Technical problems in living donor transplantation

Inferior outcomes are generally described with grafts having multiple arteries or renovascular disease. A consecutive series of 261 living donor (LD) transplants performed in the CsA era was classified in three groups with regard to the graft arterial abnormalities and the techniques employed for revascularization. Two hundred eleven recipients had a kidney with one "healthy" renal artery (Group I); 11 patients, multiple arteries, which were reconstructed by various intracorporeal techniques (Group II); 39 patients, one diseased renal artery or multiple arteries, which were reconstructed on the bench (Group III). One- and 3-year graft survivals not censored for death, were 91%, 82%, 100% and 87%, 82%, 100%, respectively, for Group I, Group II, and Group III. An aggressive policy in performing microsurgical bench reconstruction, also for kidneys with one artery that are affected by intrinsic disease, allowed us to obtain a 3-year graft survival of 100% in our more recent consecutive series of 53 LD transplants.     

Cell seeded decellularised allogeneic matrix grafts and biodegradable polydioxanone-prostheses compared with arterial autografts in a porcine model.

BACKGROUND: small diameter vascular grafts are limited by their restricted availability, early thrombosis, and requirement for anticoagulants. OBJECTIVE: to evaluate different approaches to biocompatible vascular grafts. METHODS: sixteen allogeneic acellularised arteries seeded with autologous endothelial cells were implanted to replace a segment of the common carotid artery (group I). Other animals received polydioxanone prostheses (group II: inner diameter, i.d. 4 mm, n=18; group III, i.d. 5 mm, n=20) or arterial autografts (group IV, n=8). Graft patency was evaluated by means of ultrasound duplex scanning, angiography and histology. RESULTS: patency was 54% (71%), 17% (0%), 50% (50%), and 100% (100%) in group I, II, III, and IV after 1 week (4 months), respectively. Significant differences (p<0.05) were found for group IV versus all other groups at 1 week, as well as for group IV versus groups II and III, for group II versus III, and group I versus II at 4 months. CONCLUSION: small diameter vascular grafts can be engineered from an acellular allogeneic matrix seeded with autologous cells. Patency is superior to polydioxanone prostheses but inferior to the arterial autograft.     

Advantage in using living donors with aberrant hepatic artery for partial liver graft arterialization

BACKGROUND: In living-related partial liver transplantation, the feasibility and safety of using left-sided liver grafts from donors with aberrant hepatic arteries remains to be evaluated. METHODS: Between 1996 and 2000, we harvested left-sided liver grafts from 101 living donors. Hepatic arterial variation in the donors was classified into three types: type I (n=69), normal anatomy; type II (n=24), aberrant left hepatic artery arising from the left gastric artery; and type III (n=8), replaced right hepatic artery arising from the superior mesenteric artery. We performed arterial reconstructions using the donor's left hepatic artery in 70 cases (69 in type I, 1 in type II), an aberrant left hepatic artery in 24 cases (23 in type II, 1 in type III), and the common hepatic artery in 7 cases (all in type III). RESULTS: The diameter and length of the anastomosed hepatic artery were larger (2.5+/-0.7 vs. 2.0+/-0.8 mm, P=0.03) and longer (42.0+/-14.7 vs. 9.0+/-7.3 mm, P<0.0001) in cases in which the aberrant left hepatic artery or common hepatic artery was used for the anastomosis (n=31) than in those using the left hepatic artery (n=70). Hepatic arterial occlusion occurred in nine patients, with the incidence of occlusion tending to be lower in the former cases in which aberrant left or common hepatic arteries were used (3.2% vs. 11.4% for the left hepatic artery group, P=0.15). CONCLUSION: Because thicker and longer arterial branches can be obtained in left-sided liver grafts with aberrant hepatic arteries than in grafts with normal left hepatic arteries, their use is advantageous for safe arterialization in partial liver grafts.     

Successful renovascular reconstruction for renal allografts with multiple renal arteries

BACKGROUND: Kidney grafts with multiple renal arteries have been considered a relative contraindication because of the increased risk of complications. In the present study, we retrospectively reviewed multiple renal artery reconstruction in kidney transplantation to elucidate the usefulness of these grafts. METHODS: From January 1997 until August 2001, 431 recipients underwent kidney transplantation at our institution; 393 patients are reviewed. The surgical techniques of vascular reconstruction and short-term outcome are reported. The living kidney transplant recipients were divided into vascular reconstructed and nonreconstructed groups, and mean serum creatine levels, warm and total ischemic times, and incidences of acute rejection and posttransplantation hypertension were compared. RESULTS: We noted multiple renal arteries in 96 (24.4%) of the 393 grafts. Arterial reconstruction was performed on 53 (13.5%) grafts, whereas 43 (10.9%) small polar arteries were simply ligated. Surgical management of the multiple arteries was variable. The most common reconstruction was conjoined anastomosis (17 cases) between two arteries of equal size and end-to-side anastomosis (14 cases) of smaller arteries to larger arteries. In nine cases, autogenous hypogastric or epigastric artery grafts were used to reconstruct multiple renal arteries. Multiple anastomosis was performed in six cases. In seven cases, complicated surgical vascular reconstruction was performed. The mean total ischemic times in the reconstructed and nonreconstructed groups were 102.6 and 71.0 min, respectively (P<0.01). The incidences of posttransplantation hypertension in the reconstructed and nonreconstructed groups were 68.2% (30/44) and 48.6% (141/290), respectively (P<0.05). There was no significant difference between the reconstructed and nonreconstructed groups in mean warm ischemic times, mean creatinine levels, and incidences of acute rejection. CONCLUSIONS: Allografts with multiple renal arteries can be used successfully in kidney transplantation.     

Histologic, morphometric, and biochemical evolution of vein bypass grafts in a nonhuman primate model. III. Long-term changes and their modification by platelet inhibition with aspirin and dipyridamole

The objectives of this study were to elucidate the long-term influence on vein bypass grafts of platelet inhibition and its late discontinuation. Cephalic vein grafts were interposed bilaterally in the femoral arteries of stump-tailed macaque monkeys fed a diet that sustains plasma cholesterol levels of approximately 225 mg/dl. Fifteen animals were divided into three groups of five animals each. Group I received no medications and served as a control group. Group II received for the full duration of the study a combination of aspirin, 80 mg/day, and dipyridamole, 50 mg/day. Group III received the same regimen of platelet inhibition as in group II during the first 9 months, but were not treated during the subsequent 9-month interval. Grafts were excised for analysis from groups I and II at both 9 and 18 months and from group III at 18 months. Cholesterol content in group I grafts was 470 +/- 89 micrograms/100 mg at 9 months and 388 +/- 127 micrograms/100 mg at 18 months. In group II grafts, cholesterol content was 208 +/- 72 micrograms/100 mg at 9 months (p less than 0.001 compared with group I) and 266 +/- 84 micrograms/100 mg at 18 months. In group III grafts, cholesterol content was 249 +/- 71 micrograms/100 mg at 18 months. Differences in cholesterol content among the three groups of grafts at 18 months were not found to be statistically significant. Stepwise regression analysis at 18 months showed that cholesterol content was best predicted by medial fibrosis (r2 = 0.66) followed by abundance of foam cells (increase in r2 = 0.26) in group I, by fibrin in group II (r2 = 0.63), and by prevalence of macrophages in group III (r2 = 0.74). In all groups, platelets, fibrin, and polymorphonuclear leukocytes were less abundant than they had been at 3 months. Cross-sectional area occupied by the intima was not influenced by platelet inhibition.     

Sequential anastomosis of accessory renal artery to inferior epigastric artery in the management of multiple arteries in live related renal transplantation: a critical appraisal

In live related renal transplant program, management of multiple renal arteries (MRA) is technically demanding and used to be considered a relative contraindication because of increased risk of vascular and urologic complications. We present a retrospective analysis of the outcome of grafts with MRA and suggest certain guidelines. Of the 680 live related kidney transplantations done, 53 allografts had MRA. Cases were grouped according to the reconstruction technique: group A, MRA reconstructed ex vivo into a single renal artery (n=27); group B, MRA with multiple anastomoses in vivo (n =13); group C, MRA with sequential revascularization using inferior epigastric artery (n=11). We compared serum creatinine, acute tubular necrosis, rejection rates and the rewarm ischemia time between the three groups. Overall patient survival and graft survival were excellent (100 and 96%). Mean serum creatinine at 1 yr did not differ significantly between the three groups. Rewarm ischemia time was significantly less in group C (p<0.01). Incidence of acute tubular necrosis and rejection episodes was also less in group C although the difference was statistically significant only between group C and group B. We conclude that allografts with MRA can be used successfully in a live related renal transplantation program. Bench reconstruction should be done whenever possible. For reconstruction of an accessory vessel, inferior epigastric artery with sequential revascularization is recommended.     

Cadaver kidney transplantation and vascular anomalies: a pediatric experience

BACKGROUND: The incidence of donor kidneys with vascular anomalies ranges from 18% to 30%; such kidneys are usually at increased risk of vascular and urological complications. The aim of this study was to determine whether the use of cadaver kidneys with vascular anomalies would adversely affect posttransplant graft and patient outcome. METHODS: From October 1987 to January 2004, 241 patients underwent kidney transplantation in our pediatric surgery department. Vascular anomalies were noted in 77/241 grafts (31.9%); 50 (64.9%) had multiple renal arteries and 22 (28.5%) venous anomalies. Patients were divided into three groups: Group A (1 renal artery and vein, 1 arterial and venous anastomosis [n = 161]), Group B (> 1 renal artery or vein, 1 arterial and venous anastomosis [n = 33]), and Group C (> 1 renal artery or vein, > 1 arterial and venous anastomosis [n = 47]). We compared the three groups for: patient and graft survival, incidence of posttransplant acute tubular necrosis, vascular and urological complications, postoperative mean creatinine levels, and posttransplantation hypertension. RESULTS: We found no significant differences among the three groups regarding episodes of acute rejection or acute tubular necrosis. Creatinine levels reached normal levels within 30 days in all the groups without any significant differences. Furthermore, patient and graft survival were excellent (100% and 97%). CONCLUSIONS: The presence of vascular anomalies and their multiple or complex repair does not represent a theoretical disadvantage even in pediatric patients. In order to maximize the quantity and quality of donor kidneys especially in pediatric population, kidneys with vascular anomalies may be implanted with very little risk.     

Pathological study of rabbits＇ femoral arteries subjected to gunshot wounds combining with seawater immersion

To investigate pathological characteristics of gunshot wounds concomitant seawater immersion in rabbits‘ femoral arteries. Methods: Thirty rabbits were divided randomly into 3 groups: simple gunshot-wound group (Group Ⅰ, n = 10), gunshot wound with seawater immersion for 30 mins (Group Ⅱ, n = 10), and 60 mins group (Group Ⅲ, n =10). Femoral arteries were impacted by 0.38 g steel spheres fired with a 7.62 mm rifle. After being wounded, rabbits in Groups Ⅱ and Ⅲ were immersed in seawater for 30 or 60 mins, but those in Group I were not. At 2, 4, 6, 8, 12 hours following injury, a 40 mm segment of the artery on each side of the gunshot point were excised and observed by light and electron microscopy. Results : The potterns of arterial injuries were mainly contusion and transection. Completely transected artery was classified as primary-wound-tract area, contused area and shocked area. Compared with those in Group Ⅰ, the primary-wound-tract and contused areas in Group Ⅱ manifested obvious swelling in the arterial wall especially at the outside 2/3 of the media. Vacuolar structures were often seen in smooth muscle cells of the media. Intercellular space among the smooth muscle cells were filled with homogeneous acidophilic substances. Deep rugae among endothelial cells flattened or rugal folds lost their longitudinal orientation, and marked fibrin and platelet deposition were noticed. No significant difference was detected between Group Ⅱ and Ⅲ. The pathological changes in the shocked area were similar in 3 groups. Conclusions : For gunshot wounds concomitant seawater immersion in rabbits‘ femoral arteries, there was a marked swelling of cells and intercellular space in primary-wound-tract area and contusion area. The influence of these pathological changes on surgical reparation deservers further study.     

Pathological study of rabbits' femoral arteries subjected to gunshot wounds combining with seawater immersion

I tisestimatedthattheoccurrenceoffirearminjurytogreatarteriesofthelimbsaverages0.07% 2.4%ofallwarinjuries.1Theoccurrenceissimilarinseaorgroundwarfare.2Inseawarfare,thewoundisoftenimmersedintheseawater.3Ithasnotbeenreportedtoourknowledgeintheliteratureaboutthepathologicalchangesoffirearmwoundsconcomitantseawaterimmersioningreatarteriesanditsinfluence onsurgicalrepair.Inthisstudy,weusedrabbitsas theexperimentalmodelwhosefemoralarterywas subjectedtogunshotwoundandthenimmersedintothe seawatertoobs…     

Flow waveform analysis and long-term results of autogenous saphenous vein and polytetrafluoroethylene grafts in 140 arterial reconstructions of the lower limbs

In previous work we have found that the outcome of grafts in the lower limbs correlated with the flow waveform pattern of the artery. We have retrospectively reviewed 140 femoro-popliteal bypass operations involving the use of 75 saphenous vein grafts and 65 polytetrafluoroethylene (PTFE) grafts. For grafts with type 0 or I flow waveform pattern the patency at 4 years (56%) was superior to grafts with the type II, III or IV flow waveform (35%) patterns (P less than 0.05). For saphenous vein grafts with type 0 or I flow, the patency rate was 78% at 3 years and 69% at 5 and 8 years. In contrast with type II, III or IV flow the patency rate was 52% at 3 years, 48% at 5 years and 34% at 8 years, with a statistical significance at 4 years (P less than 0.05). PTFE grafts with type 0 or I flow showed a tendency toward an increased patency which was not significant in comparison with the grafts with type II, III or IV flow (P = 0.12). Saphenous vein grafts with type II flow patterns had an increased occlusive rate in the first year whereas PTFE grafts had the same tendency within 2 years. In both types of graft, early occlusions within a month of operation were encountered in grafts with a type III or IV flow waveform pattern. These results indicate that the fate of the reconstructed arteries of the lower limb could be predicted by flow waveform analysis, and a careful and serial postoperative evaluation of the graft should be made, particularly those with type II, III or IV flow waveform patterns.     

活体肾移植血管重建69例临床分析

目的 介绍活体肾移植血管重建的临床经验.方法 自2005年12月至2008年11月共行活体肾移植69例,供者手术均采用十一肋间小切口开放手术.58例单支肾动脉除2例外均采用肾动脉与髂外动脉端侧吻合重建血管,用4 mm打孔器作髂外动脉开口;6例副肾动脉分别采用原位（肾下极副肾动脉）或离体腹壁下动脉（肾上极副肾动脉）重建血管;3例双支肾动脉根据两支动脉口径不同采用不同方法重建血管;2例3支肾动脉采用受者离体髂内动脉重建血管.结扎多支肾静脉中较小的肾静脉只吻合其较大的主干,当两支肾静脉口径相近时,则将其整形为一个开口后吻合.结果 所有血管吻合均一次完成,开放血流时吻合口均通畅;所有供者和受者术后均恢复顺利,受者未发生血管重建相关并发症;随访1个月～3年,供受者均存活, 受者除1例血肌酐250～300 μmol/L外,68例血肌酐维持在70～150 μmol/L.结论 该活体肾移植血管重建方式安全、实用、操作方便,多支供肾动脉及多支供肾静脉均能较好重建,移植肾功能良好.     

Short- and long-term outcomes of kidney transplants with multiple renal arteries.

OBJECTIVE: The authors determined whether the use of kidney allografts with multiple renal arteries adversely effects post-transplant graft and patient outcome or increases the incidence of vascular and urologic complications. BACKGROUND: Kidney grafts with multiple renal arteries have been associated with an increased incidence of early vascular and urologic complications. Kidney transplants with single versus multiple renal arteries have not been compared in regard to long-term graft and patient outcome or post-transplant incidence of hypertension, acute tubular necrosis, rejection, and late vascular and urologic complications. METHODS: We analyzed 998 adult kidney transplants done from December 1, 1985 through June 30, 1993, in which only the recipient's external or internal iliac artery was used for anastomosis. We divided the study population into 3 groups: Group A-1 renal artery, 1 arterial anastomosis (n = 835), Group B-->1 renal artery, 1 arterial anastomosis (n = 112), Group C-->1 renal artery, > 1 arterial anastomosis (n = 51). We compared the incidence of post-transplant hypertension, acute tubular necrosis, acute rejection, and vascular and urologic complications; mean creatinine levels at 1, 3, and 5 years post-transplant; and patient and graft survival. Univariate and multivariate analyses were done to identify risk factors for vascular complications. RESULTS: We found no significant differences among the three groups for the following variables: post-transplant hypertension, acute tubular necrosis, acute rejection, creatinine levels, early vascular and urologic complications, and graft and patient survival. In kidneys with single arteries, the presence (vs. absence) of an aortic patch and the type of the arterial anastomosis (end-to-end to the hypogastric vs. end-to-side to the external iliac artery) did not have an impact on the incidence of early or late vascular complications. In kidneys with multiple arteries, only the rate of late renal artery stenosis was higher, the rate of early vascular and urologic complications was not different. Our multivariate analysis identified acute tubular necrosis as a risk factor for renal artery and vein thrombosis; graft placement on the left side for arterial thrombosis; and preservation time > or = 24 hours and multiple renal arteries for renal artery stenosis. CONCLUSIONS: Results of kidney transplants using allografts with multiple versus single arteries are similar.     

Edited by ZHAO BinPathological study of rabbits' femoral arteries subjected to gunshot wounds combining with seawater immersion

Objective: To investigate pathological characteristics of gunshot wounds concomitant seawater immersion in rabbits' femoral arteries. Methods: Thirty rabbits were divided randomly into 3 groups: simple gunshot-wound group (Group I, n=10), gunshot wound with seawater immersion for 30 mins (Group II, n=10), and 60 mins group (Group III, n=10). Femoral arteries were impacted by 0.38 g steel spheres fired with a 7.62 mm rifle. After being wounded, rabbits in Groups II and III were immersed in seawater for 30 or 60 mins, but those in Group I were not. At 2, 4, 6, 8, 12 hours following injury, a 40 mm segment of the artery on each side of the gunshot point were excised and observed by light and electron microscopy. Results: The patterns of arterial injuries were mainly contusion and transection. Completely transected artery was classified as primary-wound-tract area, contused area and shocked area. Compared with those in Group I, the primary-wound-tract and contused areas in Group II manifested obvious swelling in the arterial wall especially at the outside 2/3 of the media. Vacuolar structures were often seen in smooth muscle cells of the media. Intercellular space among the smooth muscle cells were filled with homogeneous acidophilic substances. Deep rugae among endothelial cells flattened or rugal folds lost their longitudinal orientation, and marked fibrin and platelet deposition were noticed. No significant difference was detected between Group II and III. The pathological changes in the shocked area were similar in 3 groups. Conclusions: For gunshot wounds concomitant seawater immersion in rabbits' femoral arteries, there was a marked swelling of cells and intercellular space in primary-wound-tract area and contusion area. The influence of these pathological changes on surgical reparation deservers further study.     

活体肾移植供肾动脉解剖学特点及其处理的临床体会

目的 总结活体肾移植供者肾动脉解剖学特点及多支动脉供肾的手术处理方式.方法 分析我中心142例活体肾移植供者术前数字减影血管造影和CT血管成像的供肾动脉解剖结果.用6种不同方式对多支动脉供肾进行显微技术处理,比较供肾多支动脉受者(n=31)与供肾单支动脉受者(n=111)术后早期的临床疗效.结果 30.99%的供者存在肾脏多支动脉,两侧肾脏相似(左肾22.54%,右肾22.13%),在一侧存在时,对侧也存在的概率分别为56.25%和60.00%.左肾动脉主干稍粗(P=0.001)且主干上第1个分支距腹主动脉距离稍近(P=0.004).多支动脉组受者手术时间和供肾冷、热缺血时间延长,但在术中出血量、移植肾功能延迟恢复、急性排斥反应及移植肾彩超弓形动脉流速等方面与单支动脉组差异并无统计学意义.在术后7 d、1个月、3个月3个观察点2组受者血清肌酐和肌酐清除率相似,重复测量的方差分析还表明供肾是否为多支动脉对术后早期肾功能的变化趋势并无影响.结论 充分了解活体供肾的动脉解剖并采用正确的处理方式是保证移植效果的重要因素.     

Early outcomes of laparoscopic donor nephrectomy with multiple renal arteries

Purpose: We evaluated our experience with laparoscopic donor nephrectomy in patients with multiple renal arteries, comparing operative outcomes and early graft function with patients with a single renal artery. Materials and Methods: From January 2003 to February 2009, 130 patients underwent laparoscopic donor nephrectomy at our institution, 108 (83 %) with a single renal artery and 22 (17 %) with multiple arteries. Donor and recipient outcomes for single artery and multiple arteries allografts were compared. Results: The LDN operative time was similar between the single artery and multiple arteries groups (162 vs 163 min, respectively, p = 0.87). Allografts with multiple arteries had significantly longer warm ischemia time (3.9 vs 4.9 min, p = 0.05) and cold ischemia time (72 vs 94 min, p < 0.001) than those with single artery. The conversion rate was similar between single and multiple arteries groups (6 % vs 4.5 %, respectively, p = 0.7). Multiple arteries grafts had a non statistically significant higher rate of poor graft function when compared to single artery grafts (23 % vs 12 %, respectively, p = 0.18). Five patients in the single artery group (4.6 %) and one patient in the multiple arteries group (4.5 %) needed dialysis during the first postoperative week. Overall, recipient complication rates were similar between single and multiple arteries groups (12.9 % vs 18.1 %, respectively, p = 0.51). Conclusion: Laparoscopic donor nephrectomy with multiple arteries was associated with a non statistically significant higher rate of poor early graft function. The procedure appears to be safe in patients with multiple arteries, with similar complications rates. Multiple arteries should not be a contraindication for laparoscopic donor nephrectomy.     

Glutaraldehyde-preserved venous valve transplantation in the dog

Transplantation of femoral vein grafts was performed on 33 mongrel dogs to assess graft patency and valvular function after storage in glutaraldehyde. The grafts were removed from the donor, flushed with room temperature heparinized lactated Ringer's solution, and then stored in a 0.2% glutaraldehyde solution for 16 hr. At the time of grafting, the veins were again flushed with lactated Ringer's and anastomosed orthotopically to the recipient. An arteriovenous fistula was also created. Postoperatively the animals received daily doses of aspirin (2 mg/kg) and dipyridamol (50 mg). The following groups were studied: Group I (n = 10) served as controls and received fresh autografts. Group II (n = 13) received autografts stored for 16 hr in 0.2% glutaraldehyde. Group III (n = 10) received allografts stored similarly in glutaraldehyde for 16 hr. The grafts were monitored for evidence of patency. All grafts were removed for histological evaluation when patency was no longer detected or at the end of 7 weeks. Of the fresh and glutaraldehyde-preserved autografts (Group 1), 100% were patent at 7 weeks, and generally retained valve function. Patency of allografts was only slightly inferior but valve function was disappointingly poor at 7 weeks.     

Preparation of the left ventricle for anatomical correction in patients with simple transposition of the great arteries. Surgical guidelines

Pulmonary artery banding in combination with an aortopulmonary shunt was performed on 16 patients with simple transposition of the great arteries to prepare the left ventricle for anatomical correction. Three groups were identified after operation: Group I (four patients) had increased pulmonary blood flow and tight pulmonary artery banding; Group II (four patients) had increased pulmonary blood flow and moderate pulmonary artery banding; Group III (eight patients) had normal pulmonary blood flow and moderate pulmonary artery banding. Postoperative low cardiac output was present in all patients in Group I, whereas mild heart failure was present in two patients in Group II and in two in Group III. There was one hospital death (6%). The follow-up period was 125 patient-months. Left ventricular systolic pressure rose from 63 +/- 11 torr before the operation to 101 +/- 35 torr after the procedure in Group I (p less than 0.05), from 59 +/- 10 to 93 +/- 33 torr in Group II (p less than 0.05), and from 55 +/- 10 to 84 +/- 16 torr in Group III (p less than 0.005). The increase in left ventricular muscle mass was from 44 +/- 2 gm/m2 preoperatively to 108 +/- 12 gm/m2 after operation in Group I (p less than 0.01), from 43 +/- 3 to 93 +/- 8 gm/m2 in Group II (p less than 0.02), and from 46 +/- 3 to 55 +/- 14 gm/m2 in Group III (p = no statistically significant difference). The postoperative change in left ventricular end-diastolic volume was from 100% +/- 17% to 133% +/- 23% of normal in Groups I and II (p less than 0.05) and from 123% +/- 29% to 107% +/- 36% of normal in Group III (p = no statistically significant difference). In preparing the left ventricle for anatomical correction, avoidance of severe pulmonary artery banding decreases the incidence of postoperative myocardial dysfunction, a moderate degree of volume overload and pulmonary artery banding provides the most effective stimulus for ventricular growth, and a small to moderate atrial septal defect is advantageous because it ensures the volume preload necessary for the development of the left ventricle.     

Surgical considerations in bypassing coronary arteries with 100% proximal occlusion.

Objective data on the ability of cineangiography to predict the size of reconstituted totally occluded coronary arteries, as well as the clinical outcome of such revascularization, are sparse. Accordingly, we reviewed 200 consecutive cases of coronary revascularization to determine the answers to these questions. Group I patients (n = 57, with 86 totally occluded coronary arteries) had at least one coronary artery with a 100% proximal occlusion that reconstituted distally. Group II patients (n = 143, with 205 subtotally occluded coronary arteries) had 50% to 99% proximal stenosis of at least one coronary artery. Cineangiograms were blindly reviewed to measure the size of the coronary arteries, which were compared with the actual vessel size at operation. In group I, the totally occluded coronary arteries had a cineangiographic size of 1.9 +/- 0.7 mm and an actual size of 1.6 +/- 0.4 mm (p = 0.00004). In group II, the subtotally occluded coronary arteries had a cineangiographic size of 1.8 +/- 0.4 mm compared with an actual size of 1.8 +/- 0.3 mm (p = not significant). The site of bypass grafting was significantly smaller in group I (1.6 +/- 0.4 mm versus 1.8 +/- 0.3 mm; p = 0.00008). The two groups were similar with respect to preoperative and intraoperative parameters. Operative mortalities were similar (group I, 1.8%; group II, 3.5%; p = 0.68). Creatine kinase isoenzyme profiles and electrocardiographic changes were similar, except for a significant late rise of creatine kinase-MB in group I (56.1 +/- 14.7 versus 30.7 +/- 33.7 MIU/mL; p < 0.001). In conclusion, cineangiography significantly overestimates the size of totally occluded coronary arteries.(ABSTRACT TRUNCATED AT 250 WORDS)     

The long-term outcomes of transplantation of kidneys with multiple renal arteries

Kidneys with multiple renal arteries are increasingly procured for transplantation. To compare the outcomes of kidney transplantation using allografts with multiple arteries, we studied long-term graft function and survival according to their number of arterial anastomoses during an 18-year period from July 1, 1990, through December 31, 2008, in which only the recipient's external iliac artery or internal iliac artery was used for anastomosis (n = 1186). The recipients were divided into four groups: group I, single renal artery with single anastomosis (n = 890, 75.0%); group Il, multiple renal arteries, single anastomosis (n = 26, 2.2%); group Ill, multiple renal arteries, multiple anastomoses (n = 236, 19.9%); and group IV, polar artery ligation (n = 34, 2.9%). We compared the following variables patient and graft survivals; mean creatinine levels at 1 and 6 months, as well as 1-, 3-, and 5-years posttransplant; the number of acute rejection episodes, and the rates of vascular and urologic complications. The creatinine values and incidences of acute rejection episodes did not differ significantly (P = 0.399 and P = 0.990, respectively). There were no significant differences among the four groups in graft survival (P = 0.951), patient survival (P = 0.751), incidence of vascular (P = 0.999) or urologic complications (P = 0.371). The four groups were subdivided according to the recipient arterial anastomosis to the main graft renal artery. The subdivided groups showed no significant differences in graft or patient survival, or complications rates. The results indicated that multiplicity of renal arteries in kidney transplantation did not adversely affect allograft or patient survival compared with single renal artery transplantation. Moreover, the type of the arterial anastomosis (main renal artery end-to-end anastomosed to internal iliac artery or end-to-side anastomosed to external iliac artery appeared to not affect graft or patient survival or the incidence of vascular or urologic complications.     

Does bacteremia pose a direct threat to synthetic vascular grafts?

This study was undertaken to determine the significance of graft lumen exposure to blood-borne organisms in the development of graft infection. Three groups of dogs were studied. In group I (n = 20), the infrarenal aorta was dissected from surrounding tissue, divided, and reconstructed with a Dacron tube interposition graft. In group II (n = 9) the aorta was similarly isolated, but Dacron graft material was wrapped around the intact aorta. In group III (n = 13) the infrarenal aorta was isolated, but no graft material was placed. All dogs were given intravenous 1 X 10(7) Staphylococcus aureus at the completion of surgery. Group I grafts were harvested 8 hours, 1 day, or 21 days after bacterial challenge. Group II and III grafts were harvested 1 day or 21 days after infusion. At the time of harvest, selective cultures of the periaortic tissue (PAT), periaortic graft (PAG), and interposition graft lumen (GL) were taken. The overall infection rates were similar, with 17 of 20 (85%) dogs in group I, 6 of 9 (67%) in group II, and 11 of 13 (85%) in group III found to be culture positive. In group I, 3 of 3 dogs at 8 hours, 2 of 2 on day 1, and 12 of 15 on day 21 had positive PAT cultures. Only 4 of 15 on day 21 had positive GL cultures. In group II, 4 of 5 dogs on day 1 and 2 of 4 on day 21 had positive PAT and PAG cultures. In group III, 9 of 9 animals on day 1 and 2 of 4 on day 21 had positive PAT cultures. All aortic lumen cultures were negative in groups II and III. The difference between GL and PAT cultures was statistically significant in all groups (I, p = 0.01; II, p = 0.05; III, p = 0.01). Serial quantitative blood cultures revealed a mean bacterial load of 10.5 +/- 4.5 CFU/ml at 15 minutes postinfusion, which fell steadily until no bacteria were detected at 3.5 hours. Lymphangiography demonstrated periaortic pooling of lymph in the immediate postoperative period. These data suggest that the bacteremia in this model is transient and rapidly clears. Periaortic tissues quickly sequester bacteria, possibly because of lymphatic leakage. The GL appears to be secondarily infected.