl)]. / Nierentransplantation bei Kindern

During the past 2 years 7 children received kidneys from cadaveric donors. 2 transplants had to be removed because of irreversible chronic rejection and 1 recipient died on the 4th day after surgery. The remaining 4 recipients are doing well. In the evaluation of the results special emphasis is placed on the normalization of growth and puberty. The difficulties of psychosocial rehabilitation are stressed.

[Regional results of human liver transplantation in Vienna]. / Regionale Ergebnisse der humanen Lebertransplantation in Wien.

21 cases of transplantation of the liver are analysed for indication, anaesthesia, operative management, anhepatic period, immunological therapy and specific post-operative problems (jaundice and rejection episodes). Causes of death are noted and prediction of survival gives a rate of 55%/1st year in the 17 patients operated on since 1982 under a standardised management schedule. The transplantation programme in Vienna provides routine treatment for otherwise untreatable primary (57% cases) and secondary metastatic (14%) tumours of the liver, and, in the second place, for end-stage hepatic cirrhosis (14%) and certain rare liver diseases (14%).

[Measuring cyclosporin in immunosuppressive treatment following liver and heart transplantation]. / Die Messung von Cyclosporin in der immunsuppressiven Behandlung nach Leber- und Herztransplantation.

Selective suppression of the immune system in graft recipients is now achieved in most cases by treatment with cyclosporine A. Due to large individual differences in absorption, utilization and metabolisation of this drug, therapeutic blood levels (immunosuppression/toxicity) can be maintained only by frequent measurements of the cyclosporine concentrations in blood samples and dosage readjustments. In the present study, we measured cyclosporine in whole blood samples from 37 patients (23 liver and 14 heart transplant recipients) using an high pressure liquid chromatographic method for native cyclosporine A which has been developed in our laboratory and a radioimmunoassay method (cyclosporine A + metabolites). By comparison of the results of HPLC and RIA-measurements (n = 520) we found a relatively stable metabolization rate (RIA/HPLC-ratio) of 4.23 +/- 1.30 for heart transplant recipients. In contrast RIA/HPLC ratios were highly variable in liver graft recipients ranging from 1.3-9 for the same patient in the posttransplant period. The liver recipients could be classified into two groups according to their mean RIA/HPLC-ratios: for 11 patients we observed a mean ratio of 2.65 +/- 0.35, for another 12 patients one of 4.35 +/- 0.75. Lower metabolisation rates seem to be associated with low donor age. No direct correlation was found between changes in RIA/HPLC-ratios and liver function, rejection and infection periods. Rejection treatment with high doses of methylprednisolone had no systematic influence on cyclosporine metabolisation in our patients. Since cyclosporine metabolites, at least those ones which are most abundant, have less immunosuppressive and toxic effects we recommend measurements of cyclosporine blood concentrations with any HPLC-method specific for the unchanged drug.(ABSTRACT TRUNCATED AT 250 WORDS)

Aorto-Y-bifurcation graft: Dacron versus PTFE. Preliminary results of a randomized prospective study.

A randomized prospective study comparing PTFE-Y and Dacron-Y-grafts with regard to function rate, morphology, hemodynamic differences along the proximal anastomosis and body of the graft, complications and quality of material was performed. Between March 1983 and February 1987, 112 patients were admitted to the study. Randomization including the criteria of age, sex, indication to operation (chronic occlusive disease, aneurysm) run-off, diabetes, nicotine consumption and operative approach (transperitoneal, retroextraperitoneal) followed the methods of adaptive randomization developed by Pocock and Simon and was well balanced. Function rate and complications as well as morphological alterations showed no significant differences in either group. During a mean observation period of 24 months, Group I yielded a 97% and Group II a 95% function rate (Kaplan-Meier). In all patients but one in each group with limb graft occlusions (n = 5) function was regained by successful thrombectomy and profundaplasty. With respect to Doppler ultrasound differences in flow pattern, in four patients with enlarged proximal side-end anastomosis and adequate--not to large--incision is recommended performing the proximal anastomosis.

Early postoperative changes after desobliteration of the carotid artery. Subsequent diagnostic control using a high resolution ultrasonic-real-time-duplex-scanner.

The ultrasonic morphology of the carotid artery following 55 endarterectomies in 50 patients (36 males, 14 females, mean age 68 (53-83) years) was studied using a high resolution ultrasound duplex system (HUDS). The examinations were done 1-3 days before as well as 2-4 days and 1, 2, 4 and 8 weeks after surgery, respectively. The following typical appearance after carotid endarterectomy was found: At the site of endarterectomy the new vessel wall showed the following details: lack of the "sonographic tunica intima" the thickness of the vessel wall was reduced with less pronounced ultrasonic structure compared with healthy subjects the surface toward the lumen was less smooth "ultrasonic soft" thrombotic layers with irregular surface, individual distribution (sometimes only spots) and thickness (0.5 to 4.0 mm) were seen in the majority of patients. The edge of the tunica intima was always visible in the common carotid (edge of endarterectomy) whereas in the internal carotid artery there was often an interference of the jaw. The change of caliber at the site of the edge of the tunica intima was dependent on the thickness of the "sonographic intima" as well as on the layer of the vessel wall in which endarterectomy was done. At the site of arterial clamping, intramural hematomas, lesions of the tunica intima with thrombotic layers causing some stenosis were observed after 9 of 55 procedures. Vascular sutures were always visible as bright spots. A "normalization" of local flow patterns could be seen in dependence on the morphological "normalization".(ABSTRACT TRUNCATED AT 250 WORDS)