Combination embolization and radiofrequency ablation therapy for renal cell carcinoma in the setting of coexisting arterial disease

The present report describes two cases of T1b (>4 cm) renal cell carcinoma (RCC) treated with superselective embolization and radiofrequency ablation in the setting of renal artery stenosis and abdominal aortic aneurysm, respectively. In the first case, a solitary functioning kidney was treated with stent placement immediately before RCC embolization. In the second case, a brachial artery approach was used for RCC embolization after a failed femoral approach secondary to an abdominal aortic aneurysm. These cases illustrate the utility of combination therapy for T1b RCC and emphasize the need for interventional radiologists and interventional oncologists to possess the requisite endovascular skills to manage anatomic challenges from coexisting arterial disease when performing image-guided tumor interventions.     

Upper extremity bypass grafting for limb salvage in end-stage renal failure

OBJECTIVE: Patients with end-stage renal failure and upper-extremity arterial occlusive disease sometimes have painful digital ulceration. We evaluated the efficacy of distal bypass grafting from the brachial artery for limb salvage in this setting. METHODS: All patients with end-stage renal disease with painful digital ulceration or gangrene of the hand seen from 1992 to 2002 were evaluated with clinical examination and noninvasive studies. Those with evidence of occlusive disease underwent conventional angiography. Individuals with forearm occlusive disease underwent bypass grafting, from the brachial artery to either the distal radial artery or ulnar artery at the level of the wrist or proximal hand. Follow-up was scheduled at regular intervals, and included duplex scanning. Limb salvage and bypass graft patency were determined with life table analysis. RESULTS: Over 10 years, 18 forearm bypass procedures were performed in 15 patients. The outflow artery was the radial artery in 15 procedures and the ulnar artery in 3 procedures. Bypass conduit was autogenous in all patients. No patient had a functioning arteriovenous fistula at bypass grafting; six limbs had previously occluded fistulas. Two bypass grafts (11%) occluded in the early postoperative period, with resultant progression of gangrene. In the remaining 16 grafts patency was maintained (mean follow-up, 18 months), with pain control and tissue healing. CONCLUSION: Treatment in patients with renal failure with upper extremity occlusive disease may be facilitated with brachiodistal bypass grafting. Pain control and reversal of progression of hand necrosis can be achieved.     

High ligation of the saphenofemoral junction in endovenous obliteration of varicose veins

BACKGROUND: Endovenous radiofrequency (RF) ablation of the greater saphenous vein has become an accepted treatment modality. This study examines if it is necessary to perform high ligation of the saphenous vein to insure success of the procedure. STUDY DESIGN: A retrospective chart analysis was conducted on 219 patients who underwent RF ablation for venous insufficiency. All procedures were performed by 3 board-certified vascular surgeons. One surgeon always ligated the saphenofemoral junction (SFJ), the second never ligated, and the third ligated selectively. Demographic data were collected and analyzed. RESULTS: A total of 77 patients underwent RF ablation with ligation of the SFJ (group I), and 142 patients underwent ablation without ligation (group II). Both groups had similar ablation success rates (P = .0960), 92% (group I) and 84% (group II). CONCLUSION: Saphenofemoral junction ligation is not indicated on a routine basis to achieve success with endovascular ablation of the greater saphenous vein.     

The use of hyperbaric oxygen therapy to treat chronic wounds: A review

Chronic wounds, defined as those wounds which fail to proceed through an orderly process to produce anatomic and functional integrity, are a significant socioeconomic problem. A wound may fail to heal for a variety of reasons including the use of corticosteroids, formation of squamous cell carcinoma, persistent infection, unrelieved pressure, and underlying hypoxia within the wound bed. Hypoxia appears to inhibit the wound healing process by blocking fibroblast proliferation, collagen production, and capillary angiogenesis and to increase the risk of infection. Hyperbaric oxygen therapy (HBOT) has been shown to aid the healing of ulcerated wounds and demonstrated to reduce the risk of amputation in diabetic patients. However, the causal reasons for the response of the underlying biological processes of wound repair to HBOT, such as the up‐regulation of angiogenesis and collagen synthesis are unclear and, consequently, current protocols remain empirical. Here we review chronic wound healing and the use of hyperbaric oxygen as an adjunctive treatment for nonhealing wounds. Databases including PubMed, ScienceDirect, Blackwell Synergy, and The Cochrane Library were searched for relevant phrases including HBOT, HBO/HBOT, wound healing, and chronic/nonhealing wounds/ulcers.     

Preserved vision without growth retardation after laparoscopic Roux-en-Y gastric bypass in a morbidly obese child with pseudotumor cerebri: 36-month follow-up

A 12-year-old boy presented with a weight of 136 kg and a history of progressive vision loss associated with unremitting pseudotumor cerebri requiring bilateral optic nerve sheath decompression. He underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) without complication. At 36 months post-RYGBP, he has grown 5 cm since the time of surgery, his weight is 6.8 kg above his postoperative nadir weight of 68.2 kg, and his visual acuity has improved with OD 20/100 (preoperative, 20/200) and OS 20/70 (preoperative, 20/100). This case suggests that RYGBP can be performed safely and without stopping linear growth in carefully selected children.     

Subcapsular hepatic hematoma with right hepatic vein thrombosis: a complication of shock wave lithotripsy

Extracorporeal shock wave lithotripsy (ESWL) is a well-established, safe and effective therapeutic modality for surgical treatment of urolithiasis. Hematoma is a rare complication of ESWL and, when it occurs, typically involves the kidney. We report the case of a 71-year-old woman who developed severe, persistent abdominal pain after ESWL for a 9-mm stone at the ureteropelvic junction. Post-treatment CT scan demonstrated a 13 × 6–cm subcapsular hepatic hematoma. A follow-up CT scan showed expansion of the hematoma and development of hepatic vein thrombosis. This finding, along with persistent abdominal pain and rising liver transaminases, led to surgical intervention. The patient''s symptoms resolved and liver function returned to baseline following liver decompression.     

Biomechanical evaluation of a double-threaded pedicle screw in elderly vertebrae

We sought to test the hypothesis that a pedicle screw that has two parallel threads of different heights throughout the full length of the screw could increase both bone purchase and pull-out strength compared with a standard single-threaded screw of similar dimensions. A single-threaded pedicle screw and a double-threaded pedicle screw were respectively placed into the paired pedicles of 21 vertebral bodies. The screws were then pulled out of the pedicles, and output parameters were measured. Although insertional torque was, on average, 14.5% higher (p = 0.039) for the single-threaded screw, maximum pull-out strength (p = 0.12), energy-to-failure (p = 0.39), and stiffness (p = 0.54) were not statistically different for the two screw types. It is concluded that a second, smaller inner thread on a double-threaded pedicle screw does not translate into either increased bone purchase or higher pull-out strengths.     

Activation time course of activator protein-1 and effect of proline dithiocarbamate during ischemia-reperfusion in rat skeletal muscle

In this report the authors describe a new method that avoids autocannibalization by free transfer of a flap to the dorsum of the rat by means of a simple exposure technique. A total of 22 Wistar rats of both sexes (weight, 200-290 g) were used in this experiment. An anatomic study performed in 12 rats revealed that a wide exposure could be created in the axillary fossa by retracting the inferior tip of the scapular bone superiorly (after severing its attachments with the deep extrinsic back muscles), the latissimus dorsi muscle laterally, and the serratus anterior muscle medially. Furthermore, after obtaining vessel diameter measurements, it was ascertained that the subscapular and the lateral thoracic vessels could serve as the recipient vessels. Based on the anatomic study, a total of 10 conventional groin cutaneous flaps, measuring 2 x 3 cm in size, were harvested based on the femoral vessels and transferred to the dorsum of the same animal by the exposure method as just described, with microvascular anastomoses performed between the femoral vessels of the flap and either the subscapular artery and the lateral thoracic vein (N = 5) or the lateral thoracic artery and vein (N = 5). Results showed that 9 of the 10 transplanted flaps were totally viable on postoperative day 7, giving a success rate of 90%, with one failing flap belonging to the latter group. The authors conclude that by this simple method of recipient vessel exposure in the axillary fossa, free flap transfer to the dorsum of the rat is a simple and reproducible technique by microvascular anastomoses performed between the pedicle vessels of a flap and the subscapular artery and the lateral thoracic vein. This model offers the unique advantage of a dorsally located flap that is protected by autocannibalization. Moreover, daily observation and monitoring of the flap are easy and practical without the need to have the animal wear protective material such as vest.     

Combined coronary artery bypass with carotid endarterectomy: do women have worse outcomes?

OBJECTIVE: Women undergoing coronary artery bypass grafting (CABG) have higher mortality and morbidity in numerous studies. Although controversial, similar results have been seen in women undergoing carotid endarterectomy. We examined the results of combined eversion CEA/CABG by one group to analyze if the outcome is different between men and women in this setting. METHOD: The records of all patients undergoing combined eversion CEA/CABG were reviewed from our vascular registry between January 1992 and January 2001. Indications, demographics, morbidity, and mortality were retrieved. These results were compared on the basis of gender as well as to patients undergoing CEA alone. Significance was assessed using Theta(2) analysis. RESULTS: There were 563 combined eversion CEA/CABG procedures performed over the 9-year study period: 324 in men and 239 in women. Asymptomatic >70% stenosis was seen in 275 (85%) male patients and 215 (90%) female patients (P = not significant [NS]). Stroke was found in four men vs three women (1.2% vs 1.3%, P = NS), whereas death occurred in 13 men and five women (4.0% vs 2.1%, P = NS). Thirty-day stroke/mortality was 4.9% in men vs 3.3% in women (P = NS). During the same period, patients undergoing CEA alone were subject to a stroke-mortality rate of 1.6% in men and 1.2% in women (P = NS). CONCLUSION: This series demonstrated no difference in outcome among patients undergoing combined eversion CEA/CABG procedures on the basis of gender. Although the results demonstrate a significantly higher mortality and morbidity in patients undergoing combined procedures when compared to carotid surgery alone, the combined procedures can be performed safely in both genders. The large number of asymptomatic patients in both the combined and solo procedures may have positively influenced these results.     

Trends in kidney transplantation in Australia and New Zealand, 1993-2004

BACKGROUND: We hypothesize that transplant outcome in Australia and New Zealand has improved despite more unfavorable transplant characteristics. Data from the Australia and New Zealand Dialysis and Transplant registry was used to examine this hypothesis. METHODS: All adult kidney-only transplants from January 1993 to December 2004 in Australia or New Zealand were followed-up until death or December 2005. Outcomes were adjusted for covariates in multivariate models, with transplant year modeled as a continuous variable. RESULTS: Altogether 6764 patients were included. There were proportionately more live donor and primary transplants, older donors and recipients, and higher recipient body mass index, waiting time, and human leukocyte antigen mismatch in recent cohorts. Death-censored graft loss decreased (adjusted hazard ratio: 0.92 [0.90-0.95] per year, P<0.001). This trend was seen at both 0-1 and 1-5 years posttransplant, and was mainly for immune-mediated graft losses. Patient survival improved only in New Zealand, and only for the first posttransplant year (adjusted odds ratio: 0.88 [0.82-0.95] per year, P=0.001). Cardiovascular deaths decreased while infection or cancer deaths were unchanged. Adjusted delayed graft function rates were unchanged. The acute rejection incidence at 6 months decreased (adjusted odds ratio: 0.88 [0.85-0.90] per year, P<0.001). One and 3-year graft function significantly improved, even after adjusting for rejection. All outcomes did not vary by expanded donor criteria status. CONCLUSIONS: Graft survival and function have improved in recent years, but long-term patient survival remains unchanged. With longer follow-up, the improvement in rejection rates and graft function may lead to further improvements in long-term graft survival and potentially better patient survival.