Aortoiliac aneurysm repair in kidney transplant recipients.

A potential problem during endovascular aortic aneurysm repair (EVAR) or open repair in renal allograft patients is ischemia of the transplanted kidney. In this study, kidney transplant patients who underwent aortic aneurysm repair in our institution were added to similar cases extracted from the literature to represent the basis of this work. Comparisons between patients treated with open surgery versus EVAR were performed in terms of renal function. In the EVAR group, most aneurysms were infrarenal, and 84% were treated with modular bifurcated devices. Protective kidney allograft perfusion measures were not used. The pre- and postoperative Cr was 1.69 and 1.73 mg/dL, respectively (P = .412). All EVAR patients had good outcomes. Complications included 8 endoleaks and 1 limb ischemia case. Three patients died from aortic repair-unrelated reasons. In the open group, the pre-and postoperative Cr was 1.45 and 1.37 mg/dL, respectively (P = .055). Most cases were infrarenal and mostly treated by aortobiiliac bypasses. In 16%, no adjuvant allograft perfusion was provided. In the rest, temporary axillofemoral bypasses were used most often. Most outcomes were favorable (57%). Reported procedural-related complications included arterial embolism, wound infection, and pneumonia. Deaths were reported in 5 occasions (none allograft failure dependent). No differences in Cr between EVAR and open techniques (P = .13) were seen. Aneurysm repair in kidney transplant recipients is associated with excellent renal preservation. Adverse outcomes were all allograft failure independent in both groups. EVAR without special allograft protection measures seems to be equally effective as open surgery with or without adjuvant kidney transplant perfusion.

Infected upper extremity aneurysms: a review.

OBJECTIVES: To review the occurrence of mycotic aneurysm affecting upper extremity arteries. DESIGN: Literature review. MATERIALS AND METHODS: A MEDLINE search from 1950 until 2007 and an extensive manual search were carried out using bibliographies from relevant published papers including cases involving arteries distal to the subclavian. RESULTS: A total of 149 cases (68 papers) were identified. The brachial artery was the most frequently reported site, mostly associated with drug abuse, catheterization procedures or endocarditis. Since 1950 arterial trauma (drug abuse or catheterization) was the commonest cause. Gram positive organisms were the most frequent microbes involved. Acknowledging a limited follow-up, most patients did well when surgical therapy was promptly instituted. CONCLUSIONS: Infected upper extremity aneurysms have been rarely described. IV drug abusers are a unique high-risk group for mycotic aneurysms in the upper extremities, most importantly in the axillary and brachial arteries. When rapidly performed, arterial ligation, primary repair or reconstruction with autogenous conduits was associated with favorable outcomes.

Portomesenteric reconstruction during Whipple procedures: review and report of a case.

A 60-year-old man undergoing a Whipple procedure to treat a pancreatic cancer was found to have tumor adherence to the portal vein. An en block pancreaticoduodenectomy with segmental portal vein resection (PVR) was performed. A primary portal vein anastomosis was initially attempted but failed. Hemodynamic deterioration led the authors to perform a temporary prosthetic portal vein interposition graft and abdominal closure. The following morning, once stable, the patient was brought back to the operating room for autologous reconstruction with femoral vein and completion of the pancreaticoduodenectomy. The role of PVR for vein invasion or tumor adherence during a Whipple procedure is still under debate. However, there is growing evidence that the perioperative morbidity and long-term survival in patients who undergo a pancreaticoduodenectomy with PVR are similar to those of patients without vein resection. Therefore a combined resection of the pancreatic head and the portal vein has been suggested in the absence of other contraindications for resection to be able to offer a curative surgical intervention to a larger number of patients. The authors herein report the details of a patient's case and also review the currently available methods for PVR and reconstruction.

Diabetic foot infections in the elderly: primary amputation versus 'foot-sparing surgery'. A case report.

Renal failure diabetic patients who present with lower extremity gangrene represent one of the most difficult problems encountered in a typical vascular practice. We report the hospital course and management of a 74-year-old male patient with such comorbidities, affected by a non healing ulcer that progressed into a large plantar abscess. Our case unfortunately mirrors a common method of evaluation and therapy of patients with such comorbidities and sets up the stage for a very controversial subject.

Aortitis and bacterial endocarditis.

Aortitis is an inflammatory condition that can be due to numerous causes. It is a diagnostic quandary because it commonly shows similar clinical, pathologic, and aortographic features independently of the etiology. A case of aortitis, possibly secondary to bacterial endocarditis, initially misdiagnosed as an atherosclerotic aortic ulcer and managed with an endoprosthesis is presented. On the fourth postoperative day, the patient presented with fever and worsening abdominal pain, which was later diagnosed as infectious aortitis. It required débridement and replacement of the infrarenal aorta with a cadaveric cryopreserved allograft. This case emphasizes the need for early diagnosis and aggressive therapy to avoid life-threatening sequelae.

Endovascular common iliac aneurysm exclusion with antegrade hypogastric artery flow preservation: a novel approach.

Open surgical repair of iliac aneurysms has been usually associated with significant morbidity and mortality. The introduction of novel endovascular techniques has expanded the currently available options to treat these aneurysms. However, the use of endoluminal stent grafts to treat common iliac artery aneurysms by landing their distal end into the hypogastric artery in patients where flow into the latter artery is crucial to avoid end-organ ischemia has only been rarely reported in the past. A case report of a common iliac aneurysm case treated with a novel therapeutic approach, not previously reported is herein presented. Three telescopically-overlapping Hemobahn/Viabahn polytetrafluoroethylene (PTFE)-covered endoprosthesis (W.L. Gore & Associates, Flagstaff, AZ) were used with success.

A novel hybrid approach to the treatment of common iliac aneurysms: antegrade endovascular hypogastric stent grafting and femorofemoral bypass grafting.

A progressively enlarging left common iliac artery aneurysm developed in a 72-year-old man 7 years after open abdominal aortic aneurysm repair with a bifurcated Dacron graft. Because both the right hypogastric and inferior mesenteric arteries had been ligated at the initial operation, preservation of left hypogastric flow was critical to avoid pelvic or intestinal ischemia. He was a poor open surgical candidate owing to obesity, a hostile abdomen, and multiple medical comorbidities. Therefore, a novel hybrid approach was used consisting of left transbrachial selective left hypogastric artery catheterization, followed by deployment of two, overlapping, antegrade, covered stent grafts extending from the proximal left graft limb into the left hypogastric artery. A right-to-left femorofemoral crossover bypass was added to perfuse the left lower extremity and was performed in end-to-end fashion to the left common femoral artery to exclude and prevent retrograde flow into the iliac aneurysm. Also presented are potential procedural pitfalls and a detailed review of open, endovascular and hybrid options to preserve hypogastric flow when treating iliac aneurysms in complex, high-risk patients.

Comparación de la calidad de vida entre médicos graduados en el Perú que migraron al extranjero y los que permanecieron en el país / Perceived quality of life comparison between medical graduates from Peru who migrated and those who stayed in their home country

Objetivo: Comparar la calidad de vida (CDV) de los egresados de una Escuela de Medicina peruana que migraron al extranjero y de los que permanecieron en el país. Material y método: Se utilizó un cuestionario basado en una combinación de dos herramientas para medir la CDV de proveedores de salud previamente validadas, para evaluar auto-satisfacción (grupo A), las relaciones interpersonales y sociales (grupo B) y los niveles de satisfacción personal (grupo C). Es cuestionario se envió por correo electrónico a los graduados de la Universidad Peruana Cayetano Heredia. Resultados: La tasa de respuesta fue 35%. Los niveles de ingreso económico fueron significativamente menores en los médicos que permanecieron en el Perú en comparación con los que migraron. En muy pocas preguntas se encontró diferencia significativa. En el grupo A, los médicos que migraron percibieron una CDV significativamente mayor solo en la expectativa de futuro. En el grupo B, esto se alcanzó diferencias sólo en el grado de apoyo y el nivel de conflicto entre colegas , y en el grupo C, en el nivel de información recibida acerca de los resultados de su trabajo (ôfeedbackõ), el esfuerzo físico del trabajo diario (estrés físico), las oportunidades de expresar lo que se piensa y necesita, el esfuerzo del hospital para mejorar la CDV de sus trabajadores, el entrenamiento necesario para realizar el trabajo diario, y la variedad en el trabajo. Los médicos que migraron percibieron una mayor aceptación en la profesión, en la sociedad en general y dentro de la comunidad donde viven. De manera significativa más médicos que migraron no tenían intenciones de cambiar sus niveles actuales de vida. Conclusiones: La CDV percibida de los médicos estudiados fue similar en la mayoría de preguntas examinadas entre ambos grupos, a pesar de la marcada diferencia encontrada en los niveles de ingreso económico.

Objective: To compare the quality of life (QOL) of the graduated from a Peruvian medical school who migrated abroad and those who remained in the country. We also intended to address the level of integration of Peruvian international medical graduates (IMGs) into the United States (US). Material and methods: A combination of two previously validated tools designed to measure QOL of health care practitioners (HCPs) was used to create a survey, including questions that analyzed self-satisfaction (group A), interpersonal/social relationships (Group B) and professional satisfaction (Group C), which was e-mailed to graduates from a Peruvian Medical School. Results: The response rate was 35%. Income levels were significantly lower for HCPs practicing in Peru than those practicing abroad. Very few question items reached statistical significant differences between groups. In group A, IMGs who migrated perceived a significantly higher QOL only in the perception of their future. In group B, was achieved only in the peer support and the conflict level with coworkerÆs categories. In group C, only in the work feedback, job physical discomfort, expression opportunities, hospital attempts to improve the QOL of their position, necessary training for job performance and work variety categories. However, of 41/44 items showed a better (more satisfied) response from the abroad group, of which 13 achieve statistical significance (8 at the 1% level). IMGs practicing abroad perceived a high acceptance into the foreign profession, society and living community. Significantly most IMGs do not intend to change their current status. Conclusions: Very few significant differences were noted in the perceived QOL of physicians between groups, in spite of a marked income discrepancy. However, there was a clear trend for dissatisfaction in the Peru group on several important items that, without reaching statistical significance, may indicate the adverse effect of Peruvian...