Cumulative Patency Rate of Percutaneous Transluminal Angioplasty and Stent Placement for Aortoiliac Occlusive Disease

PURPOSE: To evaluate the results of iliac artery angioplasty and stent placement as an option for the treatment of aortoiliac occlusive disease. METHOD: The records of 30 patients (mean age, 65.5 years) who underwent iliac artery angioplasty and/or stent placement were reviewed retrospectively. Presenting symptoms included asymptomatic (6.7%), claudication (73.3%), rest pain (10%), ulceration/tissue loss (3.3%), and blue toe syndrome (6.7%). Follow-up included angioplasty, Doppler ultrasound, and clinical examination. Mean follow-up time was 32 months. RESULT: Forty iliac lesions were treated. Thirty-seven percent of patients had hypertension, 33% had diabetes mellitus, 23% had coronary arterial disease, 6.6% had cerebrovascular disease, 3.3% had hyperlipidemia and 3.3% had renal insufficiency. TASC (Trans Atlantic Inter-Society Consensus) A, B, C and D disease types were 11 (36.7%) patients, 5 (16.7%), 10 (33.3%) and 4 (13.3%). Ipsilateral superficial femoral artery occlusion was present in 6 (20%) patients. Concomitant femoral artery bypass surgery was performed in 10 (33.3%) patients. The cumulative primary patency rates were 83.4%, 71.9% and 64.7% at 1, 2, and 3 years, respectively. CONCLUSION: Iliac artery angioplasty and stent placement is a technically safe and effective treatment modality in patients without ipsilateral superficial femoral artery occlusion.

Significance of Plasma Homocysteine Concentration in Patients with Peripheral Arterial Disease

PURPOSE: Hyperhomocysteinemia has been identified as an important risk factor for coronary heart disease (CHD), cerebrovascular disease (CVD) and peripheral arterial disease (PAD). Previous reports have identified that elevated total homocysteine levels are associated with the development and progression of PAD, though little is known about its mechanism. Especially hyperhomocysteinemia is known to an independent risk factor for PAD. In this study, we examined the relationship between plasma homocysteine concentration and disease progression and disease severity in a patient with PAD. METHOD: We retrospectively analysed the clinical records of 65 patients, who were diagnosed with arteriosclerosis obliterans, for sex, mean homocysteine concentration, relationship between plasma homocysteine concentration and disease severity and disease progression at Kyung-Hee University Hospital from January 2002 to December 2003. Homocysteine level of 28 healthy adults was measured to identify normal value. Hyperhomocysteinemia was defined as a plasma homocysteine concentration exceeding the 95th percentile of the control group (> or =13.8mumol/L). RESULT: The study group comprised 56 men (86.29%) and 9 (13.8%) women. The mean plasma homocysteine concentration was higher in study group than in controls (11.4mumol/L vs. 10.03.mumol/L, P=0.06). Hyperhomocysteinemia was significantly more common in the disease progression groups (P=0.028). Mean plasma homocysteine concentrations associated with disease severity, according to the Rutherford classification, were 8.33mumol/L, 9.59mumol/L, 12.64 mumol/L and 14.17mumol/L at Grades 0, I, II and III, respectively. The high grade patients were significantly more likely to have high plasma homocysteine concentration (P=0.04). Plasma homocysteine concentration according to associated disease was 10.79mumol/L in patients with PAD alone, 10.88 mumol/L in patients with CVD, 15.02mumol/L in patients with CHD, and 14.99mumol/L in patients with both CVD and CHD. In patients associated with CHD, plasma homocysteine concentration was significantly higher (P=0.035). CONCLUSION: In this study, plasma homocysteine concentration was higher in patients with PAD than in controls. Especially, there was a high rate of hyperhomocysteinemia in patients associated with CHD. Progression of PAD was more likely in patients with elevated plasma homocysteine. The high-grade patients were more likely to have high plasma homocysteine concentration. Therefore, the measurement of plasma homocysteine concentration in patients with PAD is expected to be useful in making prognosis. However, a prospective, randomized study is necessary to prove the effect of homocysteine-lowering therapy in delaying disease progression.

Results of Femoro-Below Knee PTFE Bypass Graft

PURPOSE: Saphenous vein allografts are used for femoral-below knee bypass graft purposes in chronic lower limb ischemia. Polytetrafluoroethylene (PTFE) is an acceptable material for bypass graft, when it is difficult to gain a suitable vein for the graft material, such as the great saphenous, small saphenous, or arm vein. However, some controversy exists as to whether PTFE is equivalent to the saphenous vein as bypass graft material for femoral below knee revascularization. A retrospective analysis was performed to obtain results about femoral-below knee bypass graft using PTFE in chronic lower ischemia patients. METHOD: Between July 1992 and June 2002, 56 patients with chronic lower limb ischemia underwent femoral-below knee bypass graft. The results of treatment were analyzed retrospectively by the patients's clinical records. Kaplan-Meier analysis was used to estimate patency rate. RESULT: There were 52 men and 2 women, of mean age 66.6 years. The primary patency rate was 65.6%, 44.9%, 38.0%, and 34.0%, and the secondary patency rate was 85.7%, 72.0%, 72.0%, and 56.1%, after 1, 2, 3, and 5 years, respectively. The limb salvage rate was 78.8% in severe lower limb disease, such as disabling claudication, non-healing ulcer, and gangrene. The major amputation rate was 14.3%. There was no mortality within one month after bypass operation. The primary and secondary rates were not correlated with diabetes, inflow procedure, or severity of lower limb ischemia. CONCLUSION: The overall results of this study show that PTFE grafts have an acceptable patency rate when used for femoral-below knee bypass surgery in patients with chronic lower limb ischemia. This study suggests that early diagnosis of occlusion in graft and adjuvant procedures offers improved patency and limb salvage rate.

Long-term Follow Up Results of Nonoperative Treatment for Critical Lower Extremity Ischemia

PURPOSE: Immediate revascularization is required for patients with critical lower extremity ischemia, but sometimes only nonoperative treatments are performed due to multilevel arterial occlusive lesions, poor outflow tracts, deteriorated general conditions, and severe associated diseases. We undertook this study to detrmine the long-term results of nonoperative treatments for patients with critical lower extremity ischemia. METHOD: From January 1992 to July 2002, among the patients with lower extremity arterial disease who visited the Department of Surgery at Kyung Hee Medical Center, 72 patients with critical lower extremity ischemia who had been treated with only conservative managements were chosen. Medical records were reviewed retrospectively and telephone interviews were performed. We assessed the functional outcome of the salvaged limb according to the recommended scale for gauging changes in clinical status, the 1997 revised version. RESULT: There were 63 men and 9 women (M : F=7 : 1), and mean age was 70.1 years. At median follow-up of 64.7 months, amputation rate was 27.8%, limb salvage rate was 71.9%, and the mortality rate was 20.8%. Cerebrovascular attacks (40%) and ischemic heart disease (27%) were the major causes of death. Underlying disease were diabetes (65.3%), hypertension (54.2%), ischemic heart disease (11.1%), and previous cerebrovascular attacks (13.9%). Clinical categories of involved patients were grade II (ischemic rest pain) in 80.5%, and grade III (tissue loss) in 19.5%. In survivors with limb salvage, functional outcomes were +3 in 12.5%, +2 in 26.8%, +1 in 35.7%, 0 in 23.2%, and -1 in 1.8%. CONCLUSION: The long-term results of this study suggest that nonoperative treatments for patients with critical lower extremity ischemia can achieve a higher limb salvage rate and significant improvements in the functional outcomes of salvaged limbs.

A Retrospective Analysis on Reasons for Allograft Nephrectomy after Kidney Transplantation / 대한이식학회지

PURPOSE: Allograft nephrectomy has been done in considerable proportion due to many reasons after kidney transplantation. This study was undertaken to determine the incidence, causes, and time of allograft nephrectomy after kidney transplantation. METHODS: A total 141 kidney transplantations were performed between 1993 and 2003 Kyung Hee University Hospital. We found 22 cases of allograft nephrectomy in the same period and a retrospective analysis was conducted on 22 allograft nephrectomy. The patients records were reviewed for age, causes, and time of allograft nephrectomy after kidney transplantation. RESULTS: The pathological causes of allograft nephrectomy were chronic rejection in 18 cases (81.8%), acute rejection in 3 cases (13.6%), accelerated rejection in 2 cases (9.1%) and allograft infection, renal vessel thrombosis, cyclosporin toxicity, GVHD in each one case (4.5%). Of 18 cases with chronic rejection, acute rejection episode was occurred in 12 cases (66.7%). The interval from kidney transplantation to allograft nephrectomy was more than 5 years in most patients (63.6%). CONCLUSION: In our studies, allograft nephrectomy was performed in 22 cases, chronic rejection was major cause of allograft nephrectomy, and acute rejection episide was occurred in most chronic rejection. We suggested that early detection and aggressive treatment of acute rejection might be considered to lower the incidence of allograft nephrectomy after kidney transplantation.

Crawford Type III and IV Thoracoabdominal Aortic Aneurysm: 4 Cases Report

Thoracoabdominal aortic aneurysm is rare but potentially lethal, and its repair continues to present a surgical challenge because of obligate intraoperative visceral, renal, and spinal cord ischemia. In the past, the authors have experienced 4 cases of Crawford Type III and IV thoracoabdominal aortic aneurysm which were treated by a direct surgical approach. The diagnosis was made by CT scan, and aortogram. We repaired the thoracoabdominal aortic aneurysms with Knitted Dacron graft by a single inclusion button that encompasses the origins of the celiac, superior mesenteric, and right renal artery and left renal artery reconstruction with a separate side arm PTFE graft. the visceral ischemia time was less than 45 minutes in 3 operable cases and no paraplegia occurred after thoracoabdominal aortic reconstruction. two cases of Type IV thoracoabdominal aortic aneurysm with emergent presentation were fatal but elective surgical repairs of Type III and IV thoracoabdominal aortic aneurysm were survived. Appropriate patient selection and prevention of visceral or spinal cord ischemia may be helpful in the repair of Type III and IV thoracoabdominal aortic aneurysm.