Safety and adequacy of percutaneous biopsies in pediatric orthotopic kidney transplantation.

BACKGROUND: The gold standard for investigating the cause of renal graft dysfunction is renal biopsy. However, as this procedure is invasive and has inherent risks, its safety must be established. OBJECTIVE: To determine the safety of percutaneous renal biopsy in pediatric orthotopic renal transplantation. METHODS: Percutaneous renal biopsies performed on pediatric orthotopic renal transplants in a single center between 1987 and 2010 were studied. Biopsy specimen adequacy and post-procedure complications were reviewed by prospectively collected data. RESULTS: A total of 54 ultrasound "real-time" guided biopsies in 25 patients were performed. Minimum specimen adequacy was achieved in 98% of biopsy specimens. No major complications were identified; 6% of patients developed minor complications-e.g., grade 3 macroscopic hematuria that did not require intervention. CONCLUSION: Percutaneous renal biopsies using "real-time" ultrasound guidance on pediatric orthotopic kidney transplants is safe.

Risk factors for peri-operative stroke complicating carotid endarterectomy: selective analysis of a prospective audit of 1000 consecutive operations.

BACKGROUND: The aim of the present study was to investigate the role of potential clinical risk factors in the causation of peri-operative stroke associated with carotid endarterectomy. With the change in carotid endarterectomy practice from the use of a shunt to high-dose thiopental for cerebral protection (a previously undocumented method), it was essential to identify accurately the causes of all perioperative strokes. METHODS: A prospective audit was undertaken of 1000 carotid endarterectomies in which the causes and pathology of all peri-operative strokes were documented. The roles of advanced age, female gender, hypertension, previous stroke, contralateral carotid stenosis >70%, and contralateral carotid occlusion as potential causes of peri-operative stroke were defined. Results were statistically analysed using odds ratio and Fisher's exact test. RESULTS: None of the potential risk factors was statistically significant for peri-operative stroke. Female gender was associated with a significant risk of peri-operative stroke due to operative site thrombosis. Complications at the endarterectomy site were the commonest cause of stroke. CONCLUSIONS: Prospective audit is a useful tool for identifying causes of peri-operative stroke and indicating the need for modifications to surgical clinical management which might improve outcomes for carotid endarterectomy.

Hyperbaric oxygenation treatment of acute paraplegia after resection of a thoracoabdominal aortic aneurysm.

Acute spinal cord ischemic injury after resection of thoracoabdominal aneurysm remains a relatively common and potentially devastating complication. The complete resolution of postoperative paraplegia after resection of a type II thoracoabdominal aneurysm, after treatment with hyperbaric oxygenation, is reported.

Hemodynamic ischemic stroke during carotid endarterectomy: an appraisal of risk and cerebral protection.

PURPOSE: The purpose of this study was to validate the commonly accepted indicators of risk of ischemic stroke that indicate the necessity for cerebral protection during carotid endarterectomy (CEA), and to examine the efficacy of high-dose thiopentone sodium (thiopental) as a cerebral protection method in patients who are at high risk of intraoperative ischemic stroke. METHOD: In a prospective study of 37 CEAs performed for symptomatic stenosis > 70%, functional and clinical indicators of risk of ischemic stroke during carotid cross-clamping were identified. Functional indicators of risk were the development of ischemic electro-encephalogram (EEG) changes and stump pressure < 25 mm Hg. Clinical indicators of risk were previous ischemic hemispheric stroke and severe bilateral disease. These indicators were correlated in all patients, some of whom had two or three coexisting indicators of risk. The EEG and stump pressure were monitored continuously during carotid occlusion in all operations. Carotid occlusion times were recorded. Intraluminal shunting was eliminated in favor of high-dose thiopental cerebral protection in all patients. Neurologic outcome was deemed to measure the efficacy of thiopental protection in patients who are identified to be at risk and, hence, in need of cerebral protection. The validity of the indicators used to identify risk of ischemic stroke during CEA was assessed. RESULTS: The absolute stroke risk was found to be 29.7% for the whole group (37 patients) and 57.9% in 19 patients who had commonly accepted indications for protective shunting. The correlation of ischemic EEG changes with stump pressure < 25 mm Hg was only 27.3%, whereas the expected correlation based on well-documented reports in the literature was 100%. The lack of correlation may have been related to the prevention of ischemic EEG changes by thiopental. There were no neurologic deficits in the series. CONCLUSIONS: The absence of neurologic deficit in the study indicated that thiopental protection was effective in preventing ischemic stroke in high-risk patients and safely replaced intraluminal shunting.

Carotid endarterectomy without a shunt for symptomatic lesions associated with contralateral severe stenosis or occlusion.

PURPOSE: The purpose of this study was to assess the adequacy of thiopental protection against ischemic cerebral damage in patients undergoing carotid endarterectomy for symptomatic stenosis greater than 70% in association with contralateral stenosis greater than 70% or contralateral occlusion. METHODS: All patients (n=259) with severe bilateral carotid disease who underwent carotid endarterectomy for symptomatic stenosis greater than 70% were extracted from the database of an ongoing prospective carotid surgery study. Large-dose thiopental sodium without shunting was used for cerebral protection during endarterectomy. Asymmetric electroencephalogram changes during the operation, carotid occlusion time, stroke onset, and neuropathologic outcomes were analyzed. RESULTS: Three contralateral strokes occurred in the series, producing a cerebral morbidity/mortality rate of 1.2% (major 0.4%, minor 0.8%). Transient morbidity was 1.9% made of two reversible ischemic neurologic deficits and three transient ischemic attacks. New asymmetric electroencephalography changes were seen in 49 (19% patients, one of whom had transient deficit. Average occlusion time was 35 minutes. All strokes occurred within 24 hours of the procedure. Patients with previous stroke and and systemic hypertension seemed at greatest risk, and the contralateral hemisphere was the area at greatest risk. All transient deficits were ipsilateral and related to technical complications rather failed protection. CONCLUSIONS: Thiopental cerebral protection eliminates strokes caused by complications of shunting, prevents ischemic stroke during carotid occlusion for periods up to 67 minutes (average 35 minutes), allows meticulous management of the operative site, may modify or minimize clinical neurologic deficit, and in our experience has rendered intraluminal shunting obsolete.

Thiopental sodium cerebral protection during carotid endarterectomy: perioperative disease and death.

PURPOSE: This study reports our experience with thiopental sodium (Pentothal) cerebral protection, without intraluminal shunting, during carotid endarterectomy. Only those complications that occurred during surgery or within 30 days of operation have been addressed. METHOD: A prospective, unselected, consecutive series of 621 carotid endarterectomies was done during a 7-year period, with electroencephalography-monitored, high-dose Pentothal for cerebral protection. RESULTS: Five ischemic strokes (0.8%), completion of two strokes-in-evolution (0.3%) and four strokes caused by cerebral hemorrhage (0.6%) occurred in 11 patients in the perioperative (30-day) period, for a combined cerebral morbidity-mortality rate of 1.7%. Four reversible ischemic neurologic deficits (0.6%) and two transient ischemic attacks (0.3%) in six patients produced a transient deficit rate of 0.9%. Symptomatic coronary artery disease coexisted in 37% of the patients but resulted in only five acute myocardial infarctions (0.7%), one of which was fatal (0.1%). Other perioperative complications in 10 patients (1.5%) were associated with the operative procedure. There were no complications directly attributable to the high-dose Pentothal. Prospective data collection has allowed definition of the disease and cause of all cerebral complications. CONCLUSION: The complications in this series have been related to surgical and clinical management problems rather than failure of cerebral protection. Cerebral protection with high-dose Pentothal under electroencephalographic control has been effective and complication free.

Superior mesenteric vein thrombosis.

Superior mesenteric venous occlusion may be difficult to recognize, but is important as it carries a better prognosis than superior mesenteric arterial occlusion, and may be amenable to surgical treatment. Three successful cases treated by thrombectomy have appeared in the literature. A case of successful superior mesenteric vein thrombectomy with bowel resection is reported.

Clinical features of vascular insufficiency in the limbs.

Drugs (nicotine, beta blockers) can exacerbate symptoms of vascular insufficiency. Vasodilators and anticoagulants have no place in the treatment of chronic insufficiency. Analgesics rarely, if ever, relieve ischaemic pain at rest. Ischaemic pain at rest and gangrene are absolute indications for surgical restoration of the circulation. Spasm is never the determining factor in acute insufficiency associated with trauma. Surgical restoration of circulation is essential in most cases of acute insufficiency. The knee joint should be preserved if possible in lower limb amputation, even if proximal vascular reconstruction is necessary. Surgery should not be denied on the basis of age or infirmity. Restoration of normal circulation in the limb is the best treatment for vascular insufficiency. Acute or chronic vascular insufficiency is eminently correctable in most cases. Advances in diagnosis, patient selection, anaesthesia, operative surgery and rehabilitation have rendered reconstructive procedures safe and successful. Early diagnosis and referral to a vascular unit with modern facilities offers a greater chance of salvage of life and limb than that possible in earlier decades. Many patients return to an independent life free of pain and requiring minimal ongoing care.