Insulin Secretion and Insulin Resistance Trajectories over 1 Year after Kidney Transplantation: A Multicenter Prospective Cohort Study

Background@#We investigated the changing patterns of insulin secretion and resistance and risk factors contributing to the development of post-transplant diabetes mellitus (PTDM) in kidney recipients under tacrolimus-based immunosuppression regimen during 1 year after transplantation. @*Methods@#This was a multicenter prospective cohort study. Of the 168 subjects enrolled in this study, we analyzed a total 87 kidney transplant recipients without diabetes which was assessed by oral glucose tolerance test before transplantation. We evaluated the incidence of PTDM and followed up the index of insulin secretion (insulinogenic index [IGI]) and resistance (homeostatic model assessment for insulin resistance [HOMA-IR]) at 3, 6, 9 months, and 1 year after transplantation by oral glucose tolerance test and diabetes treatment. We also assessed the risk factors for incident PTDM. @*Results@#PTDM developed in 23 of 87 subjects (26.4%) during 1 year after transplantation. More than half of total PTDM (56.5%) occurred in the first 3 months after transplantation. During 1 year after transplantation, insulin resistance (HOMA-IR) was increased in both PTDM and no PTDM group. In no PTDM group, the increase in insulin secretory function to overcome insulin resistance was also observed. However, PTDM group showed no increase in insulin secretion function (IGI). Old age, status of prediabetes and episode of acute rejection were significantly associated with the development of PTDM. @*Conclusion@#In tacrolimus-based immunosuppressive drugs regimen, impaired insulin secretory function for reduced insulin sensitivity contributed to the development of PTDM than insulin resistance during 1 year after transplantation.

Insulin Secretion and Insulin Resistance Trajectories over 1 Year after Kidney Transplantation: A Multicenter Prospective Cohort Study

Background@#We investigated the changing patterns of insulin secretion and resistance and risk factors contributing to the development of post-transplant diabetes mellitus (PTDM) in kidney recipients under tacrolimus-based immunosuppression regimen during 1 year after transplantation. @*Methods@#This was a multicenter prospective cohort study. Of the 168 subjects enrolled in this study, we analyzed a total 87 kidney transplant recipients without diabetes which was assessed by oral glucose tolerance test before transplantation. We evaluated the incidence of PTDM and followed up the index of insulin secretion (insulinogenic index [IGI]) and resistance (homeostatic model assessment for insulin resistance [HOMA-IR]) at 3, 6, 9 months, and 1 year after transplantation by oral glucose tolerance test and diabetes treatment. We also assessed the risk factors for incident PTDM. @*Results@#PTDM developed in 23 of 87 subjects (26.4%) during 1 year after transplantation. More than half of total PTDM (56.5%) occurred in the first 3 months after transplantation. During 1 year after transplantation, insulin resistance (HOMA-IR) was increased in both PTDM and no PTDM group. In no PTDM group, the increase in insulin secretory function to overcome insulin resistance was also observed. However, PTDM group showed no increase in insulin secretion function (IGI). Old age, status of prediabetes and episode of acute rejection were significantly associated with the development of PTDM. @*Conclusion@#In tacrolimus-based immunosuppressive drugs regimen, impaired insulin secretory function for reduced insulin sensitivity contributed to the development of PTDM than insulin resistance during 1 year after transplantation.

Surgical Removal of the Inferior Vena Cava Filter Using Minimal Cavotomy: A Case Report

The use of retrievable inferior vena cava (IVC) filters has markedly increased in the recent years. However, the failure rate for the retrieval of the IVC filters using the endovascular method is reported to be up to 19%. Open surgical removal of the IVC filters is technically challenging and may require longitudinal cavotomy, clamping, and repair of the IVC. Here, we present a case of successful open surgical removal of the IVC filter using minimal cavotomy. This technique is an effective method after a failed endovascular removal attempt.

The Advantage of Common Femoral Endarterectomy Alone or Combined with Endovascular Treatment

PURPOSE: Although common femoral artery endarterectomy (CFAE) is regarded as the standard treatment modality for common femoral artery (CFA) disease, availability of advanced endovascular techniques has resulted in an increased number of CFA disease being treated. We evaluated clinical outcomes in a contemporary series of patients who were treated for CFA disease using endarterectomy alone or combined with endovascular treatment. MATERIALS AND METHODS: We retrospectively reviewed 46 patients from November 2001 through December 2007. The treated lesions were divided into 4 groups based on operative procedure: group I (n=11), CFAE alone; group II (n=15), CFAE and iliac artery (IA) endovascular treatment; group III (n=6), CFAE and superficial femoral artery (SFA) endovascular treatment; group IV (n=14), CFAE and IA and SFA endovascular treatment or bypass surgery. RESULTS: The degree of CFA steno-occlusion was not different among the groups. The 3-year primary patency rates of each group were 88.9±10.5%, 60.0±14.5%, 62.5±21.3%, and 83.9±10.4%, respectively. The 3-year primary assisted patency rates were 100%, 70.0±13.0%, 62.5±21.3%, and 89.3±10.4%, while 3-year secondary patency rates were 100%, 80.0±13.0%, 62.5±21.3%, and 92.3±7.4%, respectively. There was no procedure-related mortality. Significant improvement of ankle-brachial index was achieved in all groups. CONCLUSION: CFAE alone is the treatment of choice for excellent patency and clinical improvement in steno-occlusive lesions confined to the CFA. In multiple steno-occlusive diseases, this procedure could be combined with endovascular procedures to reduce the operative risk in conditions with high morbidity.

Pseudoaneurysm Formation due to Popliteal Artery Injury Caused by Drilling during Medial Opening Wedge High Tibial Osteotomy

We report a case of 53-year-old woman with an injured popliteal artery due to excessive drilling with a drill bit during medial opening wedge high tibial osteotomy (MOWHTO). Pseudoaneurysm was diagnosed three days after surgery and confirmed by urgent computed tomography (CT) angiography. Open vascular surgery with resection of the perivascular hematoma and end-to-end anastomosis using ipsilateral saphenous vein interposition graft was performed. CT angiography at 8 months postoperatively showed that blood flow was maintained without obstruction of the graft site and active dorsiflexion of the foot was possible. To reduce neurovascular injury during MOWHTO, it is important not to drill the far cortex at the proximal part of the osteotomy site when using a drill bit, and the metal should be positioned posteromedially as much as possible.

Long-Term Results of Catheter-Directed Thrombolysis Combined with Iliac Vein Stenting for Iliofemoral Deep Vein Thrombosis

PURPOSE: We were going to access the effect of catheter-directed thrombolytic therapy (CDT) on post-thrombotic syndrome (PTS) and the long term effects of iliac vein stenting in acute iliofemoral deep vein thrombosis (IFDVT). MATERIALS AND METHODS: Fifty-six limbs in fifty-one patients (46 unilateral, 5 bilateral) were included from November 2001 through December 2007. Patients were classified based on the method of treatment: with stent implantation (n=37) and without stent implantation (n=19). The Villalta scale was chosen to assess for severity of PTS. The validated outcome measures were compared between the treatment groups. Statistical analysis was estimated according to the Kaplan-Meier test and Pearson chi-square test. RESULTS: Mean age was 57+/-13 years (range, 27-76 years). Mean follow up duration was 56+/-12 months (range, 24-144 months). Overall 5-year primary patency rate was 66.1% (77.8% in the stenting group and 42.1% in the non-stenting group) and showed statistically significant difference between the two groups (P=0.02). The recurrence rate of deep vein thrombosis was 10/37 (27.1%) in the stenting group and 11/19 (57.9%) in the non-stenting group, respectively, which showed statistically significant difference between the two groups (P=0.024). Overall incidence of mild PTS was 8/30 (26.7%): 4/13 (30.8%) in the stenting group and 4/17 (23.5%) in the non-stenting group. None of the other factors showed statistically significant difference between the groups. CONCLUSION: Long term results of CDT in IFDVT were acceptable, and stent implantation to the iliac segment seems to have a good effect on the long term results. Therefore CDT with simultaneous stenting is recommended to improve long term results of IFDVT, if indicated.

Management of inferior vena cava thrombosis after blunt liver injury

Inferior vena cava (IVC) thrombosis after traumatic liver injury is an extremely rare condition, and only 12 cases have been reported in the English literature since 1911. We report a case of a 26-year-old man who presented with IVC thrombosis after blunt liver injury. IVC thrombosis was incidentally detected by computed tomography 15 days after conservative management of blunt liver injury. The patient denied any symptoms of thrombophlebitis and did not have any evidence of hypercoagulable state. We placed an IVC filter via the right jugular vein and started the anticoagulation treatment. The patient recovered successfully without operative treatment and IVC thrombosis disappeared completely two months later. We suggest that that the possibility of IVC thrombosis should be considered in patients with a large hematoma of the liver, which may cause compression of the IVC.

Successful aspiration and thrombolytic therapy for acute superior mesenteric artery occlusion / 대한외과학회지

To report a case of acute superior mesenteric artery (SMA) embolism successfully treated with aspiration and pharmacological thrombolysis. A 74-year-old female was admitted to the hospital with acute abdominal pain 5 hours in duration. Computed tomography angiography revealed a complete embolic occlusion distal to the first jejunal branch of the SMA. Aspiration and local continuous thrombolysis with urokinase resulted in near complete revascularization of the mesenteric flow after 4 hours and almost complete restoration after 20 hours. The patient made a complete recovery and continues to do well on warfarin therapy after treatment. Aspiration and thrombolytic therapy can be an alternative treatment modality in surgical high risk patient.

Early experience of thoracic endovascular aortic repair: a local single hospital experience / 대한외과학회지

PURPOSE: The purpose of this retrospective study was to evaluate the short- to mid-term results of thoracic endovascular aortic repair (TEVAR) in Wonkwang University School of Medicine & Hospital. METHODS: Between February 2009 and May 2011, 8 consecutive patients had undergone endovascular stent-grafting for thoracic aortic diseases. Five patients were treated for traumatic thoracic aortic injuries, two patients were treated for thoracic aneurysms and one patient was treated for a pseudoaneurysm due to penetrating aortic ulcers. Attempted stent-graft deployment was performed electively in 6 patients and emergently in 2. Follow-up was performed at 1-month, 6-month, 1-year, and annually thereafter. RESULTS: Technical success rates were achieved in 87.5% and the 30-day mortality rate was 0%. Mean hospital length of stay after TEVAR was 30 days in traumatic thoracic aortic injuries and 10 days in thoracic aneurismal diseases. Intra-operative Type I endoleak due to migration at deflation was visualized in 1 patient, which was treated by insertion of another stent-graft. During follow-up, a major complication was encountered in one patient who received carotid-subclavian bypass to relieve left arm ischemia. After 5 months he was treated with arch replacement for aortic arch aneurysm with type I endoleak at proximal site after endovascular treatment. The 30-day mortality rate was 0%. However, 1 case of mortality (12.5%) was observed during the follow-up period. CONCLUSION: The short and mid-term results of endovascular repair of thoracic aortic diseases are promising. TEVAR is an effective procedure in the management of thoracic aortic diseases.

For a Better Understanding of the Bypass Versus Angioplasty in Severe Ischemia of the Leg Trial

Non-invasive treatment has been going under active developments and is considered as a prior choice in modern medical circles. It is no exception to the field of vascular surgery. It is rather going under more radical changes. The irreversible trend has come so far, and the Korean Vascular Surgery Society should adapt well to this new environment and try to dominate in intravascular treatment. Therefore, it is crucial to draw interest in the methods of intravascular treatment among the members of our association and to encourage the usage of this method wider and more actively. A lot of vascular surgeons like to quote the results of Bypass versus Angioplasty in Severe Ischemia of the Leg (BASIL) trial to self-assure and have pride in the excellency of vascular surgery. However, the current citations are not accurate enough, so it is essential to understand the results of the BASIL trial more exactly to change the current trend of the Korean Vascular Surgery Society and make a huge step forward. This paper will analyse the results of BASIL trial in a more specific and objective way.

Usefulness of PTFE Graft in Above-Knee Femoropopliteal Artery Bypass

PURPOSE: Which graft material is appropriate for the above-knee femoropopliteal (AK fem-pop) bypass has been a controversy. We were to evaluate the usefulness of PTFE graft in AK fem-pop bypass by comparing the results of autogenous vein graft in below-knee femoropopliteal bypass. METHODS: This was a retrospective study of data for Fem-Pop bypass from August 1999 to August 2008. The median follow-up was 59.9+/-27.3 months. The demographic data, patency rate, secondary procedures, and amputation rate were compared, and statistical comparison was performed by Kaplan-Meier method, Log-rank test, and Chi-square test. RESULTS: Seventy-three bypasses were performed in 63 patients: PTFE graft in 48 cases (Group A), autogenous vein in 25 cases (Group B). Sixty-one patients (96.81%) were men. The mean age was 67.3+/-8.0 years. The indication for surgery was intermittent claudication in 27 cases (37.0%), critical limb in 46 cases (63.0%). The 6-yr primary patency rates were 28.1%; 60.3%, the 6-yr secondary patency rates were 37.2+/-8.4%, 67.0+/-14.7% in Group A and Group B, respectively (P<0.05). The number of secondary procedures was 31 and 3, respectively (P<0.05). Major amputation at later periods was not needed in Group B, but there were 9 cases in group A (P<0.05). CONCLUSION: PTFE graft for above-knee femoropopliteal bypass shows poor long-term patency with a large number of secondary procedures and a higher amputation rate than vein graft in BK Fem-Pop bypass. PTFE graft should be limited to patients with high operative risk, or poor venous graft.

Clinical Features of Lower Extremity Artery Embolism: Comparison of the Clinical Features between Ilio-femoral and Popliteal Artery Embolism

PURPOSE: Prompt operative management of patients with peripheral artery embolism remains the treatment of choice for this malady. The clinical status of the limb, rather than the elapsed time from the onset of occlusion, was recently determined to be the best predictor of limb salvage. We investigated the clinical features, therapeutic modalities and treatment results of popliteal artery embolism compared with that of ilio-femoral artery embolism. METHODS: A retrospective review was carried out for 21 cases that were treated for lower extremity arterial embolism, from March 2000 to June 2006. The patients were classified into two groups; Group A (ilio-femoral artery embolism, n=11) and Group B (popliteal artery embolism, n=10). We analyzed the interval time from the onset of symptoms to starting treatment (the interval time), the degree of limb ischemia, the therapeutic modalities and the treatment results. RESULTS: The average interval time was 16.2+/-16.9 hours in the total 21 cases; the average interval time for Group A was 7.7+/-2.9 hours and that for Group B was 25.5+/-20.9 hours (P<0.05), and the incidence of severe limb ischemia (class IIb according to the SVS/ISCVS reporting standard) was 72.7% vs 20.0%, respectively (P<0.05). For the therapeutic modalities, surgical thromboembolectomy was performed in all cases of Group A and for 3 cases of Group B. Seven cases of Group B received radiologic intervention (3 cases percutaneous aspiration embolectomy only, and 4 cases of additional thrombolytic therapy). CONCLUSION: This study shows that the interval time for popliteal artery embolism is longer than that for ilio-femoral artery embolism. In other words, it is suggested that the symptomatic progression of popliteal artery embolism is slower than that of ilio-femoral artery embolism. Therefore, we can have more chances for variable therapeutic options such as surgical thromboembolectomy, percutaneous aspiration embolectomy and/or thrombolytic therapy in patients suffering with popliteal artery embolism.

Renal Vein Thrombosis after Delivery / 대한비뇨기과학회지

Renal vein thrombosis is a rare, renal disease in adults that is related to hypercoagulability. We experienced a case of renal vein thrombosis in a 30-years old woman who presented with fever, chills and left flank pain after delivery. She was treated with catheter-directed thrombolytic therapy and oral anticoagulants.

Hemodynamic Characteristics of Vascular Occlusive Disease

No abstract available.

Hemodynamic Characteristics of Vascular Occlusive Disease

No abstract available.

Isolated Aneurysm of the Left Common Iliac Artery that was Secondary to Medial Degeneration

Isolated aneurysm of the common iliac artery that is secondary to medial degeneration (MD) is a very rare clinical entity. MD is an important histological abnormality that is commonly seen in the annuloaortic ectasia with Marfan syndrome. This abnormality is also observed in congenital aortic disease, atherosclerosis, and aging. This aortic disease develops as the consequences of disruption of the medial elastic layers in association with loss of vascular smooth muscle cells and the accumulation of proteoglycans. An iliac aneurysm greater than 3 cm in diameter should be treated. The treatment options include open surgical replacement with prosthetic graft or endovascular stent grafting. We experienced one case of the isolated common iliac artery aneurysm in a 60 year-old female patient. Her chief complaint was a pulsatile painful mass in the left lower quadrant of the abdomen that she had suffered with for 5 days. She was treated by performing aorto-left external iliac artery bypass with a Dacron graft (10 mm in diameter). The result was excellent. We report here on a case of a isolated common iliac artery aneurysm that was caused by MD, and we include a review of the relevant literature.

Buerger's Disease in Korea

PURPOSE: Buerger's disease (Thromboangiitis obliterans, TAO) is characterized by non- atheromatous inflammatory disease, and segmental inflammatory thrombotic occlusions of the small & middle-sized arteries and veins of the upper or lower extremities. Any epidemiological study of Buerger's disease in Korea has not been carried out until now. This study was undertaken to investigate the incidence of Buerger's disease in Korea among the patients suffering with arterial disease. METHODS: We collected and analyzed the data on 11,128 patients who were admitted to or visited the participating 22 hospitals for chronic arterial diseases throughout the major region of the South Korea from January 1986 to December 2003. The clinical diagnostic inclusion criteria for Buerger's disease were the followings: (1) a history of smoking or tobacco abuse; (2) an age of onset less than 50 years; (3) infrapopliteal, segmental arterial occlusions with sparing of the proximal vasculature; (4) frequent distal upper extremity arterial involvement (Raynaud's syndrome or digital ulceration) or-superficial phlebitis; and (5) the absence of arteriosclerotic risk factors other than smoking. RESULTS: The incidence rate of Buerger's disease among the arterial disease (11,128 patients) was 93 patients (0.83%) when the strict criteria of Shionoya was applied. 699 male-patients (6.55%) and 30 female patients (4.12%) who met the less strict criteria (the extended clinical diagnostic criteria group) were also reviewed. The 4th and 5th decades were the most common ages with-249 patients (34.2%) and 222 patients (30.5%) respectively, being found at these ages. The mean age was 40.4+/-1.6 years (age range: 16~83 years) and this was similar in both the strict criteria group and the less strict criteria group. CONCLUSIONS: This study suggests there was a low incidence of Buerger's disease in Korea among the patients who visited the participating hospitals when the strict diagnostic criteria were used. The incidence was lower than expected even when the less strict criteria were used. The more accurate incidence of Buerger's disease among the general population can be obtained by performing careful prospective study that is participated in by not only vascular surgeons, but also the other medical specialists with utilizing the strict diagnostic criteria.

Risk Factor of Recurrent Venous Thrombosis after Endovascular Management of Iliofemoral Deep Vein Thrombosis

PURPOSE: We wanted to evaluate the recurrence rate and risk factors of recurrent venous thrombosis after the endovascular management of acute iliofemoral deep vein thrombosis (DVT). METHOD: Between January 2002 and March 2005, catheter-directed thrombolysis with Urokinase (n=40) and/or stent placement (n=33) and/or aspiration (n=29) was performed in 40 patients with acute iliofemoral DVT. The patients were divided into two groups according to DVT recurrence during the follow-up period: Group A (n=9) with recurrence and Group B (n=31) without recurrence. The risk factors of each group were analyzed for the duration of symptom before the thrombolytic therapy, the risk factors, the dose of Urokinase, and the duration and results of thrombolytic therapy. RESULT: 15 patients were men (mean age; 56.8 yr) and 25 were women (mean age; 61.4yr). The mean duration of symptoms prior to the initiation of thrombolysis for each group was 16.3+/-11.3 days vs. 7.0+/-7.0 days (P=0.040), the average total Urokinase dose was 4.83 million IU vs 2.07 million IU, respectively (P=0.080), and the average duration of therapy was 86.1 hours vs. 59.1 hours, respectively. Complete thrombus resolution was obtained in 33/40 cases. The incidence of decreased anticoagulants such as protein C/S, Antithrombin did not show any difference between two groups. DVT recurred in 5/33 (15.1%) patients for whom the DVT were completely resolved, and in 4/7 (57.1%) patients among the incompletely resolved cases (P=0.034). The causes of recurrence (5/33) in the completely resolved cases were as follows; poor compliance, and other anatomical and systemic diseases (lumbar body anomaly, Behcet's disease and cancer peritonii, after obstetrical dilatation & curettage). CONCLUSION: We can conclude that the residual venous thrombosis and duration of symptom before the thrombolytic therapy are important risk factors for recurrent thrombosis. Its assessment may help to modify the duration of anticoagulation therapy for DVT patient. Whether the evaluation of DVT risk factors may help for the secondary preventive treatment should be assessed by specifically designed intervention studies.

Anatomic and Functional Diagnosis for Deep Vein Thrombosis

No abstract available.

The Risk Factors of Pancreatic Fistula after Pancratoduodenectomy

PURPOSE: Pancretojejunostomy leakage is the most dreaded complication after a pancratoduodenectomy. However, little is known about what causes the leakage and how to prevent it. The aim of this study was to dentify the risk factors for pancreatic leakage. This paper describes our experience of its management. METHODS: Between Aug. 1996 and Aug. 2003, 75 consecutive patients with periampullary cancer or benign disease received a pancreatoduodenectomy. The patients' clinical characterisitcs, pathological features and surgical findings were retrospectively evaluated. The patients were classified into those with major complication and rhose with no complications and the risk factors were analyzed. Pancreatic leakage, intraabdomnial fluid collection and abscess, intraabdomnial bleeding were categorized as major complications related to a pancreatic fistula. RESULTS: The postoperative mortality and morbidity rate was 2.6% and 36%, respectively. Univariate analysis showed that the pancreatic texture, pathologic diagnoses and comorbidity were significant risk factors for major complications (P= 0.003, 0.045, 0.02). Multivariate analyses revealed that the, pancreatic texture was the only significant risk factor (P=0.003). The preoperative serum albumin level and pancreatic texture were significant risk factors for pancreatic leakage (p=0.03, 0.025) and multivariate analysis showed that the pancreatic texture was also the most significant risk factor. CONCLUSION: Considering that the pancreatic texture is the most significant risk factor for a pancreatic fistula, the technical skill and experience of the surgeon appears to be important for its prevention.