Initial experience with endovascular aneurysm repair: comparison of early results with outcome of conventional open repair

PURPOSE: To determine the safety, effectiveness, and problems encountered with endovascular repair of abdominal aortic aneurysm (AAA). Initial experience with endoluminal stent grafts was examined and compared with outcome for a matched concurrent control group undergoing conventional operative repair of AAA. METHODS: Over a 3-year period, 30 patients underwent attempts at endovascular repair of infrarenal AAA. Of the 28 (93%) successfully implanted endografts, 8 were tube endografts, 8 bifurcated grafts, and 12 aortouniiliac grafts combined with femorofemoral bypass. Most of the procedures were performed in the past year because the availability of bifurcated and aortoiliac endografts markedly expanded the percentage of patients with AAA who might be treated with endoluminal methods. The follow-up period ranged from 1 to 44 months, with a mean value of 11 months. RESULTS: Endovascular procedures demonstrated significant advantages with respect to reduced blood loss (408 versus 1287 ml), use of an intensive care unit (0.1 versus 1.75 days), length of hospitalization (3.9 versus 10.3 days), and quicker recovery (11 versus 47 days). Although the total number of postoperative complications was identical for the two groups, the nature of the complications differed considerably. Local and vascular complications characteristic of endovascular repair could frequently be corrected at the time of the procedure and tended to be less severe than systemic or remote complications, which predominated among the open surgical repair group. On an intent-to-treat basis, 23 (77%) of the 30 AAAs were successfully managed with endoluminal repair. The seven (23%) failures were attributable to two immediate conversions caused by access problems, three persistent endoleaks, one late conversion caused by AAA expansion, and one late rupture. CONCLUSIONS: Although less definitive than those for conventional operations, these early results suggest that endovascular AAA repair offers considerable benefits for appropriate patients. The results justify continued application of this method of AAA repair, particularly in the treatment of older persons at high risk.     

Bilateral skeletonized mammary artery grafting: experience with 560 consecutive patients

OBJECTIVE: To test the hypothesis that the skeletonized technique of harvesting the internal thoracic artery improves the surgical results of bilateral internal thoracic artery grafting, we reviewed our 7-year experience with this technique. METHODS: Between July 1987 and December 1994, 560 patients received bilateral internal thoracic artery grafts and 236 additional grafts (average 2.6 +/- 0.6 anastomoses per patient). There were 515 men (92%) and the average age was 56.9 +/- 8.8 years. There were 63 diabetic patients (11.3%). During harvesting, the internal thoracic arteries were always totally skeletonized from the surrounding tissues without the use of electrocautery. RESULTS: Postoperative complications included reoperation for bleeding, 17 patients (3%), phrenic nerve paresis, 17 patients (3%), acute respiratory distress syndrome, 9 patients (1.6%), digestive complications, 8 patients (1.4%), neurologic complications, 6 patients (1.1%), and sternal complications, 6 patients (1.1%). No wound complications were observed in diabetic patients. The hospital mortality rate was 1.6% (9 patients, 2 cardiac causes). The early patency of internal thoracic artery grafts was 97.9%. Follow-up averages 29 +/- 20 months. There were 14 late deaths (4 cardiac causes). Angina recurred in 51 patients and the maximal stress test was abnormal in 47 patients. CONCLUSION: Bilateral internal thoracic artery grafting with skeletonized harvesting carried low post-operative mortality and morbidity and therefore it could be applied routinely without the fear of increased complication rate.     

Detailed evaluation of 2959 allogeneic and xenogeneic dense connective tissue grafts (fascia lata, pericardium, and dura mater) used in the course of 20 years for duraplasty in neurosurgery

Surgical experience with 2959 allogeneic and xenogeneic dense connective tissue grafts (1767 of fascia lata, 909 of pericardium, and 283 of dura mater), used in 2665 neurosurgical operations performed in the course of 20 years (1976 to 1995) is reported. Duraplasty using either allogeneic or xenogeneic grafts has had a similar, and favourable clinical outcome. Nevertheless, the pliable deep frozen fascia lata grafts, which could be used in any location, have been reserved for sella turcica plugging, anterior cranial base plasty, aneurysmal wrapping, and surgery of lipomyelomeningocele. Pericardium and dura mater grafts were in the majority of cases used over the brain convexity and posterior cranial fossa. Ovine pericardium proved to be superior to bovine and allogeneic pericardia because of its workability, flexibility, reduced thickness, and better transparency. Postsurgical complications occurred in 7.3%, and they were: 1) cerebrospinal fluid fistulas in 2.8%; 2) meningites in 2.3% (aseptic 1.4%, bacterial 0.8%, and tumoural 0.1% meningites); 3) pseudomeningoceles in 2.2%; 4) wound infections in 0.6%; 5) malresorptive hydrocephalus in 0.5%; and 6) adhesions to nerve tissue in 0.5%. The majority of complications healed without surgery. Forty-eight grafts (1.6%) failed to fulfil the requirements of the surgeon, and 46 of them were re-operated upon. Though another thirty-nine grafts healed successfully, 39 shunts (1.5%) had to be performed for malresorptive hydrocephalus (0.9%), and/or for a big pseudomeningocele (0.6%). So, the pure complication rate in 2665 duraplasties was 3.1%. The complex evaluation of the allogeneic and xenogeneic grafts (fascia, pericardium, and dura mater), used for duraplasty in neurosurgery during the last 20 years proved them, as remarkably good, with a success rates of 96.9%.     

A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative noninvasive evaluation

PURPOSE: We studied the efficacy of preoperative noninvasive assessment of the upper extremity to identify arteries and veins suitable for hemodialysis access to increase our use of autogenous fistulas (AF). METHODS: From Sep. 1, 1994, to Apr. 1, 1997, 172 patients who required chronic hemodialysis underwent segmental upper extremity Doppler pressures and duplex ultrasound with mapping of arteries and veins. The following criteria were necessary for satisfactory arterial inflow: absence of a pressure gradient between arms, patent palmar arch, and arterial lumen diameter 2.0 mm or more. The criteria necessary for satisfactory venous outflow were venous luminal diameter greater than or equal to 2.5 mm for AF and greater than or equal to 4.0 mm for synthetic bridging grafts (BG) and continuity with distal superficial veins in the arm. Intraoperative and duplex ultrasound measurements were compared. Contemporary experience was compared with the 2-year period (1992 to 1994) before implementation of the protocol. RESULTS: During the period from Sep. 1, 1994, to Apr. 1, 1997, 108 patients (63%) had AF, 52 (30%) had prosthetic BG, and 12 (7%) had permanent catheters (PC) placed. Early failure was seen in 8.3% of AFs. Primary cumulative patency rates were 83% for AF and 74% for BG at 1 year (p < 0.05), with a mean clinical follow-up of 15.2 months. No postoperative infections were observed with AF, whereas six infections (12%) were observed with BG and two (17%) with PC insertion. During the period from June 1, 1992, to Aug. 31, 1994, 183 procedures were performed with a distribution of 14% AF, 62% BG, and 24% PC. In this earlier period the AF early failure rate was 36%, and the patency rates were 48%, 63%, and 48% for AF, BG, and PC, respectively (mean follow-up, 13.8 months). CONCLUSION: A protocol of noninvasive assessment increased use of AFs. The cumulative patency rate of AFs was improved, and early failure rates were reduced when compared with the preceding institutional experience. Routine noninvasive assessment is recommended to document adequacy of arterial inflow and delineate venous outflow to maximize opportunities for AF.     

Predictive value of access blood flow in detecting access thrombosis

The aim of this study was to evaluate whether repeated measurement of access blood flow (Qac) using the ultrasound dilution technique could predict access failure in patients on hemodialysis. One hundred thirty-one patients were evaluated at intervals of 8 weeks for a period of 6 months. The incidence of thrombosis was determined within each study period. During the 6 month follow-up, 36 thrombotic events occurred in 27 of 68 polytetrafluoroethylene (PTFE) grafts, and only six thrombotic events in 5 of 63 arteriovenous (AV) fistulas. The relative risk for access thrombosis for patients with PTFE grafts was 5.6 times greater than for patients with AV fistulas. Qac was significantly lower in thrombotic compared with patent PTFE grafts (958 +/- 506 ml/min vs 1141 +/- 482 ml/min, p < 0.05). A significant relationship was found between the incidence of subsequent PTFE graft thrombotic events and Qac (p < 0.001). Compared with accesses with high blood flow (1100-1400 ml/min), the risk for subsequent thrombosis tripled in grafts with a Qac of less than 500 ml/min. This relationship was not seen with AV fistulas. In patent PTFE grafts, Qac remained unchanged within each 2 month interval, whereas it decreased in thrombotic PTFE grafts. Thus, repeated measurements of Qac have the potential to predict future access failure in PTFE grafts; however, an increased measuring frequency might improve the predictive value of graft failure with high Qac.     

Homologous central limbo-keratoplasty in limbus stem cell damage. Retrospective study of 3 years' experience

BACKGROUND: Problems with epithelial healing are the main cause of corneal graft failure in patients with limbal stem cell deficiency. This post-operative complication cannot be eliminated by conventional penetrating keratoplasty alone, but only by additional limbal grafting, which is, however, highly immunogenic. We report here our 3 years' experience with a new surgical procedure which we developed called homologous central limbokeratoplasty. PATIENTS AND METHODS: We have performed 52 homologous central limbo-keratoplasties in patients with limbal stem cell deficiency since February 1993. We report here the results of the first 18 transplantations with the longest follow-up periods (mean 22 months). The unmatched donor cornea was trephined in a way such that 40% of its circumference contained limbus. These grafts were then sutured centrally into the host cornea. Systemic cyclosporin A (CSA) was administered for at least 1 year after all transplantations. RESULTS: Fourteen of the 18 grafts failed during the follow-up period. The reasons for graft failure were severe surface disorders (7), severe surface disorders in combination with endothelial immune reactions (5) and endothelial immune reactions alone (2). The four patients with centrally clear grafts no longer receive systemic CSA with follow-up periods between 20 and 30 months. CONCLUSIONS: Central limbo-keratoplasty is a very promising procedure. However, the average results are not yet satisfying, because the majority of limbal stem cells undergo rejection within 2 years. Improved results will be achievable in the future by using well-matched instead of non-matched transplants and by further improving immune modulation beyond the effectiveness of current CSA treatment.     

Surgical treatment of threatened reversed infrainguinal vein grafts

PURPOSE: Current information concerning the results of surgical revision of threatened infrainguinal vein grafts is largely limited to in situ conduits. Infrainguinal grafts may be threatened by intrinsic graft lesions or significant stenosis in the adjacent inflow or outflow arteries. To assess the results of operative revision of infrainguinal reversed vein grafts, we reviewed our experience with surgical revision of threatened infrainguinal reversed vein grafts identified through a program of postoperative clinical and vascular laboratory graft surveillance. METHODS: All patients who underwent surgical revision of a threatened but patent infrainguinal reversed vein graft from January 1987 through April 1993 were identified through review of our vascular registry. Data were analyzed for type of vein used, date of original reversed vein graft, clinical and vascular laboratory findings leading to reversed vein graft revision, results of preoperative angiography, patient risk factors, operative techniques and complications, and long-term assisted primary graft patency and limb salvage. RESULTS: Ninety-six patients with 100 infrainguinal reversed vein grafts (69) femoral-popliteal, 31 femoral-tibial) underwent 117 surgical vein graft revisions or inflow procedures during the study period. Eighty-one percent of the original reversed vein grafts consisted of a single segment of greater saphenous vein. All revised grafts had at least a 50% stenosis in the graft itself or the proximal or distal artery. A single revision was performed in 85 grafts, two revisions in 13 grafts, and three revisions in two grafts. There were nine (8%) isolated inflow procedures, eight (7%) vein patch angioplasties, 62 (53%) interposition vein grafts, and 29 (25%) vein graft extensions to a new distal anastomotic site. The remaining nine (8%) procedures consisted of combinations of the above. Median time to primary graft revision after initial graft implantation was 15 months (range 2 days to 316 months). Mean time to secondary revision after primary revision was 21 months. Operative mortality was 0.9%. Cumulative assisted primary patency of the original grafts revised for stenotic lesions was 99%, 96%, and 92% at 1, 3, and 5 years, respectively. Limb salvage was 99%, 97%, and 97% at 1, 3, and 5 years, respectively. CONCLUSIONS: Although surgical revision of reversed vein graft requires much use of alternative vein sources, these procedures can be performed with minimum mortality and provide excellent assisted primary graft patency and limb salvage.     

Ablation of irreversibly rejected renal allograft by embolization with absolute ethanol: a new clinical application

Surgical allograft nephrectomy has been the conventional therapy for removing failed kidney allografts when clinical manifestations of graft intolerance appear. However, removal of a transplanted kidney is an extensive surgical procedure. On the other hand, transcatheter vascular embolization (TVE) has proven useful in ablating organs and could be applied to renal transplant ablation. The aim of this study was to present the results of TVE for the treatment of graft intolerance syndrome (GIS) in failed allograft kidneys. Transcatheter vascular embolization was performed in 14 allograft recipients (33 +/- 13 years of age; 10 men and four women) affected by GIS after irreversible kidney allograft failure. Graft intolerance syndrome was diagnosed by fever (93%), hematuria (50%), graft pain (36%), flu-like symptoms (29%), and increased graft size (29%). Absolute ethanol (0.1 mL/kg body weight) was injected in the allograft artery, and in seven patients a stainless steel coil was left in the renal artery following ethanol injection. All patients showed clinical disappearance of the GIS. No major complication occurred, although a postembolization syndrome of pain, fever, hematuria, numbness, and paresthesia of the affected area appeared in 11 of the 14 patients. After 2 to 56 months of follow-up no late complications occurred, with the exception of a graft abscess formation in one patient after 6 months of embolization. Subsequent transplantectomy was uneventful. In conclusion, TVE is a safe and effective method for kidney graft ablation, and it may become an alternative treatment for GIS following irreversible rejection.     

Impact of inflow reconstruction on infrainguinal bypass

PURPOSE: This study assessed whether multisegmental disease that is severe enough to require an inflow procedure adversely affects infrainguinal bypass patency, limb salvage, or patient survival rates. METHODS: The records of 495 patients who underwent 551 infrainguinal bypass grafting procedures were reviewed. Saphenous vein and prosthetic grafts were evaluated separately. Graft patency rates, patient limb salvage rates, and patient survival rates in those grafts that arose from a reconstructed inflow source were compared with those that arose from normal, nonreconstructed inflow sources. When grafts had either hemodynamic failure or occlusion, the cause of failure was identified. RESULTS: Four-year primary patency rates in vein grafts that arose from a reconstructed inflow sources were lower than those in grafts that arose from nonreconstructed inflow sources (41% vs 54%; p = 0.006). Assisted primary patency rates and secondary patency rates, however, were similar (62% vs 74% and 64% vs 77%, respectively). The 4-year primary patency rate (45% vs 55%), assisted primary patency rate (60% vs 60%), and secondary patency rate (60% vs 61%) in prosthetic grafts did not vary based on inflow source. The most common cause of graft failure was inflow failure, except in the vein grafts that did not require an inflow procedure, in which the most common cause of failure was graft failure. Inflow failure occurred in 24% and 22% of the vein and prosthetic grafts with multisegmental disease, respectively, but in only 7% (p < 0.001) and 10% (p < 0.05), respectively, of those that arose from normal nonreconstructed inflow. The presence of an inflow procedure did not affect limb salvage rates or patient survival rates, regardless of graft material. CONCLUSIONS: Long-term patency rates, patient limb salvage rates, and survival rates in patients with a reconstructed inflow source were similar to those of patients with a normal nonreconstructed inflow. A major cause of occlusion is inflow failure, and this occurs in a greater proportion of patients with multisegmental disease. These patients, in particular, may benefit from patient surveillance to screen for progression of their inflow disease and to allow for intervention before infrainguinal graft occlusion.     

Small-intestinal transplantation

The management of patients with intestinal failure has benefited from progress in parenteral nutrition (PN), especially home-based PN. Intestinal transplantation is therefore possible and is now, in some conditions, the logical therapeutic option. Since 1985, more than 180 small-bowel grafts have been done, involving the isolated small bowel with or without the colon (38%), the liver-small bowel (46%) or several organs (16%). Two-thirds of recipients were under 20 years of age, and indications were short-bowel syndrome (64%), severe intractable diarrhoea (13%), abdominal cancer (13%) or chronic intestinal pseudo-obstruction syndrome (8%). Of the patients, 51% survived > 2 years after the graft. Patient and graft survival depends on the type of immunosuppression, i.e. cyclosporine or FK506. The results must be interpreted carefully as they represent the first experience in numerous centres using different immunosuppressive protocols, without any randomization. The results from the largest of these centres reflect the current situation more closely. Functional grafts lead to gastrointestinal autonomy (weaning of PN) while maintaining satisfactory nutritional status and normal growth in childhood. Intestinal transplantation is theoretically indicated for all patients permanently or dependent for a long time on PN. However, as PN is generally well tolerated, even for long periods, each indication for transplantation must be carefully weighed up in terms of the iatrogenic risk and quality of life. When PN has reached its limits, especially in those associated with vascular, infectious, hepatic or metabolic complications, intestinal transplantation must be undertaken. Transplantation of the small bowel alone remains the first option, as combined liver-small bowel grafting is only indicated in the case of life-threatening progressive cirrhogenic liver disease.     

A three-year follow-up on standard versus thin wall ePTFE grafts for hemodialysis

PURPOSE: Expanded polytetraflouroethylene (ePTFE) grafts are the most popular prosthetic grafts for hemodialysis patients in whom autogenous fistulas cannot be constructed. Long-term studies to study the durability and complication rate of the different wall configurations of ePTFE grafts have not been carried out. The primary, secondary, and cumulative patency and other complications between standard thickness (STD) and thin wall (THN) 6 mm stretch ePTFE grafts (WL Gore & Assoc, Flagstaff, AZ) was prospectively evaluated. METHODS: From September 1993 to August 1995, 108 patients receiving new grafts were randomized into 2 groups: those receiving STD grafts (n = 56) or those receiving THN (n = 52) grafts. Data prospectively collected included day of first access, primary patency, interventions required, and long-term results. Infections, pseudoaneurysms, and mortality were also documented. Student's unpaired t-test was used to compare the 2 groups, and log-rank life tables were constructed and compared. RESULTS: Mean follow-up examination time was 38.1 +/- 0.8 months for STD grafts and 35.1 +/- 1.0 months for THN grafts (P<.03). Longer patency was noted in the STD group of grafts (18.2 months for STD vs. 12.1 months for THN). Biographical data and complications, including pseudoaneurysm (6% vs. 5%), infection (2% vs. 3%), and mortality (22% vs. 19%), between STD and THN groups were not different statistically. Mean primary (18.2 months vs. 12.1 months), secondary (20.9 months vs. 13.7 months), and cumulative patency times (22.2 months vs. 15.2 months) for the STD group were significantly more than those for the THN group (P<.000 by log rank of life tables). Other complications were not different between groups. CONCLUSION: Standard thickness ePTFE is the graft of choice when placing ePTFE arteriovenous grafts for hemodialysis.     

A case of de novo translocation 16;21: trisomy 16q phenotype and origin of the aberration

We reviewed our experience over a 12 month period with using minimally invasive direct coronary artery bypass (MIDCAB) for the management of high-risk patients with three-vessel coronary artery disease. Twenty patients (4 females, mean age 67 years) received left internal mammary artery (LIMA) grafts to the left anterior descending (LAD) coronary artery. Associated co-morbidity included: severe chronic renal failure, severe extensive arteriopathy, chronic obstructive airway disease, poor general condition and severely impaired left ventricular function. There was one early postoperative mortality and no other cardiac-related morbidity. Graft patency investigated, using angiography was 90%, and 5 patients underwent follow-up angioplasty to other coronary arteries. All patients remain entirely angina free at a follow-up period between 3 and 12 months. We conclude that MIDCAB is a safe and effective approach for managing high-risk patients with three-vessel coronary artery disease.     

Internal mammary artery graft angioplasty: acute and long-term outcome

Secondary to the low attrition rate of internal mammary artery grafts, limited data are available on the clinical and angiographic outcome of patients who have undergone balloon angioplasty of an internal mammary artery stenosis. This study examined a consecutive series of 68 patients who underwent balloon angioplasty of an internal mammary artery graft over a 9-year period. Procedural success was achieved in 60 of 68 (88%) patients. The primary reason for procedural failure was extreme vessel tortuosity. There were no major in-hospital complications. Angiographic follow-up was obtained in 78% of the patients with an angiographic restenosis rate of 19%. The overall event-free survival in patients with an initially successful procedure was 92%. In conclusion, internal mammary artery balloon angioplasty has both an excellent initial success rate as well as a low incidence of restenosis and repeat target lesion revascularization.     

Interleukin-18 (IFNgamma-inducing factor) induces IL-8 and IL-1beta via TNFalpha production from non-CD14+ human blood mononuclear cells

Over a 6-month period, 23 members of the International Microvascular Research Group participated in a prospective survey of their microvascular free-flap practice. Data were recorded with each case for 60 variables covering patient characteristics, surgical technique, pharmacologic treatment, and postoperative outcome. A total of 493 free flaps were reported with a representative demographic distribution for age, sex, indications for surgery, risk factors, flap type, surgical technique, and pharmacologic intervention. Mixed effects logistic regression modeling was used to determine predictors of flap failure and associated complications. The overall incidence of flap failure was 4.1 percent (20 of 493). Reconstruction of an irradiated recipient site and the use of a skin-grafted muscle flap were the only statistically significant predictors of flap failure, with increased odds of failure of 4.2 (p = 0.01) and 11.1 (p = 0.03), respectively. A postoperative thrombosis requiring re-exploration surgery occurred in 9.9 percent of the flaps. The incidence of this complication was significantly higher when the flap was transferred to a chronic wound and when vein grafts were needed, with increased odds of failure of 2.9 (p = 0.02) and 2.5 (p = 0.02), respectively. There was a lower incidence of postoperative thrombosis when rectus/transverse rectus abdominis muscle (TRAM) flaps were used, where odds of failure decreased by 0.36 (p = 0.04), and when subcutaneous heparin was administered in the postoperative period, where odds decreased by 0.27 (p = 0.04). There was an overall 69-percent salvage rate for flaps identified with a postoperative thrombosis. Intraoperative thrombosis occurred in 41 cases (8.3 percent) and was observed more frequently in myocutaneous flaps or when vein grafts were needed (5.5 and 5.0 greater odds, respectively; p < 0.001) but was not associated with higher flap failure (2 of 41 cases; 4.9-percent failure rate). The incidence of a hematoma and/or hemorrhage was increased in obese patients and when vein grafts were needed [2.7 (p = 0.02) and 2.6 (p = 0.03) greater odds, respectively], whereas this complication was significantly decreased in muscle flaps (myocutaneous or skin-grafted muscle), in tobacco users, when a heparinized solution was used for general wound irrigation, and when the attending surgeon performed the arterial anastomosis (in contrast to the resident or fellow on staff) (p < 0.05 for each factor). With the multivariable analysis, many factors were found not to have a significant effect on flap outcome, including the recipient site (e.g., head/neck, breast, lower limb, etc.); indications for surgery (trauma, cancer, etc.); flap transfer in extremes of age, smokers, or diabetics; arterial anastomosis with an end-to-end versus end-to-side technique; irrigation of the vessel without or with heparin added to the irrigation solution; and a wide spectrum of antithrombotic drug therapies. These results present a current baseline for free-flap surgery to which future advances and improvements in technique and practice may be compared.     

Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience

OBJECTIVE: The primary objectives of this report were, first, to determine the number and incidence of complications of transsphenoidal surgery performed by a cross-section of neurosurgeons in the United States and, second, to ascertain the influence of the surgeon's experience with the procedure on the occurrence of these complications. The secondary objective was to review complications of transsphenoidal surgery from the standpoint of their causation, treatment, and prevention. METHODS: Questionnaires regarding 14 specific complications of transsphenoidal surgery were mailed to 3172 neurosurgeons. The data reported were analyzed from the 958 respondents (82%) who reported performing the operation. The neurosurgeons surveyed were asked to estimate the number of transsphenoidal operations performed, to identify any complications observed, and to estimate the percentage of operations that had resulted in any of the 14 specific complications. The 958 respondents were placed into three experience groups, based on the number of transsphenoidal operations performed. The data were analyzed by using chi 2 tests and Spearman correlation coefficients. The secondary objectives were met through a detailed review of the literature, in light of our experience. RESULTS: Of the respondents, 87.3% reported having performed < 200 operations and 9.7% reported 200 to 500 previous operations. The remaining 3% reported more than 500 previous operations. More extensive previous experience with transsphenoidal surgery was associated with a greater likelihood of having witnessed each specific complication. The mean operative mortality rate for all three groups was 0.9%. Anterior pituitary insufficiency (19.4%) and diabetes insipidus (17.8%) were complications with the highest incidence of occurrence. The overall incidence of cerebrospinal fluid fistulas was 3.9%. Other significant complications, such as carotid artery injuries, hypothalamic injuries, loss of vision, and meningitis, occurred with incidence rates between 1 and 2%. An inverse relationship was found between the experience group and the likelihood of complications, as indicated by significant negative Spearman correlation coefficients for all but 2 of the 14 complications listed in the survey (P < 0.05). Thus, increased experience with transsphenoidal surgery seems to be associated with a decreased percentage of operations resulting in complications. Some caution should be exercised in interpreting these data, because they are based on the respondents' estimates. CONCLUSION: Transsphenoidal surgery seems to be a reasonably safe procedure, with a mortality rate of less than 1%. However, a significant number of complications do occur. The incidence of these complications seems to be higher, with statistical significance, in the hands of less experienced surgeons. The learning curve seems to be relatively shallow, because a statistically significantly decreased incidence of morbidity and death could be documented after 200 and even 500 transsphenoidal operations. Better understanding of the indications for transsphenoidal surgery and improved familiarity with the regional anatomy should further lower the incidence of death and morbidity resulting from this procedure in the hands of all neurosurgeons.     

Gastrostomy buttons for nutritional support on chronic dialysis

RATIONALE: Nutritional support for children on chronic dialysis often involves the use of nasogastric tubes or gastrostomy feeding. We report our experience using gastrostomy buttons (GB) over a 6.6-year period to document their success/failure, the feeding regimens employed and the impact on growth. DESIGN: In 339 patient months of prospective observation, 22 children (14 male) commenced gastrostomy feeding at a median age of 2.3 years (range 0.2-10.3 years). Sixteen patients had an initial gastrostomy catheter inserted at the same time as a chronic dialysis catheter. Eighteen patients were established on continuous cycling peritoneal dialysis (CCPD) and four on haemodialysis (HD). RESULTS: The mean duration of combined gastrostomy feeding and chronic dialysis was 14.5 months (range 2.4 56 months). In 20 of the children followed for 6 months on combined GB feeding and dialysis, the mean protein and energy intakes were 2.5 g/kg bodyweight/day (range 1.7-3.4 g) and 108 kcal/kg bodyweight/day (range 72-129 kcal). The mean energy intake achieved was 116% (range 98-155%) of the estimated average requirement (EAR) for energy. The mean percentage of total energy and protein intakes delivered via the GB during the study period was 61% (33-95%) and 61% (23-98%) respectively. Mean height standard deviation score (SDS) was -2.22 prior to GB feeding and -2.06 at the end of the study period (P = 0.005) and mean weight SDS was -2.22 and -1.16 (P = 0.001) respectively. The mean life of the GB was 7.7 months (range 2.6 14 months) with most button changes due to leakage problems. Two episodes of peritonitis were attributable to the GB with one requiring peritoneal dialysis catheter removal due to candida infection. The GB was removed at a mean of 2.8 months (range 0.8-8.3 months) after renal transplantation in 13 children. CONCLUSION: The gastrostomy button provides a valuable and aesthetically appealing route for nutritional support with few complications.     

Pulse-spray pharmacomechanical thrombolysis of thrombosed hemodialysis access grafts: long-term experience and comparison of original and current techniques

OBJECTIVE: Pulse-spray pharmacomechanical thrombolysis is an evolving method for the treatment of vascular occlusions in which a highly concentrated fibrinolytic agent is injected as a high-pressure spray directly into thrombus. The purpose of this retrospective study was to analyze our long-term experience with this technique for the treatment of clotted hemodialysis grafts and to compare the efficacy and safety of the original and current methods. SUBJECTS AND METHODS: Over 6 years, 284 cases of dialysis graft thrombosis were considered suitable for treatment with pulse-spray thrombolysis. The original technique involved the injection of highly concentrated urokinase directly into a clot through two crisscross catheters with multiple side holes. The current technique includes early fragmentation of residual clot with a balloon catheter, intrathrombic injection of heparin, mechanical treatment of a lysis-resistant clot at the arterial anastomosis, and routine administration of aspirin. After thrombolysis, underlying obstructions were treated with balloon angioplasty, atherectomy, or stents. The technical success, immediate clinical success, and frequency of complications for the entire population were analyzed. In addition, the results for 36 cases treated with the original technique were compared with the results for 37 recent cases treated with the current technique. RESULTS: Of 284 cases considered suitable for treatment, thrombolysis was not done in eight cases because the venous anastomosis could not be crossed. Thrombolysis was discontinued in two cases because of extravasation of contrast material. The technical success for all grafts considered for treatment was 96%; 92% of treated grafts remained patent for at least 24 hr. Major complications occurred in 1% of cases, and minor complications occurred in 9% of cases. The clinical efficacies of the original and current techniques were 86% and 92%, respectively. The mean thrombolytic agent infusion time was reduced from 44 +/- 20 min to 23 +/- 13 min (p < .001). The overall procedure time for the recently treated subgroup was 67 +/- 26 min. There was no significant difference in the frequencies of major and minor complications between the treatment subgroups. CONCLUSION: Pulse-spray pharmacomechanical thrombolysis is a reliable, rapid, and safe method for recanalization of occluded dialysis grafts. The current technique has been proven as safe and effective as the original technique but offers the advantage of a significant reduction in the time required for the infusion of thrombolytic agent.     

Restoring abdominal wall integrity in contaminated tissue-deficient wounds using autologous fascia grafts

Necrotizing abdominal wall infections, enteric fistulae, or exposed prosthetic material after ventral hernia repair often results in a loss of abdominal wall integrity. Further surgical reconstruction with prosthetic material is usually contraindicated in the contaminated wound because of the high infection rate necessitating prosthetic removal and further abdominal wall debridement. Consequently, for the past 9 years, we have been using free grafts of autologous fascia lata to replace deficient abdominal wall fascia and muscle in situations where prosthetic material is contraindicated and local tissue rearrangement (i.e., component separation) would be inadequate. Thirty-two patients (mean age 59 years) underwent abdominal wall reconstruction with autologous fascia lata grafts. Indications included exposed mesh (31 percent), enteric fistulae (28 percent), enteric contamination (22 percent), wound infection (13 percent), and immunosuppression alone (6 percent); 31 percent of all patients were immunosuppressed secondary to either a solid organ transplant or a systemic inflammatory disorder. Fascia grafts (mean size 10 x 17 cm) were sutured to the surrounding abdominal wall and covered by local skin flap advancement and/or myocutaneous flap rotation. All abdominal reconstructions were initially successful. Subsequent local abdominal wall complications included cellulitis (n = 3), seroma (n = 2), and skin dehiscence with exposed fascia grafts (n = 7). Five of seven patients with skin dehiscence healed by secondary intention, whereas two had split-thickness skin grafts successfully applied to the granulating fascia. Thigh donor site complications included hematoma (n = 1), skin dehiscence (n = 1), and seroma (n = 2). There have been no cases of lateral knee instability. The average follow-up period is 27 months (range 3 to 106 months). Recurrent hernia has been seen in three patients (9 percent). Interestingly, laparotomy has been performed through an intact fascia lata patch in three patients for unrelated intra-abdominal conditions. In each case, the graft was intact and revascularized, confirming experimental animal data performed in our laboratory. Recurrent hernia has not been observed through the laparotomy site. Our 9-year experience has demonstrated that in the face of large, contaminated abdominal wounds where prosthetic material is contraindicated and local tissue rearrangement would be inadequate, fascia lata autografts are a reliable adjuvant to abdominal wall reconstruction.     

Luminal foam cell accumulation is associated with smooth muscle cell death in the intimal thickening of human saphenous vein grafts

BACKGROUND: Occlusion of saphenous vein grafts is a major problem after coronary artery bypass graft surgery. Diffuse intimal thickening develops in all implanted aortocoronary saphenous vein grafts within 6 months to 1 year. In some regions of the thickened intima, foam cells accumulate along the luminal margin. This particular morphology resembles the morphology of unstable atherosclerotic plaques as they occur in coronary arteries. In the present study, we focused on the possible topographic relation between luminal foam cell accumulation and cell death of smooth muscle cells (SMCs) within the adjacent thickened intima. METHODS AND RESULTS: Segments of occluded and suboccluded implanted human aortocoronary saphenous vein grafts were obtained during reintervention coronary artery bypass graft surgery in 30 patients. In the regions of the vein grafts with luminal foam cell accumulation, the percentage of SMC alpha-actin immunoreactive area of the superficial intimal thickening was 6 +/- 1.4%, which was different from the 17.6 +/- 2.3% of the deep intimal thickening. A strong negative correlation between the number of foam cell nuclei and the percentage of SMC alpha-actin immunoreactive area in the adjacent superficial intimal thickening was present (r = -.77, P < .001). Within the superficial intimal thickening, cytoplasmic and DNA fragmentation could be detected, which points to apoptotic cell death. A fraction of the cytoplasmic fragments fitted the ultrastructural characteristics of matrix vesicles and showed pronounced calcium and phosphorus accumulation as demonstrated with the use of x-ray microanalysis. CONCLUSIONS: The close spatial relation among foam cell accumulation, pronounced intimal SMC loss, and cell death suggests the presence of a foam cell-derived factor that can induce cell death in the SMC population of the intimal thickening. The depletion of the intimal SMC population could promote plaque rupture and thrombotic complications in the grafts.     

Fate of infected and eroded hemodialysis grafts and autogenous fistulas

Between 1970 and 1991, we placed 1,090 grafts (bovine and polytetrafluoroethylene) in 1,041 patients and created 1,034 autogenous fistulas in 856 patients for hemodialysis. Subsequent revisions for complications resulted in a total of 3,944 operations performed in patients with grafts and 1,633 operations in patients with autogenous fistulas. A total of 255 infections developed in 158 of the patients with grafts, whereas 8 infections developed in 7 patients with autogenous fistulas. The puncture infection rate was 5%/yr (12%/yr for a second puncture infection). The clean wound infection rate was 3% for grafts and 0.4% for autogenous fistulas. We made an attempt to salvage the graft, usually with a segmental bypass, in 75% of patients with a graft infection. Grafts were salvaged in 80% of patients in whom salvage was attempted (60% of all patients with an infection). The results in the few patients with infected autogenous fistulas were relatively poor.