High Prevalence of Peripheral Arterial Disease in Korean Patients with Coronary or Cerebrovascular Disease

This prospective study surveyed the prevalence of peripheral arterial disease (PAD) in Korean patients with coronary arterial disease (CAD) or cerebrovascular disorder (CVD). From March 2010, 576 hospitalized patients in cardiovascular or stroke center were enrolled as the study group. Ankle-brachial index (ABI) was measured and the cut-off point for diagnosing PAD was or = 50 yr was enrolled as the control group. The prevalence of PAD was significantly higher in the study group than the control group (7.6% vs 1.7%; P < 0.001). To analyze the relationship of other vascular diseases and PAD, the patients were regrouped; group A (no CAD or CVD), group B (CAD only), group C (CVD only), and group D (CAD and CVD). Compared with group A, those with other vascular diseases (group B, C, D) had significantly higher prevalence of PAD, diabetes, dyslipidemia, renal insufficiency and claudication. The trend that patients with CAD or CVD are at risk of PAD is observed in this cross-sectional study in Koreans. Routine ABI measurement is recommended in these high-risk groups for early detection and proper management of PAD.

Iliac Artery Thrombosis Due to Plaque Rupture During Performance of Anterior Lumbar Interbody Fusion: A Case Report

Anterior lumbar interbody fusion (ALIF) is a popular procedure that is used in spine surgery for treating disc herniation. Although this operation is usually safe, it can cause vascular injury, including arterial thrombosis. We report here on the case of 59-year-old woman who developed acute arterial thrombosis during ALIF. Toward the end of the operation, the somatosensory evoked potential signals decreased more than 50% in the left lower extremity, suggesting acute arterial occlusion. Therefore, a vascular surgeon was contacted and immediate thrombo-endarterectomy was performed. Thrombosis developed due to rupture of preexisting plaque during the arterial retraction. After the endarterectomy, the somatosensory evoked potentials signals and pulse were restored. To avoid vascular injury, preoperative evaluation of the vascular images and careful handling of the vessels during surgery are important. A vascular surgeon should be available not only in the event of complications, but such a surgeon should also be included from the planning of the operation.

Effects of Antiplatelet Agents on the Graft Survival in Murine Cardiac and Skin Transplantation Model / 대한이식학회지

BACKGROUND: At the initiation of immunologic response, platelets rapidly release chemical mediators which may induce rejection of transplanted organ. The purpose of this study was to investigate the effect of antiplatelet agents in murine cardiac and skin transplantation models. METHODS: In the minor major histocompatibility (MHC) mismatch model, BALB/c (H2d) mice underwent heart transplantation from B10.D2 (H2d) mice. In the major MHC mismatch model, CBA (H2k) mice were used as the recipients and C57BL/10 (H2b) mice as donors. The recipients were divided into four groups and each group was treated with distilled water (DW), sarpogrelate, cilostazol, or clopidogrel respectively. For skin transplantation, the recipients in the minor MHC mismatch model were divided into four groups similar to those in cardiac transplantation. The recipients in the major MHC mismatch model were divided into DW-treated and sarpogrelate-treated groups. All treatments were done by the per oral route of administration. RESULTS: For graft survival in the minor MHC mismatch model of cardiac transplantation, sarpogrelate-treated group showed increased median survival time (MST) compared to the other groups (DW-treated group 17.5 days, sarpogrelate-treated group 88 days, cilostazol-treated group 13 days, clopidogrel-treated group 23 days). Similar results were observed in the major MHC mismatch model. In the major MHC mismatch model, the expression of adhesion molecules (L-selectin, intercellular adhesion molecule-1 [ICAM-1], Mac-1, lymphocyte function associated antigen-1 [LFA-1]) was significantly higher in DW-treated group compared to sarpogrelate-treated group (P<0.05) In the minor MHC mismatch model, MST in the antiplatelet-treated skin graft group was not remarkably prolonged compared to DW-treated group. In the major MHC mismatch model, sarpogrelate-treated group showed prolonged survival compared to DW-treated group (MST 25 vs. 19 days, P<0.05). There was no statistically significant difference in the proportion of activated T cells and regulatory T cells. CONCLUSIONS: The tendency for a better survival of grafts was observed in the sarpogrelate-treated skin and heart transplant group compared to DW-treated group. However, further mechanistic study is necessary to these results.

A Clinical Comparison of Laparoscopic versus Open Appendectomy for Complicated Appendicitis

PURPOSE: Although laparoscopic appendectomies (LAs) are performed universally, a controversy still exists whether the LA is an appropriate surgical approach to complicated appendicitis (CA). We retrospectively evaluated the outcomes of laparoscopic versus open appendectomies for CA. METHODS: We retrospectively analyzed 60 consecutive patients who were diagnosed as having CA from July 2009 to January 2011. Outcomes such as operative time, time to soft diet, length of hospital stay, and postoperative complications were analyzed. RESULTS: There were no statistically significant differences in operative time between the LA and the open appendectomy (OA) groups. Return to soft diet was faster in the LA group (2.1 +/- 1.2 vs. 3.5 +/- 1.5 days; P = 0.001). Length of hospital stay was shorter for the LA group (4.4 +/- 2.3 vs. 5.8 +/- 2.9 days; P = 0.045). The overall complication rates showed no statistically significant difference between the two groups. In cases involving a periappendiceal abscess, the LA had a significantly higher incidence of intra-abdominal abscess (IAA) and postoperative ileus (PI; P = 0.028). CONCLUSION: The LA showed good results in terms of the time to soft diet, the length of hospital stay, and surgical site infection (SSI) whereas the overall complication rates were similar for the two groups. However, the LA was associated with significantly higher incidence of IAA and PI for the cases with a periappendiceal abscess. Therefore, when using a LA, the surgeon must take great care to minimize the incidence of IAA and PI if a periappendiceal abscess is present.

Oral Ulceration an Overlooked Complication of Mycophenolate Mofetil in a Renal Transplant Recipient / 대한이식학회지

Mycophenolate mofetil (MMF) is being widely used as a maintenance imunosuppressive therapy in renal transplant patients. Myelotoxicity and gastrointestinal symptoms are the well-known adverse effects of this immunosuppressant. However, there areexistonly two reports on oral ulceration associtated with MMF. Although oral ulcerations are not life-threatening, they may seriously affect the quality of life. We report ourthe experience of a case of a 57-year-old female patient with painful oral mucosal ulcerations that improved following MMF discontinuation.

Optimized Tacrolimus Therapy in the Early Stage after Renal Transplantation

PURPOSE: Immunosuppressive regimen based on reduced-dose Tacrolimus (TAC) is widely accepted in the field of renal transplantation. However, optimal targetsfor TAC whole blood trough concentrations during the early period after kidney transplantation remain uncertain. METHODS: A total of 184 consecutive adult renal transplant recipients with triple immunosuppression (TAC/Mycophenolate/corticosteroid) were included in this study. According to the trough level of TAC at day 7 after transplantation, patients were classified as low TAC concentration (LT, 15 ng/ml, n=24) groups. Rate of acute rejection, graft function and side effects of TAC within 1 yr after transplantation were evaluated. RESULTS: There was no difference in trough concentrations of TAC at 2 weeks, 1 month, 3 months, 6 months and 12 months after transplantation among the three groups. Significantly higher incidence of acute rejection within 2 weeks after transplantation was observed in LT group compared with IT and HT groups (17.4%, 5.6% and 4.8%, respectively, P=0.037). HT patients showed significantly better estimated glomerular filtration rates until 6 months after transplantation than IT and LT patients (75.5+/-24.8 vs. 63.8+/-12.8 and 64.3+/-15.2 ml/min at 6 months, P=0.03). There was no significant difference in TAC toxicity in terms of post-transplant diabetes and renal toxicity. CONCLUSION: Short-term high TAC exposure immediately after kidney transplantation may provide lower incidence of acute rejection and better restoration of graft function compared with low or intermediate TAC exposure.

Infectious Complications in Renal Transplant Recipients: Changing Epidemiology under Modern Immunosuppression / 대한이식학회지

BACKGROUND: Immunosuppressive agents with higher potencies, such as tacrolimus and mycophenolate mofetil (MMF), have been introduced and widely accepted in clinical practice. This study evaluated the impact of these newer immunosuppressive drugs on the pattern and timing of post-kidney transplantation infections. METHODS: Data of kidney transplant recipients at the Seoul National University Hospital between January 1990 and November 2005 were analyzed. Recipients were divided into double immunosuppression (double group, n=198), triple immunosuppression including MMF (MMF group, n=253), and azathioprine (AZA, n=184) groups. RESULTS: The MMF group demonstrated higher graft survival and reduced rates of acute rejection within the fifth post-transplant year than both the AZA (P<0.001) and the double (P<0.001) groups. The overall incidence of infection in the first month was significantly higher in the MMF group (2.17/1,000 transplant-days) than in the AZA (0.73/1,000 transplant-days) and double (0.84/1,000 transplant-days) groups (P=0.01, ANOVA), and this was caused by viral infections that were significantly higher in the MMF (1.57/1,000 transplant-days) group than in the AZA (0.54/1,000 transplant-days) and double (0.67/1,000 transplant-days) groups. MMF was identified as a significant risk factor for viral infection (P=0.013; OR, 2.04; 95% CI, 1.16-3.60) in a multivariate logistic regression analysis. CONCLUSIONS: The results suggest that viral infection rates were higher in the MMF group and should be considered the primary source of perioperative infectious complications in MMF-receiving recipients.

Effect of Nanoparticle with VEGF in Mouse Ischemic Hindlimb Model

PURPOSE: Vascular endothelial growth factor (VEGF) is one of the factors regulating angiogenesis. For angiogenesis, the local concentration of VEGF has to be maintained. Because of its short half-life, VEGF has been conjugated with nanoparticles. Some nanoparticles, such as poly (lactic-co-glycolic acid (PLGA)) or polyethylenimine (PEI) are commonly used in this field, but have weak points such as faster release than expected and cell toxicity. We investigated the effect of core/shell nanoparticles including lecithin lipid cores in the ischemic hindlimb model. METHODS: Mice were anesthetized and a region of the common femoral artery and vein was ligated and excised. Hindlimb ischemic mice (n=28) were divided randomly into four groups: Control group (normal saline, n=7), mouse VEGF group (mVEGF, n=7), nanoparticle including mVEGF group (N-mVEGF, n=7), and nanoparticle/hydrogel mouse VEGF group (NH-mVEGF, n=7). The drug was injected postoperatively into the thigh muscle of the ischemic limb. Perfusion, capillary number and H&E stain were assessed 28 d after treatment. RESULTS: The capillary number increased in N-mVEGF and mVEGF group (P=0.026). Improvements of ischemic limb perfusion were inferior in N-mVEGF, NH-mVEGF groups (P=0.006) compared to other groups. Mice received N-mVEGF, NH-mVEGF treatment showed significant inflammation in the H&E staining. CONCLUSION: Sustained VEGF delivery via core/shell nanoparticle with lecithin core did not show improved perfusion rate despite an increase in capillary number. Furthermore, vacuolization and induction of inflammation requiring a different composition of nanoparticle should be tested.

Trends in Deceased Organ Donation and Utilization in Korea: 2000-2009

Continuous efforts have been made by the organ donation and transplantation community in Korea to increase organ donation by the deceased. The authors detailed trends of organ donation and utilization over the past 10 yr using data provided by the KONOS. The yearly number of deceased donors has grown gradually since 2003. The number and percentage of old donors (> or =50 yr) and donors dying from intracranial hemorrhage has increased continuously. Therefore, the percentage of standard criteria donors (SCD) has been declining significantly, from 94% in 2000 to 79.2% in 2009. The number of organs transplanted per donor (OTPD) has also declined slightly since 2007, from 3.28 in 2007 to 2.95 in 2009. This decline may be attributable to increases in the number and percentage of extended criteria donors (ECD) and donors after cardiac death (DCD), since the OTPD was 2.25 for DCD, 2.5 for ECD, and 3.09 for SCD in 2009. In summary, the makeup of donors has changed significantly. There is an urgent need for establishment of an institutional framework including an independent organ procurement organization and for improvement for the National Transplant Act to increase deceased donor pool and to optimize management of ECD and DCD.

New Operative Treatment of Hyperfunctioning Arteriovenous Fistula for Hemodialysis: A Case Report

Hyperfunctioning fistulas are rare complications of hemodialysis access. They give rise to devastating complications, including a steal syndrome with reduced perfusion to the dependent limb and cardiac insufficiency caused by the high shunt volume. Numerous techniques such as fistula ligation, banding, plication, T-banding and distal revascularization with interval ligation have been developed. However, each technique bears the potential for its own complications, such as failure to resolve symptoms, recurrence and technical difficulty. Herein, we report a new technique that remedies the shortcomings of the other procedures. All the patients first underwent partial aneurysmal resection and lateral aneurysmorrhaphy of the enlarged vein from just distal to the anastomosis using a 6-0 prolene running sutures and then external wrapping with an 8 mm expanded polytetrafluoroethylene graft was done for a length of approximately 5 cm. Two patients with hyperfunctioning brachiocephalic arteriovenous fistula were treated this way. Doppler measurement of the fistula flow showed a mean flow reduction of about 60%. The procedure was effective and safe, with a mean follow up of 2 months.