Editor's Choice - Ex vivo Renal Artery Repair with Kidney Autotransplantation for Renal Artery Branch Aneurysms: Long-term Results of Sixty-seven Procedures.

OBJECTIVE/BACKGROUND: To evaluate the long-term outcome of renal revascularization by ex vivo renal artery reconstruction and autotransplantation for renal artery branch aneurysms (RABAs). METHODS: Between 1991 and 2015, 67 ex vivo renal artery reconstructions with kidney autotransplantation were performed in 55 adults (mean age 47 years) and 10 children to repair 87 RABAs. The main underlying disease was fibromuscular dysplasia in 34 patients. Other etiologies were systemic congenital disease in eight patients, spontaneous dissecting aneurysms in five, iatrogenic aneurysms in three, atheromatous aneurysms in two and unknown etiology in 13. Median RABA diameter was 20.5 mm. Fifty-three patients (82%) were hypertensive, 60 had normal renal function and no patient was on hemodialysis. Seven patients (11%) were operated on after failure of an endovascular procedure. The mean number of renal artery branches repaired per patient was 3.5 and multiple aneurysms were treated in 14 patients (22%). The hypogastric artery was used in 41 patients, the saphenous vein in 18, the superficial femoral artery in five and a combination of different materials in three. RESULTS: No deaths occurred during the first 30 days. Primary patency at 30 days was 90.8% following to six early thromboses. Three patients (5%) were lost to follow up. No other thrombosis occurred. At 8 years, the primary and primary-assisted patency were 88% and 91%, respectively. Survival was 95% at 9 years. Among the 53 hypertensive patients, two were lost to follow up. At 9 years, 22 (43%) were cured and nine (18%) were improved with a significant reduction of antihypertensive medication (p < .05). The pre-operative modification of the diet in renal disease (MDRD) clearance was 93 ± 29 mL/minute, the immediate post-operative MDRD was 94 ± 33 mL/minute, and at the end of follow up it was 86 ± 26 mL/minute (p > .05). CONCLUSION: Ex vivo renal artery reconstruction for complex RABAs eliminates the risk of rupture, confers a benefit to hypertension, and preserves renal function with a satisfactory long-term patency.

Common hepatic artery as inflow in kidney transplantation.

Kidney transplantation originating from the hepatic artery has not previously been reported. Herein, we report a third kidney transplantation with the common hepatic artery as inflow. A 62-year-old male with chronic renal failure due to polycystic kidney disease was proposed to a third kidney transplantation. CT-scan showed diffuse calcification of the aorto-iliac axis and the splenic artery. The common hepatic artery was the only artery suitable for anastomosis and as such was chosen as the inflow for retransplantation. The operation was performed through a right subcostal laparotomy. A saphenous bypass was interposed between the common hepatic artery and the graft, then the renal vein was anastomosed to the suprarenal inferior vena cava. Duration of warm ischemia was 27 min. Postoperative course was complicated with delayed graft function of 17 days and pulmonary infection. Patient was discharged at day 30. With a follow-up of 40 months, serum creatinine level and eGFR are, respectively, 191 µmol/L and 32 mL/min. Hepato-renal bypass technique can be used in kidney retransplantation when patient anatomy is not compatible with other classical options.

Computational prediction of proximal sealing in endovascular abdominal aortic aneurysm repair with unfavorable necks.

BACKGROUND AND OBJECTIVE: Endovascular aortic aneurysm repair (EVAR) has become the standard treatment for abdominal aortic aneurysms in most centers. However, proximal sealing complications leading to endoleaks and migrations sometimes occur, particularly in unfavorable aortic anatomies and are strongly dependent on biomechanical interactions between the aortic wall and the endograft. The objective of the present work is to develop and validate a computational patient-specific model that can accurately predict these complications. METHODS: Based on pre-operative CT-scans, we developed finite element models of the aorta of 10 patients who underwent endovascular aortic aneurysm repair, 7 with standard morphologies and 3 with unfavorable anatomies. We simulated the deployment of stent grafts in each aorta by solving mechanical equilibrium with a virtual shell method. Eventually we compared the actual stent ring positions from post-operative computed-tomography-scans with the predicted simulated positions. RESULTS: A successful deployment simulation could be performed for each patient. Relative radial, transverse and longitudinal deviations were 6.3 ± 4.4%, 2.5 ± 0.9 mm and 1.4 ± 1.1 mm, respectively. CONCLUSIONS: The numerical model predicted accurately stent-graft positions in the aortic neck of 10 patients, even in complex anatomies. This shows the potential of computer simulation to anticipate possible proximal endoleak complications before EVAR interventions.

Early and late results of ex vivo repair and autotransplantation in solitary kidneys.

INTRODUCTION: Autotransplantation of a solitary kidney provides an excellent opportunity to study the immediate and long-term consequences of intra-operative renal ischaemia. The purpose of this report is to describe a series of nine patients who underwent ex vivo repair and autotransplantation on solitary kidneys. PATIENTS AND METHODS: The series included six females and three males with a mean age of 36 years. Seven of the nine patients were hypertensive (mean number of anti-hypertensive agents: 3). Two patients had chronic renal failure (serum creatinine levels: 192 and 205 µmol l(-1)). All arteries except one with Takayasu disease were affected by dysplastic aneurysm or fibrodysplasia lesion. There was no atherosclerotic lesion. The mean number of renal artery branches repaired was 3.1 per patient. Mean duration of ischaemia was 161 min. RESULTS: Creatinaemia increased in all patients following the procedure. Creatinaemia and clearance returned to preoperative values between the 3rd and 10th postoperative days. One kidney was lost due to renal vein thrombosis. Late findings indicated that renal function was stable and there was no deterioration in the function of the autotransplanted kidneys after a follow-up period of 89 months. Preoperative versus postoperative creatinaemia and clearance levels were respectively 111 vs. 105 µmol l(-1) and 66.9 vs. 62.0 ml min(-1) (ns). During the same time, the mean number of anti-hypertensive agents decreased slightly from 3 to 2.5. CONCLUSION: In this small series of patients who underwent ex vivo repair and autotransplantation on solitary kidneys, intra-operative renal ischaemia had no detrimental effect on renal function.

Predictive Numerical Simulations of Double Branch Stent-Graft Deployment in an Aortic Arch Aneurysm.

Total endovascular repair of the aortic arch represents a promising option for patients ineligible to open surgery. Custom-made design of stent-grafts (SG), such as the Terumo Aortic® RelayBranch device (DB), requires complex preoperative measures. Accurate SG deployment is required to avoid intraoperative or postoperative complications, which is extremely challenging in the aortic arch. In that context, our aim is to develop a computational tool able to predict SG deployment in such highly complex situations. A patient-specific case is performed with complete deployment of the DB and its bridging stents in an aneurysmal aortic arch. Deviations of our simulation predictions from actual stent positions are estimated based on post-operative scan and a sensitivity analysis is performed to assess the effects of material parameters. Results show a very good agreement between simulations and post-operative scan, with especially a torsion effect, which is successfully reproduced by our simulation. Relative diameter, transverse and longitudinal deviations are of 3.2 ± 4.0%, 2.6 ± 2.9 mm and 5.2 ± 3.5 mm respectively. Our numerical simulations show their ability to successfully predict the DB deployment in complex anatomy. The results emphasize the potential of computational simulations to assist practitioners in planning and performing complex and secure interventions.

B-type natriuretic peptide, a marker of asymptomatic left ventricular dysfunction in type 2 diabetic patients.

AIM: To evaluate BNP in assessing LV functions in asymptomatic type 2 diabetic patients. METHODS: BNP was measured in 91 consecutive patients with type 2 diabetes mellitus. According to Doppler echocardiography, patients were first separated into three categories: normal LV function, or isolated diastolic or systolic LV dysfunction. As some patients with diastolic dysfunction were treated for hypertension, the population was divided into four groups: groups 1, 2 and 3 all had no antihypertensive treatment, and had normal LV function, and isolated diastolic and systolic LV dysfunction, respectively; and group 4 were being treated with antihypertensive drugs and had diastolic LV dysfunction. RESULTS: In group 1, BNP levels (13+/-2 ng/L) were lower than in group 2 (87+/-20 ng/L, P<0.0001) or group 3 (213+/-32 ng/L, P<0.0001), but were similar to those of group 4 (32+/-6 ng/L, P=0.14). ROC analysis revealed a rule-out value of 23 ng/L for group 1 versus group 2, and of 239 ng/L for group 2 versus group 3. In groups 1, 2 and 3 taken together, BNP levels were correlated with urinary albumin excretion rate (r=0.80, P<0.0001) and pulse pressure (r=0.65, P<0.0001). In group 4, patients receiving ACE inhibitors had lower BNP levels than those receiving ss-blockers. CONCLUSION: BNP can be used to pre-screen asymptomatic type 2 diabetic patients with LV dysfunction, and may reveal vascular remodelling in type 2 diabetes mellitus.

Model reduction methodology for computational simulations of endovascular repair.

Endovascular aneurysm repair (EVAR) is a current alternative treatment for thoracic and abdominal aortic aneurysms, but is still sometimes compromised by possible complications such as device migration or endoleaks. In order to assist clinicians in preventing these complications, finite element analysis (FEA) is a promising tool. However, the strong material and geometrical nonlinearities added to the complex multiple contacts result in costly finite-element models. To reduce this computational cost, we establish here an alternative and systematic methodology to simplify the computational simulations of stent-grafts (SG) based on FEA. The model reduction methodology relies on equivalent shell models with appropriate geometrical and mechanical parameters. It simplifies significantly the contact interactions but still shows very good agreement with a complete reference finite-element model. Finally, the computational time for EVAR simulations is reduced of a factor 6-10. An application is shown for the deployment of a SG during thoracic endovascular repair, showing that the developed methodology is both effective and accurate to determine the final position of the deployed SG inside the aneurysm.

Effect of cerivastatin on peripheral capillary permeability to albumin and peripheral nerve function in diabetic rats.

OBJECTIVE: To examine the effect of cerivastatin on capillary permeability to albumin and peripheral nerve function in diabetic rats. ANIMALS: Diabetes was induced in male Wistar rats by i.p. injection of streptozotocin (STZ) at the age of 5 days. Forty diabetic rats were randomized in two groups: one treated by cerivastatin (diabetic treated group, DT) and the other untreated (diabetic untreated group, DU). The data were compared to a group of normal rats. MEASUREMENTS: The peripheral capillary filtration of albumin (CFA) was studied on a limb by a non-invasive isotopic method, and nerve electrophysiological measurements were performed. Rats were followed-up until 6 months. In group DU albumin retention (AR) increased by 3 months and lymphatic uptake of interstitial albumin was impaired at 6 months. None of these disorders was observed in group DT. Motor and sensory nerve conduction velocities (MNCV and SNCV) were significantly slower at 6 months in group DU but not in group DT as compared to control rats. The duration of the sensory nerve action potential (SNAP) was significantly longer in group DU than in control rats at 6 months whereas it did not differ in group DT and in control animals. CONCLUSIONS: This study shows that cerivastatin may prevent the peripheral increase in CFA and lymphatic dysfunction induced by diabetes. These beneficial effects on microcirculation may be involved in the prevention of nerve function deterioration. The underlying mechanisms are likely to be independent of a lipid-lowering effect, but their clarification needs further investigations.

Endovascular repair of abdominal aortic aneurysms in patients with severe angulation of the proximal neck using a flexible stent-graft: European Multicenter Experience.

AIM: The aim of this paper was to report the results of a multicenter study on endovascular repair of abdominal aortic aneurysms (AAA) in patients with important angulation of proximal neck using a flexible stent-graft (Aorfix). METHODS: Endovascular repair of AAA using a flexible stent-graft was performed at 16 centers in 29 patients with angulation of proximal neck greater than 45 degrees. Twenty-three patients (79%) had angulation greater than 60 degrees and were therefore contraindicated for repair with other contemporary devices. RESULTS: Technical success was achieved in all but one case (96%). There was one postoperative death due to multiorgan failure following revision of groin wound for hemorrhage. No patients were converted to open repair. One patient had persisting proximal endoleak despite placement of proximal extension. One patient in whom wireform fractures had been detected died from ruptured aneurysm at nearly 4 year follow-up. CONCLUSION: Endovascular repair using a flexible stent-graft is feasible in patients with highly angulated necks. This stent-graft allows the possibility of a to offer repair for patients un-suitable for the currently available commercial grafts. Mid-term results are acceptable and need to be confirmed by longer follow-up and larger series.

[Carotid endarterectomy: current indications]. / Chirurgie carotide conventionnelle: mise au point des indications.

Indications for carotid endarterectomy have been clarified after the publication of European and North American randomised controlled trials between 1990 and 2004. Recent analysis of pooled data concerning symptomatic carotid stenosis has enhanced the initial results. Surgery in complement to best medical treatment is indicated for stenosis equal or superior to 70% (American calculation of degree of stenosis), especially if the patient is a man, older then 75 years, during the first 2 weeks after the initial neurological event. Benefit of surgery for stenosis between 50 and 69% appears only after 2 years. Surgery is also beneficial for asymptomatic severe stenosis but the precise threshold of carotid stenosis remains unclear. The benefit is lower for women and would be greater in case of stenosis more than 70%, and for patients less than 75 years.

Soluble L-selectin level is a marker for coronary artery disease in type 2 diabetic patients.

OBJECTIVE: To investigate whether the fall in soluble L-selectin (sL-selectin) level constitutes a marker for myocardial ischemia. RESEARCH DESIGN AND METHODS: The levels of soluble forms of adhesion molecules, i.e., intercellular adhesion molecule-1 (sICAM-1), vascular cell adhesion molecule-1 (sVCAM-1), E-selectin (sE-selectin), P-selectin (sP-selectin), and L-selectin (sL-selectin), were compared in type 2 diabetic patients without inflammatory syndrome but with symptomatic coronary artery disease (CAD) (group 1, n = 11), with silent ischemic disorders and proven coronary stenoses (group 2, n = 11), with silent myocardial ischemia (SMI) and normal coronary angiography (group 3, n = 10), and without proven SMI (group 4, n = 13). These levels were compared with those of 22 control subjects. RESULTS: The sL-selectin level was significantly lower in groups 1, 2, or 3 with symptomatic CAD or with SMI as compared with the control group (P = 0.0004). Group 4 without myocardial ischemia did not significantly differ from the control subjects (P = 0.6). In type 2 diabetic patients, after controlling for HbA1c, a partial correlation between sL-selectin and the CAD status was significant (P = 0.001). sICAM-1 and sP- or sE-selectin did not differ significantly between type 2 diabetic patients and control subjects or among the different groups of patients. The sVCAM-1 level in type 2 diabetic patients was significantly higher than in the control subjects (P = 0.001), but there were no significant intergroup differences (P = 0.4). CONCLUSIONS: In type 2 diabetic patients, sVCAM-1 is increased with regard to glycemic control, whatever the CAD status. In type 2 diabetic patients with symptomatic CAD or SMI associated with coronary stenoses, sL-selectin is significantly decreased. A marked fall in sL-selectin might constitute a marker for silent CAD in type 2 diabetic patients.

Elevated concentrations of soluble E-selectin and vascular cell adhesion molecule-1 in NIDDM. Effect of intensive insulin treatment.

OBJECTIVE: To evaluate the effects of a 14-day intensive insulin therapy and short-term improvement of glycemic control on serum levels of soluble forms of adhesion molecules, i.e., intercellular adhesion molecule-1 (sICAM-1), vascular cell adhesion molecule-1 (sVCAM-1), and E-selectin (sE-selectin) in NIDDM patients with poor glycemic control. RESEARCH DESIGN AND METHODS: A total of 16 NIDDM patients were compared with 23 healthy subjects (control group) and investigated before and after intensive insulin treatment. RESULTS: On day 0, sE-selectin and sVCAM-1 levels were significantly higher in NIDDM patients than in nondiabetic control subjects (median 87, range 63-115; median 544, range 408-797 vs. 58, 43-80; 443, 395-573 ng/ml, respectively) (P < 0.008 in both cases). On day 15, the fall in sE-selectin levels was significant (P < 0.0001) and at a lesser extent in sVCAM-1 levels (64, 48-85; 506, 417-678 ng/ml, respectively); these levels reached values that no longer differed from those of control subjects (P = 0.23 and 0.15, respectively). Moreover, the fall in sE-selectin was positively associated with the change in LDL cholesterol and the improvement of glycemia. CONCLUSIONS: In poorly controlled NIDDM patients, sE-selectin levels are increased and significantly fall to normal after short-term improvement of glycemic control. This suggests that assaying sE-selectin makes it possible to detect endothelium activation and to follow its reversal with euglycemia.

Preoperative prediction of postoperative respiratory outcome. Coronary artery bypass grafting.

OBJECTIVE: The hypothesis that traditionally defined preoperative risk factors predict prolonged mechanical ventilation after coronary artery bypass graft surgery (CABG) was tested in our cohort. The predictive power of these factors was quantified, and specific patient subsets destined for prolonged mechanical ventilation after CABG surgery were defined. DESIGN: Five hundred thirteen consecutive patients undergoing CABG were prospectively evaluated. Preoperative pulmonary evaluation included clinical historic data, standard spirometry, and arterial blood gas. Preoperative cardiac parameters included clinical parameters and left ventricular function assessment. Nonthoracic organ (renal, endocrine, pancreas, liver) function was assessed. SETTING: University-based, tertiary referral center. INTERVENTIONS: None (observational only). OUTCOMES MEASURED: Duration of mechanical ventilation, duration of surgical ICU stay, and mortality. RESULTS: Multivariate regression analyses revealed that for the patient undergoing routine elective surgery and the patient undergoing urgent surgery, prolonged mechanical ventilation and death were rare events (8.3% and 2.0%, respectively). The combination of reduced left ventricular ejection fraction and the presence of selected preexisting comorbid conditions (clinical congestive heart failure, angina, current smoking, diabetes) served as modest risk factors for prolonged mechanical ventilation; their absence strongly predicted an uncomplicated postoperative respiratory course. No pulmonary diagnosis, mechanical lung function, or blood gas parameter substantially contributed to predicting adverse outcome. Classification and regression tree subgroup analysis refined specific factors important in specific subgroups. CONCLUSION: With the exception of left ventricular ejection fraction, no preoperative factors emerge as good predictors across all subgroups. This series suggests that pulmonary diagnosis, lung mechanics, and blood gas parameters do not offer the clinician global rules in predicting postoperative respiratory outcome, nor should they be used as exclusion crteria for CABG surgery.

Adenocarcinoma in a continent colonic urinary reservoir.

We report the first case of an adenocarcinoma developing in a continent ileocolonic urinary reservoir. The tumor presented 7 years after the urinary diversion and more than 6 years after the resection of a Dukes' B lesion of the left colon. This report demonstrates that the colonic segment used for urinary diversion retains its malignant potential and that surveillance pouchoscopy should be performed in these patients.

Ulcerative sarcoidosis. Case report and review of the literature.

BACKGROUND: Sarcoidosis is a chronic granulomatous multisystem disease of unknown origin. Cutaneous manifestations are common but ulcerative skin lesions rarely occur. We report a case of generalized ulcerative sarcoidosis in a patient with fatal multisystem involvement. A review of the literature revealed only 34 other cases of ulcerative sarcoidosis, 5 of which were generalized. We reviewed the clinicopathologic spectrum of the disease and available treatment options. OBSERVATIONS: Ulcerative sarcoidosis affects women (23 of 35 cases) and blacks (18 of 30 cases) most commonly and occurs in young adulthood. Cutaneous sarcoid lesions, including ulcers (11 of 26 cases), were the presenting complaint in 26 of 35 cases. Ulcers developed both de novo and within other sarcoid lesions. The lower extremities were most often involved (29 of 35 cases). A histological diagnosis was made using skin biopsy specimens in all cases. Corticosteroid therapy seems most effective for treatment of ulcerative sarcoidosis, with methotrexate a proven alternative for refractory cases. CONCLUSIONS: Dermatologists most often make the initial diagnosis of sarcoidosis in patients with ulcerative lesions. In the proper clinical setting, a skin biopsy of ulcerative lesions establishes the diagnosis and prompt treatment reduces morbidity.

Accurate Nodal Staging of Malignant Melanoma.

The incidence of malignant melanoma is increasing at a faster pace than that of any other cancer in the United States. It is estimated that people born in the year 2000 will have a 1:75 risk of developing melanoma sometime during his or her lifetime. Stimulated by novel lymphatic mapping techniques, the surgical care of the melanoma patient is evolving toward more conservative resections that can provide the same staging information but without the added morbidity of more radical surgeries. This approach promises to yield positive results in the age of health care reform, outcome measurements, and cost:benefit considerations.

Formation of copper-bleomycin complexes: evidence of a three-step process.

The formation of Cu(II)-bleomycin complexes as a function of pH has been studied using circular dichroism, absorption, electron paramagnetic resonance spectroscopy, and potentiometric titration. Our data support the following points: the formation of Cu(II)-bleomycin complexes occurs in a three-step process: a first complex (I) is formed at pH 1.2, which most probably involves the pyrimidine nitrogen, the secondary amine nitrogen, and two water molecules as the four in-plane ligands of copper. A second complex (II) is formed at pH 2.5, through the further coordination of the peptide nitrogen of histidine residue, and histidine imidazole nitrogen giving rise to the release of two protons. The fixation, in apical position, of the alpha-amino nitrogen of beta-aminoalanine occurs in a last step through the release of one additional proton. A value of 2.7 has been obtained for the pK of formation of this third complex, which is the species present at physiological pH. In the Cu(II)-depbleomycin system only one complex (II') has been detected.

Multiple valve replacement increases the risk of reoperation for structural degeneration of bioprostheses.

BACKGROUND AND AIM OF THE STUDY: The study aim was to analyze the results of reoperations for structural degeneration of bioprostheses, and to define a high-risk population for reoperative procedures. METHODS: A series of 524 consecutive patients who had undergone a first reoperative replacement for a failed bioprosthesis between 1978 and 1998 was reviewed retrospectively. The reoperative procedure comprised 363 single valve replacements, and 161 multiple valve replacements. During the original procedure, 648 bioprostheses had been implanted in the mitral (n = 403), aortic (n = 220) and tricuspid (n = 25) positions. RESULTS: The mean interval between the original procedure and reoperation was 8.8 +/- 3.3 years. Tissue valve failure was revealed by recurrence of cardiac insufficiency in 70% of cases. The overall early mortality rate was 8%, but early mortality rates for elective single mitral and aortic reoperative valve replacements were only 3.9% and 4%, respectively. Early mortality following reoperation for single and multiple valve replacement was 6.0% and 12.4% respectively (p = 0.02). Other significant multivariable predictors for early mortality were old age (p = 0.003), NYHA functional class (p = 0.007), presence of ascites (p = 0.02) and reoperation performed before 1988 (p = 0.013). CONCLUSIONS: The risk of reoperation for structural degeneration of bioprostheses is acceptable for elective single reoperative valve replacement as opposed to multiple reoperative valve replacement. This may limit the use of bioprostheses during the original procedure when multiple valve replacement is required.

Laparoscopic nephrectomy using the harmonic scalpel.

Laparoscopic nephrectomy is gaining popularity. Improved instrumentation is making surgery easier with fewer complications. Our first three laparoscopic nephrectomies using the Harmonic Scalpel were performed on two women and one man. The surgical indications were nonfunctioning kidneys (two left, one right) with hypertension in one patient and stone disease in two. The three patients had a mean age of 46.3 years. The average hospital stay was 4 days, the average operative time 3.7 hours, and the average blood loss 160 mL. No complications occurred. Patients resumed oral intake within 8 hours postoperatively. We found the Harmonic Scalpel easy and safe to use. It saved time, was cost effective, and was capable of easily controlling small-vessel bleeding. In conclusion, the Harmonic Scalpel could be used effectively for both dissection and bleeding control without suction or other instrumentation.