The role of arterial reconstruction in spontaneous renal artery dissection.

Spontaneous renal artery dissection is an uncommon cause of renovascular hypertension, usually associated with fibromuscular dysplasia. Among reported nonautopsy cases (N = 80), arterial reconstruction has seldom been attempted (N = 21) and the outcome has frequently been poor (48% clinical failure rate). This is attributed in part to the frequent involvement of renal artery branches by the dissection.

Chronic visceral ischemia. Three decades of progress.

Symptomatic visceral atherosclerosis is a major surgical challenge because of its life-threatening course and the complexity of its definitive operative treatment. Evolution in the operative approach to the visceral aorta and progress in the intraoperative management of patients undergoing complex vascular reconstructions prompted a review of the authors' cumulative experience in the surgical management of chronic visceral ischemia. Among all patients undergoing visceral revascularization at the University of California, San Francisco during the past three decades, 74 patients were identified whose primary reconstruction used transaortic endarterectomy (TA TEA) (n = 48) or antegrade bypass (AB) (n = 26), the authors' preferred revascularization techniques.

Comparison of the findings on preoperative dipyridamole perfusion scintigraphy and intraoperative transesophageal echocardiography: implications regarding the identification of myocardium at ischemic risk.

The evidence of myocardium at potential ischemic risk on preoperative dipyridamole perfusion scintigraphy was compared with that of manifest ischemia on intraoperative transesophageal echocardiography in 26 patients at high risk of a coronary event undergoing noncardiac surgery. The clinical outcome was also assessed. Induced intraoperative wall motion abnormalities were more common in patients and myocardial segments with, than in those without, a preoperative reversible perfusion defect (both p less than 0.

Clinical spectrum of symptomatic external iliac fibromuscular dysplasia.

External iliac fibromuscular dysplasia is a rare and usually asymptomatic disorder. We report eight symptomatic patients seen over a 15-year period and review pathophysiologic mechanisms accounting for the three following distinct lower extremity ischemic sequelae: (1) Emboli--episodic focal digital ischemia (blue toe) was seen in three patients. Resection and primary anastomosis of focal iliac ulcerative fibromuscular dysplasia (one patient) or resection and replacement (two patients) removed the embolic source and relieved the symptoms.

Angiotensin-converting enzyme inhibitors. 9. Novel [[N-(1-carboxy-3-phenylpropyl)amino]acyl]glycine derivatives with diuretic activity.

A series of molecules 1 having sulfonamide diuretic moieties covalently linked to non-sulfhydryl angiotensin-converting enzyme inhibitors (ACEI) were prepared and tested for both activities. IC50 values for ACEI as low as 7 nM were observed. Discernable diuretic activity was seen for several hydrochlorothiazide-based molecules.

Aortoenteric fistula and perigraft infection: evaluation with CT.

A blinded retrospective study was performed to determine the sensitivity and specificity of computed tomography (CT) in detecting perigraft infection (PGI) and aortoenteric fistula (AEF), rare but devastating complications of aortic reconstructive surgery. Two observers independently reviewed CT scans in 55 cases including AEF (n = 23); PGI (n = 12); and normal, noninfected grafts (n = 20). Each scan was assessed for ectopic gas, focal bowel wall thickening, perigraft fluid, perigraft soft tissue, pseudoaneurysm formation, disruption of the aneurysmal wrap, and increased soft tissue between the graft and surrounding wrap.

Recurrent carotid stenosis: a consequence of local or systemic factors? The influence of unrepaired technical defects.

To determine the influence of unrepaired technical defects as well as systemic risk factors for atherogenesis on carotid artery healing after endarterectomy, we conducted a prospective study using intraoperative duplex scanning with spectral analysis to establish the initial status of the artery (N = 131 arteries), and then we studied these vessels at regular postoperative intervals with the same technique (N = 108 arteries, 265 studies). The vessels were divided into the operated and nonoperated segments of the common, internal, and external carotid arteries, and both intraoperative image and flow data were tabulated by artery segment. The technical factors that were analyzed included defect size, defect type, adjacent segment defects, number of defects, shunt use, vessel reopening, and peak, mean, and end-diastolic frequency and velocity.

Infrarenal aortic occlusion: does it threaten renal perfusion or function?

Proximal propagation of aortic thrombus with resultant impaired renal perfusion has been considered a significant risk of untreated infrarenal aortic occlusion. To investigate this question, we studied 52 patients surviving 1 year or more after surgical interruption of the infrarenal aorta in the course of treatment of aortic graft infection. Blood pressure, renal function, and renal artery anatomy were studied before and after aortic interruption.

Saphenous vein bypass to pedal arteries. An aggressive strategy for foot salvage.

Patients with forefoot ischemia and severe tibial artery disease present a major challenge to revascularization and foot preservation. Encouraged by the success of saphenous vein bypass to the more proximal arteries of the lower leg, we extended this technique to the pedal arteries. Between February 1986 and September 1988, we performed 26 bypasses in 24 men (mean age, 66 years) with critical foot ischemia.

Early interactions of pseudorabies virus with host cells: functions of glycoprotein gIII.

Adsorption of mutants of pseudorabies virus (PrV) lacking glycoprotein gIII is slower and less efficient than is that of wild-type virus (C. Schreurs, T. C.

Renal endarterectomy through the transected aorta: a new technique for combined aortorenal atherosclerosis--a preliminary report.

The optimal surgical management of combined aortic and renal atherosclerosis has not been defined. A modified technique of renal endarterectomy performed through the transected aorta before anastomosis of the aortic prosthesis is presented. The surgical course and early follow-up results of the first 44 consecutive patients treated by this technique are reported.

Particle size distribution of lipoproteins from human atherosclerotic plaque: a preliminary report.

It is commonly believed that low-density lipoproteins (LDLs) carry cholesterol into the artery wall. In addition, some epidemiologic studies have suggested that triglyceride-rich lipoproteins, such as very-low-density lipoproteins (VLDLs), may be much less important than LDLs in atherogenesis. To determine if VLDLs or their metabolic remnants could have a direct role in the formation of atherosclerotic plaque, we examined lipoproteins isolated from endarterectomy specimens.

Supraclavicular approach for thoracic outlet decompression.

Supraclavicular decompression of the thoracic outlet was performed in 40 patients with symptoms arising from brachial plexus compression were irritation. Both osseous and soft tissue structures responsible for this nerve compression were identified and removed without significant neurologic morbidity despite a 25% incidence of secondary operative procedures in this series. The cure or improvement rate matched what we previously reported for combined transaxillary and supraclavicular approach.

Evolving strategies for the repair of complex renovascular lesions.

Fifty-five patients with 59 complex renovascular lesions required two or more branch artery anastomoses during aortorenal grafting. Forty-five reconstructions involving 112 branches were facilitated using hypothermic ex vivo perfusion preservation, whereas 14 involving 28 branches were repaired in situ. Ex vivo repair was used whenever the kidney was considered unreconstructable by in situ techniques.

Improved management of aortic graft infection: the influence of operation sequence and staging.

To investigate the influence of operation sequence and staging on the outcome of aortic graft infection, we studied the mortality and amputation rates and incidence of new graft infection involving the extra-anatomic bypass (EAB) among 101 patients treated for secondary aortoenteric fistula (N = 43) or primary perigraft infection (N = 58). Patients were retrospectively grouped according to the operative treatment technique. Seven patients underwent infected graft removal (IGR) followed immediately by EAB (traditional).

Intraoperative assessment of renal and visceral artery reconstruction: the role of duplex scanning and spectral analysis.

To refine our ability to assess intraoperatively renal and visceral reconstructions, we have investigated the usefulness of combined duplex scanning and Doppler spectral analysis to determine the technical adequacy and flow characteristics of these repairs. We studied 62 patients (116 arteries) who underwent renal (83 arteries) or visceral (13) reconstruction by transaortic endarterectomy (76), autogenous graft (12) or prosthetic (5) bypass, reimplantation (2), and dilation (1). Twenty-six nonreconstructed vessels were also studied, including preoperative arteries (6), unrepaired arteries (14), and normal renal arteries (donor nephrectomies) (6).

Middle aortic syndrome. Effectiveness and durability of complex arterial revascularization techniques.

Middle aortic syndrome typically occurs as severe hypertension in young patients who have weak or absent femoral pulses and an abdominal bruit. It results from a diffuse narrowing of the distal thoracic and abdominal aorta, commonly involving the visceral and renal arteries. The clinical presentation, angiographic assessment, and surgical outcome of 10 patients (mean age: 19.

Ischemia of the upper extremity: significance of proximal arterial disease.

Thirty-four patients had upper extremity ischemia due to proximal arterial disease, including subclavian compression at the thoracic outlet, innominate or subclavian atherosclerosis, and other causes. Nineteen lesions caused distal embolization. Although successful arterial reconstructions were performed in all but one patient, there were five major amputations.

Durability of endarterectomy and antegrade grafts in the treatment of chronic visceral ischemia.

Several techniques have been used to revascularize the visceral circulation. Although initially successful, these repairs often have a significant rate of late occlusion. To determine the durability of transaortic endarterectomy (TEA) and antegrade aortovisceral grafting, we reviewed the last 67 consecutive patients operated on at the University of California, San Francisco for chronic visceral ischemia.

Management of pararenal aneurysms of the abdominal aorta.

The operative treatment of 77 patients with atherosclerotic aneurysms of the pararenal aorta (54 juxtarenal and 23 suprarenal) is analyzed. Repair of these complex lesions is formidable because of difficult exposure, renal ischemia and myocardial strain as a result of proximal aortic occlusion, and associated renal atherosclerosis with secondary renal functional impairment. Nineteen (25%) patients were normotensive with normal renal function.

Prostacyclin production in regions of arterial stenosis.

The effect of abnormal flow dynamics on prostacyclin (PGI2) production by intact endothelium is unknown. To investigate this we studied the effects of graded stenoses on vessel wall PGI2 production in dogs (n = 8) whose femoral and carotid arteries (n = 32) were narrowed by machine-milled clips, producing 1.0 cm segmental stenoses of 25%, 50%, 75%, and 90% diameter reduction.

Gastrointestinal tract involvement by prosthetic graft infection. The significance of gastrointestinal hemorrhage.

To investigate the patterns of interaction between vascular graft complications and the gastrointestinal (GI) tract, the incidence, pattern, and cause of GI bleeding among patients treated for secondary aortoenteric fistula (AEF) or chronic perigraft infection (PGI) was reviewed. Among 110 patients with infected grafts, there were 39 with secondary AEF and 71 chronic PGI. GI hemorrhage occurred in 24 AEF patients (61.

Metoclopramide: dose-related toxicity and preliminary antiemetic studies in children receiving cancer chemotherapy.

Prior studies in adults have shown that metoclopramide (MCP), when given in high intravenous (IV) doses (2 mg/kg), is a highly effective antiemetic for chemotherapy-induced vomiting. It is well-tolerated in older adults, but younger adults have an increased disposition to acute extrapyramidal reactions (EPRs). Before studying the efficacy of MCP as an antiemetic in children, we first had to establish the safe dose range.