Staged Open and Endovascular Repair of Thoracoabdominal Aneurysms Using the Common Carotid Artery

The purpose of this study was to demonstrate the feasibility of staged open and endoluminal repair of complex thoracoabdominal aneurysms. We report the management of two patients with a staged, open abdominal and endoluminal thoracic repair of Crawford extent II aneurysms, where iliofemoral access was impossible and thoracic repair effected by endograft deployment via a common carotid artery. From this experience we conclude that staged open and endovascular repair for both ruptured and elective Crawford extent II thoracoabdominal aneurysms can be performed using the common carotid artery, when anatomy is favorable.     

Older living donors provide excellent quality kidneys: a single center experience (older living donors)

BACKGROUND: The role of advanced age live donors remains controversial because of decline in glomerular filtration rate and perceived increased risks of perioperative complications. METHODS: A retrospective review of all live donor transplants performed from January 2000 to December 2003. RESULTS: Seventy-eight live donor transplants were performed during the period of review, 47 (60.3%) female and 31 (39.7%) male. Twenty-two (28.2%) of the donors were >50 yr old, 15 (68%) female and seven (32%) male. Living related donation was performed in 56 (74.4%) and unrelated in 20 (35.6%). Laparoscopic nephrectomy was performed in 29 (37.2%) and open nephrectomy in 49 (62.8%). More donors >50 underwent laparoscopic nephrectomy, 13 of 22 (59.1%) vs. 16 of 56 (28.6%). Overall patient and graft survival at 1 yr are 97 and 97%. One-year patient and graft survival is 100% vs. 96% and 100% vs. 96% in the older vs. young donors. Rejection occurred in nine of 78 (11.5%), but was not different between groups. Older donors had a reduced creatinine clearance 107.5 +/- 3.4 vs. 124.2 +/- 3.1 mL/min (p = 0.002) and a reduced clearance normalized for body surface area 60.6 +/- 3.6 mL/(min m2) vs. 70.2 +/- 2.6 mL/(min m2) (p = 0.045). Recipient serum creatinine was higher on postoperative day 1 in the older donor group 5.4 mg/dL vs. 4.4 mg/dL (p = 0.009). There was no difference in recipient serum creatinine at postoperative day 7, 30, 90, 180, 365 and 730. Donor serum creatinine was not different between groups on postoperative days 1, 7 and 30 but was higher in group 1 vs. group 2 on postoperative day 365, 1.26 +/- 0.26 mg/dL vs. 1.01 +/- 0.18 mg/dL (p = 0.020). CONCLUSIONS: Despite a reduced initial creatinine clearance, renal function is comparable in recipients of both young and old donor kidneys. Older donors had a slightly reduced serum creatinine 1 yr post-donation that warrants additional follow-up to determine if the observations continue. The introduction of laparoscopic nephrectomy may provide additional incentive for older donors to present for live donor nephrectomy.     

Long-term nicotine treatment decreases striatal alpha 6* nicotinic acetylcholine receptor sites and function in mice

Alpha-conotoxin MII-sensitive nicotinic acetylcholine receptors (nAChRs) are distinct from other subtypes in their relatively restricted localization to the striatum and some other brain regions. The effect of nicotine treatment on nAChR subtypes has been extensively investigated, with the exception of changes in alpha-conotoxin MII-sensitive receptor expression. We therefore determined the consequence of long-term nicotine administration on this subtype and its function. Nicotine was given in drinking water to provide a long-term yet intermittent treatment. Consistent with previous studies, nicotine exposure increased 125I-epibatidine and 125I-A85380 (3-[2-(S)-azetidinylmethoxy]pyridine), but not 125I-alpha-bungarotoxin, receptors in cortex and striatum. We observed an unexpected reduction (30%) in striatal 125I-alpha-conotoxin MII sites, which occurred because of a decrease in B(max). This decline was more robust in older (>8-month-old) compared with younger (2-4-month-old) mice, suggesting age is important for nicotine-induced disruption of nAChR phenotype. Immunoprecipitation experiments using nAChR subunit-directed antibodies indicate that alterations in subunit-immunoreactivity with nicotine treatment agree with those in the receptor binding studies. To determine the relationship between striatal nAChR sites and function, we measured nicotine-evoked [3H]dopamine release. A decline was obtained with nicotine treatment that was caused by a selective decrease in alpha-conotoxin MII-sensitive but not alpha-conotoxin MII-resistant dopamine release. These results may explain previous findings that nicotine treatment decreased striatal nAChR-mediated dopamine function, despite an increase in [3H]nicotine (alpha4*) sites. The present data suggest that the alpha6* nAChR subtype represents a key factor in the control of dopamine release from striatum, which adapts to long-term nicotine treatment by down-regulation of alpha6* receptor sites and function.     

Hypertonic saline resuscitation attenuates neutrophil lung sequestration and transmigration by diminishing leukocyte-endothelial interactions in a two-hit model of hemorrhagic shock and infection

BACKGROUND: Hypertonic saline (HTS) attenuates polymorphonuclear neutrophil (PMN)-mediated tissue injury after hemorrhagic shock. We hypothesized that HTS resuscitation reduces early in vivo endothelial cell (EC)-PMN interactions and late lung PMN sequestration in a two-hit model of hemorrhagic shock followed by mimicked infection. METHODS: Thirty-two mice were hemorrhaged (40 mm Hg) for 60 minutes and then given intratracheal lipopolysaccharide (10 microg) 1 hour after resuscitation with shed blood and either HTS (4 mL/kg 7.5% NaCl) or Ringer's lactate (RL) (twice shed blood volume). Eleven controls were not manipulated. Cremaster intravital microscopy quantified 5-hour EC-PMN adherence, myeloperoxidase assay assessed lung PMN content (2 1/2 and 24 hours), and lung histology determined 24-hour PMN transmigration. RESULTS: Compared with RL, HTS animals displayed 55% less 5-hour EC-PMN adherence (p = 0.01), 61% lower 24-hour lung myeloperoxidase ( p= 0.007), and 57% lower mean 24-hour lung histologic score ( p= 0.027). CONCLUSION: Compared with RL, HTS resuscitation attenuates early EC-PMN adhesion and late lung PMN accumulation in hemorrhagic shock followed by inflammation. HTS resuscitation may attenuate PMN-mediated organ damage.     

Aortic dissection in the setting of an infrarenal endoprosthesis: a fatal combination

Approximately 6 months after the successful implantation of an abdominal aortic endovascular graft, a patient suffered an acute aortic dissection. The false lumen of the dissection terminated in the excluded aneurysm sac, resulting in a lack of outflow. Extreme true lumen compression eliminated blood flow within the distal aorta, resulting in the patient's demise.     

Gender disparities in the live kidney donor evaluation process

BACKGROUND: Females are live kidney donors more often than males. We examined the pool of potential donors to determine at what point in the donor evaluation process this gender disparity develops. METHODS: We selected patients who underwent blood typing as potential live kidney donors for recipients being evaluated for transplantation at our center between January 2000 and January 2004. We reviewed patient records to determine when in the evaluation process elimination occurred: ABO incompatible, positive cross-match, no medical workup, medical workup incomplete, medical contraindication, social contraindication, recipient too sick or dead, approved but did not donate, or donated. RESULTS: A total of 506 potential donors (55% female, 45% male) were evaluated. Males and females were equally likely to get through each step of the evaluation and be approved for donation. Overall, females were significantly more likely to donate than males. However, when approved donors are divided into those who were evaluated during the open nephrectomy (ON) era versus the laparoscopic nephrectomy (LN) era, the gender disparity among donors was present only in the ON era. In the ON era, there were 54 donors, 37 females and 17 males (P=0.004), whereas in the LN era, there were 61 donors, 32 females and 29 males (P=NS). CONCLUSION: Among potential donors approved for donation, females have been significantly more likely to donate than males. The introduction of LN at our center was associated with a decrease in the gender difference in kidney donation.     

Surgical management of pericarditis in Zaria, Nigeria.

Over eight years, 58 rural Nigerians with pericarditis were treated surgically in Zaria using basic surgical facilities. Eighteen patients had purulent pericarditis, associated with staphylococcal pneumonia in children, or pneumococcal pneumonia in adults. Treatment with antibiotics and prompt pericardiectomy appeared to be superior to drainage, since a quarter of those initially treated with surgical drainage developed early constriction and required pericardiectomy soon after. Thirteen patients had chronic pericardial effusions, of whom one had epicardial constriction and two had cardiomyopathy. Twenty-seven patients had chronic constrictive pericarditis but tuberculosis was confirmed histologically in three only. Echocardiographic findings remained unchanged in five patients evaluated before and after pericardiectomy. Eight of the 13 patients who died had already developed myocardial or hepatic insufficiency before operation, because of late presentation or diagnosis. Greater awareness of the significance of precordial pain in this rural population where ischaemic heart disease is rare would help in making an earlier diagnosis.