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Recipient selection criteria for pancreas (Px) transplantation differ among centers, based on perceived recipient risk factors, and their validity has not been determined. At the University of Minnesota we have been very liberal in accepting patients for Tx, some of whom have risk factors cited as exclusion criteria by other centers, giving us the opportunity to determine, retrospectively, the impact of their presence on outcome. Between July 1986 and March 1993, we performed 319 bladder-drained cadaver Px Txs at the University of Minnesota, 166 simultaneous with a kidney (SPK), 68 after a kidney (PAK), and 85 alone (PTA). To determine which putative "risk factors" influence patient and graft survival, we used uni- and multivariate (Cox regression) analyses to assess the impact of recipient category, duration of diabetes, and age at onset and at Tx; presence of pre-Tx cardiac (CD) disease (myocardial infarction, bypass, angioplasty), peripheral vascular disease (PVD) (stroke, bypass, angioplasty, amputation); blindness, hypertension, and excess weight; and of Px re-Txs. The incidences of all risk factors except re-Tx were significantly higher in SPK than PTA recipients. Px re-Txs comprised 40% of PAK, 26% of PTA, and 10% of SPK cases (P < 0.0001). Duration of diabetes correlated (P < or = 0.01) with all risk factors but one (hypertension). Recipient age correlated (P < or = 0.01) with CD, blindness, duration of diabetes, and age at onset of diabetes; CD risk factors correlated (P < 0.015) with hypertension and PVD. Recipient age (> or = 45) influenced the technical failure rate only in SPK recipients, with a relative risk (RR) of 2.13 (P = 0.08). Recipient age influenced Px graft and patient survival rates in both SPK and PAK recipients; for those > or = 45, the RR of graft loss was 1.73 and 1.76, respectively (P < or = 0.25), and the RR for ultimately dying was 3.07 in PAK (P = 0.02) and 5.86 in SPK (P = 0.17) recipients. SPK recipients with CD factors were at higher risk to ultimately die (RR = 3.78, P = 0.009), independent of age. Px re-Txs were not at higher risk to fail in PTA, but were in PAK recipients (RR = 1.86, P = 0.09); the risk for technical failure was higher for re-Txs only in SPK recipients (RR = 2.11, P = 0.24). Blindness, hypertension, PVD, and duration of diabetes did not negatively influence patient and graft outcome in any recipient category.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Recipient risk factors have an impact on technical failure and patient and graft survival rates in bladder-drained pancreas transplants. 800 94

Intravascular ultrasonography, balloon angioplasty, stent placement, and endovascular septal fenestration have been used in the evaluation and treatment of vascular complications of acute and chronic aortic dissection in five patients. There were three men and two women with an average age of 52 years (range 39 to 64 years). There were three chronic type A dissections, one acute type B, and one subacute type B dissection. Intravascular ultrasonography was used in all five cases. The three patients with chronic type A dissections underwent unilateral renal artery angioplasty (RA PTA) and stent placement; one patient with an acute type B dissection and associated fibromuscular dysplasia underwent bilateral RA PTA without stent placement. These procedures were performed to ameliorate severe hypertension. The final patient, with a subacute type B dissection, underwent iliac artery stenting to correct severe lower extremity ischemia. During a second intervention, this patient, who also had bowel ischemia and nonresolving acute renal failure, underwent balloon dilatation of a preexisting septal fenestration to augment visceral blood supply and bilateral RA PTA and stent placement in an effort to improve renal function. This patient eventually died of gut ischemia. After RA PTA and stent placement, one patient had a major intrarenal hemorrhage that required coil embolization and transfusion. In the four survivors, RA PTA and stent placement resulted in immediate improvement in blood pressure control. This response has been sustained during follow-up intervals ranging from 8 to 18 months (average 10 months). Intravascular ultrasonography can clearly demonstrate the pathologic anatomy associated with aortic dissection (even when angiography is ambiguous) and is essential for guiding therapeutic endovascular interventions. Further exploration of the efficacy of these endovascular techniques is warranted in this high-risk group of patients with aortic dissection who have appropriate clinical indications.
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PMID:The use of endovascular techniques for the treatment of complications of aortic dissection. 826 33

24 patients with renovascular hypertension were operated from 1995 to 1997. Patients were divided into three groups: group I-atherosclerotic stricture of renal arteries with or without aorta stenosis (13), group II-fibromuscular dysplasia (8), group III-stricture of vascular anastomosis after renal transplantation (5). All patients were disqualified from PTA. Operations of reanastomosis of renal arteries to aorta or prosthesis and TEA dominated in group I, the operation of choice in groups II and III was plastic procedure with patch or venous graft. Authors conclude that surgical treatment of renovascular hypertension is an efficient method of treatment in case of disqualification from PTA and the way of reconstruction should be dependent on the reason of renovascular hypertension.
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PMID:[Surgical treatment of different forms of renovascular hypertension]. 942 26

A 30 years old female patient, to whom a cadaveric kidney transplantation was performed 7 years earlier, presented severe hypertension attacks for 2 years. Renal artery stenosis diagnosed by angiography, PTA could not be performed. She underwent an operation for surgical correction of stenosis and successful internal iliac renal artery anastomosis performed by saphenous vein interposition. The patient was discharged at the fourteenth postoperative day with excellent kidney function and stable blood pressure.
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PMID:Renal artery reconstruction in transplant kidney. Case report. 993 11

In recent years, organized basic care and the use of thrombolysis have been significantly effective in improving the acute stroke therapy especially for the ischemic stroke subtype. Combining the efforts for the basic care of stroke patients in the setting of the so-called stroke-units is the goal for a qualified therapy. Main parts in the basic care algorhythm are: optimization of the cerebral perfusion, maintenance of an initial high blood pressure, best oxygen supply, reduction of an increased body temperature and antiinfectious treatment, reduction in the rate of complications (like deep vein thrombosis, pneumonia, falls etc.) and the early physiotherapeutic therapy. Thrombolysis is restricted to selected patients with infarctions of the middle cerebral artery with symptoms starting not longer than three hours before treatment, without hemorrhage in CCT and fulfilling the strict in- and exclusion criteriae established by the recent multicenter trials. The use of rt-PA (0.9 mg/kg body weight) is recommended. Local fibrinolysis is used in patients suffering from basilar artery thrombosis. The use of other recanalizing techniques like PTA or stenting is yet still experimental in acute stroke patients. Neuroprotective agents which were proven in clinical trials are still not available. In recent years therapy with hemodilution was widely used, nowadays the intravenous application of fluids with hemodilutive properties is restricted to patients with reduced cardiac output and macroangiopathy to maintain or to improve cerebral perfusion. Early intravenous anticoagulation with heparin is defined as secondary prevention and not as therapeutical intervention.
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PMID:[Acute therapy of stroke]. 1041 99

We reported a rare case, which was successfully treated by PTA, of right common carotid artery dissection propagated from acute aortic dissection (AAD) type A. A 45-year-old male with a past history of hypertension and an artificial graft replacement of the abdominal aorta due to AAD type B, 7 years ago, was brought into our hospital by ambulance 30 minutes after an attack of fainting and left hemiparesis. On admission, the patient complained not of chest pain or left hemiparesis, but nausea. At that time his consciousness level was JCS 1. During examinations, he had the same attack twice and his consciousness level deteriorated to JCS 2. Brain MRI showed no abnormality, but cervical MRA did not visualize the right carotid artery and thoracic CT depicted acute aortic dissection including branches of the aorta. Emergent angiography disclosed that the dissecting 99% stenosis of the right common carotid artery had developed from AAD type A with poor collateral blood flow. PTA was carried out 8 times and reduced the residual stenosis to about 50% with shortened circulation time. The patient's consciousness disturbance improved. After the replacement of the whole aortic arch in an artificial graft, the residual stenosis disappeared. The patient recovered without neurological deficit but right frontal silent embolic infarction caused by the artificial graft replacement was detected. AAD is a catastrophic illness and sometimes accompanied by devastating ischemic cerebral disease (ICD) because of propagation of dissecting to extracranial vessels. This is the first report that shows the efficacy of PTA for treatment of ICD associated with AAD.
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PMID:[Common carotid artery dissection propagated from acute aortic dissection: a case successfully treated by PTA]. 1112 87

The aim of this study was to evaluate renal function changes after percutaneous transluminal renal artery angioplasty (PTRA) done to treat atheromatous renal artery stenosis with renal failure. Between 1990 and 1995, PTRA was performed in 99 renal failure patients (creatinine clearance less than 80 ml/min) with atheromatous stenosis of one or more native renal arteries. Indications for PTRA were chronic renal failure with poorly controlled hypertension (group A, 67 patients) or rapidly deteriorating renal function (group B, 32 patients). Renal function changes after PTRA were evaluated based on the percentages of patients with improved, stabilized, and worsened serum creatinine and creatinine clearance values, and on mean differences between final and baseline creatinine clearances. At the end of follow-up (19+/-10 months), group A had a significantly smaller creatinine clearance gain (42.9 ml/min before PTA to 44.5 ml/min after PTA, D=1.6 ml/min, in group A, vs 24.1-28.4 ml/min, D=4.3, in group B, p=0.03), and a significantly smaller percentage of improved patients (36 vs 62%) than group B. Most stenoses in group B either were bilateral or occurred on a solitary kidney ( p=0.001). Percutaneous transluminal renal artery angioplasty combined with aggressive medical treatment may be useful in maintaining or improving renal function, particularly in patients with a recent, sharp deterioration in renal function.
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PMID:Percutaneous transluminal renal angioplasty in atheroma with renal failure: long-term outcomes in 99 patients. 1173 53

The attitude to treatment of renal artery stenosis has recently been modified from an active to a more expectant strategy based on informations from randomised studies. The primary treatment should be antihypertensive agents. Revascularisation should be considered in patients with refractory hypertension, recurrent pulmonary oedema, bilateral renal artery stenosis or progressive azotaemia, and in patients with a narrow stenosis to a single kidney. The treatment, i.e. surgery or PTA with or without stent, should be selected on an overall view of the patients' health using a combination of clinical, pathophysiological, and angiographic investigations.
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PMID:[Treatment of renal artery stenosis]. 1208 59

Renal artery stenosis (RAS) leading to hypertension or ischemic nephropathy can be treated by endovascular revascularization using balloon angioplasty or stent implantation. Although high technical success rates > 95%, relatively low frequencies of complications and good long-term patency can be achieved, the indications for interventional treatment are a matter of ongoing debate. Curing hypertension by means of angioplasty rarely occurs, although the number of antihypertensive medication usually can be reduced after successful treatment. Targeting ischemic nephropathy, revascularization can stabilize or at least slow the decline of renal function. Nevertheless, angioplasty also bears the risk of inducing renal deterioration. Careful patient selection remains the most crucial point in renal interventions, however, current data are insufficient to give final recommendations on this issue. The present review focuses on the potential beneficial effects of renal artery PTA and stenting in patients with RAS.
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PMID:Treating renal artery stenosis. A statement pro endovascular therapy. 1496 43

Arterial hypertension is most often the first symptom of renal artery stenosis (RAS). Appropriate screening methods for the diagnostic workup of hypertension are colour-coded duplex ultrasound and captopril scintigraphy. Angiography (intraarterial digital subtraction angiography) represents the diagnostic "gold standard", which is the prerequisite for the selection of the most suitable therapeutic method. Atherosclerosis is the most common disease in elderly patients presenting with RAS. In younger patients, fibromuscular dysplasia is more frequent. Five main types with different prognosis and therapeutic indications can be classified. Rare causes of RAS are dissection, renal artery aneurysm with combined stenosis, and especially in children and adolescents middle aortic syndrome with hypoplasia of the visceral arteries. Every patient with RAS of hemodynamic relevance in the presence of hypertension should be treated, whereas therapeutic risk and benefit must be weighed up individually. Aims are the improvement of hypertension and the maintenance of renal function. Surgical techniques, which are described subsequently, are indicated in all patients who need further simultaneous treatment of the abdominal vessels (abdominal aortic aneurysm, aortoiliac or visceral artery stenosis or aneurysm, respectively). In atherosclerotic ostial stenoses, angioplasty (PTA) and open surgery (normally transaortic endarterectomy) are concurrent methods. In our experience, the long-term results of surgical reconstruction seem to be superior. Both procedures are subject to an ongoing randomized study in our department. The outcome of surgical treatment for RAS is satisfying, the operative risk especially in isolated renal artery lesions is negligible.
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PMID:[Management of patients with renal artery stenosis. Reappraisal of operative treatment]. 1496 44


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