Management of peripheral vascular problems in recipients of cardiac allografts.

Five hundred and twenty consecutive heart transplant cases (458 adult, 62 pediatric) were reviewed to assess the impact of peripheral vascular problems. Peritransplant interventions requiring vascular cannulation (e.g., intraaortic balloon pump procedures, catheterization of the right and left sides of the heart, femoral bypass) resulted in 10 complications that necessitated nine surgical procedures. Five aortic aneurysms (three infrarenal and two suprarenal) were resected. There was one death unrelated to the aneurysm resection. Sixteen patients had evidence of peripheral vascular disease (PVD). There were three deaths in this group, none directly related to the PVD. Three patients required vascular reconstruction (axillobifemoral, bilateral femoral distal and popliteal endarterectomy) in the posttransplant period, all for advanced ischemic symptoms. Except for one patient in whom ischemia-related ulcers developed on the heels, all patients had improved or stable symptoms that did not require intervention. There were no limb losses or vascular infections. We conclude that despite the rigors of posttransplant immunosuppression, patients with stable manifestations of PVD may successfully undergo heart transplantation and subsequent vascular reconstruction, when indicated, without prohibitive risk.

Hepatobiliary complications of polyarteritis nodosa.

Although polyarteritis nodosa (PAN) may result in thrombosis or aneurysm formation in any organ in the body, hepatobiliary complications are unusual. We reviewed seven cases that demonstrated the diagnostic difficulties and therapeutic options available in the management of hepatobiliary PAN. No consistent sign that indicated the severity of hepatobiliary PAN could be identified. In cases of thrombotic PAN, acalculus cholecystitis usually could be diagnosed preoperatively. Early tissue diagnosis and aggressive intervention are required for appropriate patient treatment. If the diagnosis is unclear, a preoperative muscle or skin biopsy specimen is often helpful in establishing a tissue diagnosis of PAN, even if no obvious pathologic condition is evident. Patients who undergo celiotomy for acalculus cholecystitis or peritoneal signs of an unclear origin should have tissue specimens (gallbladder wall, liver, or omentum) submitted for pathologic study. Angiography may be diagnostic preoperatively or when results of biopsies are equivocal. In addition, early angiography can define the extent of visceral involvement and permit control by embolization of hemorrhage secondary to aneurysm rupture. Awareness of the possibilities of thrombotic, ischemic, or bleeding complications from PAN allows more aggressive and rapid management of abdominal complaints, especially in patients who are receiving immunosuppressant therapy.

A ten-year experience with bacterial aortitis.

Twenty-one patients with bacterial aortitis were treated in four institutions over a 10-year period. Clues to the diagnosis were a pulsatile mass; fever; positive blood culture; CT scan revealing aortic nodularity, an aneurysm of irregular configuration, or air in the aortic wall; and angiography revealing a lobulated aneurysm. The most commonly identified organisms were Salmonella and Staphylococcus. Excision with in situ repair was performed in nine patients; 11 patients underwent extraanatomic bypass grafting with aortic ligation. In situ graft repair was performed when the infected aorta could be removed entirely or when the thoracic or suprarenal aorta was involved. Axillofemoral bypass grafting was used when infection was extensive. There were eight disease-related deaths. No graft infections were encountered in patients who survived.

Evaluation of surgical response in renovascular hypertension using angiotensin II blockade.

The mechanisms involved in residual or recurrent hypertension following operation to correct renal artery stenosis were studied in 10 patients by performing angiotensin II blockade with Saralasin (Sarcosine, alanine, angiotensin II) before and after operation. Peripheral renin and renal vein renin determinations, angiography, and renography were done as well. The limitations of renin determinations are cited and the application of angiotensin II blockade as a specific method of detecting renin-dependent hypertension before and after operation are presented. Saralasin infusion under the controlled conditions of our study proved to be a sensitive method for detection of renin-dependent hypertension. The results of Saralasin infusion correlated closely with peripheral and renal vein renin determinations. Thus angiotensin II blockade before and after operation may supercede more invasive and less specific diagnostic methods.

Predictability of surgical response in renovascular hypertension.

One hundred sixteen patients underwent operation for renovascular hypertension from 1962 through 1975; 64% had aortorenal reconstruction and 36% had nephrectomy. Sixty-six percent were cured and 19% were improved. Rapid sequence intravenous pyelography, radioisotope renography, and renal arteriography were equal in ability to detect renovascular hypertension. Bilateral renal biopsy specimens had excellent prognostic value when performed in a graded semiquantitative manner. Plasma renin activity was the most consistently useful criterion for prediction of surgical cure if the following requirements were used: (1) elevated peripheral plasma renin activity, (2) elevated renin from the affected kidney, and (3) suppressed renin secretion from the contralateral kidney. An angiotensin II antagonist, saralasin acetate, used in six patients before operation in an attempt to identify those whose hypertension depended on angiotensin II activity, produced a depressor response correlating well with the surgical result.

Factors influencing patency of femoropopliteal artery bypass grafts.

An analysis of 276 femoropopliteal bypass procedures performed in 264 patients at the Columbia-Presbyterian Medical Center over the past two decades showed a direct relationship of graft patency to preoperative popliteal artery runoff. Fuctional results were better than patency results. Sympathectomy and anticoagulation did not improve graft patency. The risk of amputation is outweighed by the benefits of restoration of blood flow to the ischemic extremity by a byass procedure.

Acute ureteral obstruction by lymphoceles following cadaver kidney transplantation.

Acute ureteral obstruction caused by perinephric and pelvic lymphoceles developed after the transplantation of a cadaver kidney in a patient who had been on chronic hemodialysis for two years. The patient was readmitted two months after the transplantation and found to have three large cystic masses in the pelvic region, which were successfully drained. Early diagnosis and aggressive surgical treatment of post-transplantation lymphoceles are essential, if the function of the transplanted kidney is to be preserved.

Impaired cytotoxicity of lymphocytes from patients with cancer.

We have investigated the ability of peripheral blood lymphocytes from 57 cancer patients and from 54 normal controls to exert cytotoxic activity in vitro on allogeneic target cells by using a residual tritiated proline assay. Phytohemagglutin was added to the cultures for potentiating the reaction. The cytotoxic potential of lymphocytes from cancer patients was significantly lower than that of healthy controls. Increased survival of target cells was found in numerous reactions with patients' lymphocytes, probably reflecting a "feeder" effect. The source of plasma used for testing, i.e., autologous or pooled normal homologous plasma, did not affect the strength of cytotoxicity reactions displayed by lymphocytes from either normal or cancer patients. A lower reactivity was generally seen in patients with metastatic disease than in patients with no evidence of distant spread.

Impaired cell-mediated immunity in patients with cancer.

The ability of peripheral blood lymphocytes to respond in vitro to phytohemagglutinin (PHA) and to allogeneic cells in mixed leukocyte reaction (MLC) was studied in 85 patients with cancer and in 50 healthy controls. The effect produced by sera from cancer patients on in vitro lymphocyte blastogenesis was tested on autologous cells and on homologous cells from a constant panel of 10 normal volunteers. Patients with cancer showed a distinct deficiency of cellular immune responsiveness reflected in a stage-related impairment of PHA and MLC reactivity. This deficiency seems at least partially attributable to the presence of lymphocyte depressive factors in cancer sera, since such sera reduced the reactivity of both autologous and normal homologous lymphocytes to a level that was significantly lower than that found in the presence of pooled normal serum. The inhibitory activity of cancer sera was directly related to the extent of the neoplasia.

Comparison of lymphocyte reactivity in patients with cancer, systemic lupus erythematosus and renal allografts.

The PHA and MLC reactivity of lymphocytes from patients with cancer, SLE or renal allografts was comparatively tested in the presence of autologous and of normal homologous serum. Sera from patients with advanced cancer, active SLE or chronic allograft rejection strongly inhibited the MLC reactivity of autologous lymphocytes. It is suggested that serum inhibitory factors might be antibodies which are directed against modified antigenic determinants of the major histocompatibility complex, and are capable of blocking T lymphocyte receptors.