Liberalized screening for blunt carotid and vertebral artery injuries is justified.

BACKGROUND: Current literature suggests that blunt carotid injuries (BCIs) and vertebral artery injuries (BVIs) are more common than once appreciated. Screening criteria have been suggested, but only one previous study has attempted to identify factors that predict the presence of BCI/BVI. This current study was conducted for two reasons. First, we wanted to determine the incidence of BCI/BVI in our institution. Second, we wanted to determine the incidence of abnormal four-vessel cerebral angiograms ordered for injuries and signs believed to be associated with BCI/BVI and thus to determine whether the screening protocol developed was appropriate. METHODS: From August 1998, we used liberalized screening criteria for patients who were prospectively identified and suspected to be at high risk for BCI/BVI if any of the following were present: anisocoria, unexplained mono-/hemiparesis, unexplained neurologic exam, basilar skull fracture through or near the carotid canal, fracture through the foramen transversarium, cerebrovascular accident or transient ischemic attack, massive epistaxis, severe flexion or extension cervical spine fracture, massive facial fractures, or neck hematoma. Four-vessel cerebral angiograms were used for screening for BCI/BVI. RESULTS: Over the 18-month study period, 48 patients were angiographically screened, with 21 patients (44%) being identified as having a total of 19 BCIs and 10 BVIs. Nine patients had unilateral carotid artery injuries and three patients had bilateral carotid artery injuries. Vertebral artery injuries were unilateral in six patients. One patient had bilateral carotid artery injuries and a unilateral vertebral artery injury. One patient had a unilateral carotid artery injury and a unilateral vertebral artery injury, and one patient had a unilateral carotid artery injury and bilateral vertebral artery injuries. During the same study period, 2,331 trauma patients were admitted, with 1,941 (83%) secondary to blunt trauma. The overall incidence of BCI/BVI was 1.1%. The frequency of abnormal angiograms ordered for cerebrovascular accident or transient ischemic attack, massive epistaxis, or severe cervical spine fractures was 100%. The frequency of abnormal angiograms ordered for the other indications was as follows: fracture through foramen transversarium, 60%; unexplained mono- or hemiparesis, 44%; basilar skull fracture, 42%; unexplained neurologic examination, 38%; anisocoria, 33%; and severe facial fractures, 0%. CONCLUSION: The liberalized screening criteria used in this study were appropriate to identify patients with BCI/BVI. This study suggests BCI/BVI to be more common than previously believed and justifies that screening should be liberalized.

Spontaneous renal artery dissection in a healthy man.

We have presented a unique case of isolated renal artery dissection in an otherwise healthy young man, whose diagnosis was demonstrated by renal angiography. He was anticoagulated with warfarin for one year with resolution of the false channel in his renal artery as demonstrated by magnetic resonance angiography. Duplex ultrasonography of his renal artery was important in monitoring his renal artery flow velocities.

Carcinoma of the bladder in renal transplant patients. A case report and collective review of cases.

Bladder malignancy in the renal transplant recipient is an infrequent occurrence. The 11 previously reported cases reflect an aggressive tumor growth with invasion, requiring partial or complete cystectomy with or without conduit diversion. We report an additional case in a 40-yr-old woman with a living related renal transplant, who experienced rapid progression of her tumor over 3 wk from initial hematuria to a pelvic mass involving the anterior bladder. Her allograft ureter and native ureters, as well as her left iliac vein, became obstructed with tumor in another 2 wk. Biopsy showed poorly differentiated, invasive transitional carcinoma. Attempted resection was abandoned because of finding tumor involvement in most of the pelvis. Chemotherapy was not attempted. She died 2 wk after her attempted resection from tumor burden. Our report presents a collective review of these previously reported 11 cases plus our case. These bladder tumors demonstrate a rapid progression of invasive disease and respond poorly to chemotherapy. There is a possible association of bladder tumors with cyclophosphamide immunosuppression. An aggressive surgical approach should be followed, especially since these tumors present in a younger age group.

Urokinase does not upregulate the vascular endothelial cell-mediated inflammatory response.

PURPOSE: Urokinase is used clinically for thrombolysis, but little is known of its direct effect on vascular endothelial cells. The following experiments were preformed to assess the in vitro effects of urokinase on vascular endothelial cell growth, adhesion molecule expression, and interaction with lymphocytes, polymorphonuclear leukocytes, and platelets. METHODS: Commercially available human umbilical vein endothelial cells (HUVEC) were cultured with varying concentrations of urokinase (0 to 10,000 IU/ml) (clinical dosage, < or = 500 IU/ml). HUVEC viability was determined from 1 to 4 days. HUVECs were incubated with urokinase (0 to 2000 IU/ml) from 4 to 72 hours. Adherence of 51-chromium-labeled polymorphonuclear leukocytes, platelets, or lymphocytes was then quantitated. In separate experiments HUVEC adhesion molecule expression (intercellular adhesion molecule-1, vascular cell adhesion molecule-1, or endothelial leukocyte adhesion molecule-1) was determined by flow cytometry. RESULTS: There was a decrease of HUVEC viability at suprapharmacologic urokinase concentrations of > or = 2000 IU/ml compared with nontreated control samples (0 IU/ml, 73% +/- 2%, 2000 IU/ml, 60.5% +/- 1.9%, p < 0.05) presumably because of drug toxicity. There was no significantly increased polymorphonuclear leukocyte, lymphocyte, or platelet adhesion to urokinase-treated HUVEC monolayes at any time point. This was also true for each adhesion molecule tested. CONCLUSIONS: Urokinase at clinically relevant concentrations (< or = 500 IU/ml) did not affect endothelial cell viability or growth, nor did it upregulate adhesion molecule expression or cellular adhesion associated with the cell vascular inflammatory response. It is therefore implied that the use of urokinase in vivo similarly would not initiate the vascular inflammatory response.

Recurrent type I membranoproliferative glomerulonephritis after renal transplantation and protective role of cyclosporine in acute crescentic transformation.

Almost all diseases affecting the native kidney may recur in the transplanted kidney, with one of the most frequent being recurrent glomerulonephritis. Among the glomerulonephritides, membranoproliferative glomerulonephritis (MPGN), immunoglobulin A nephropathy (IgA), and focal-segmental glomerulosclerosis (FSGS) have the highest rates of recurrence. Here we report a patient who, after living-related kidney transplantation, suffered allograft loss shortly after surgery due to recurrence of glomerulonephritis. Two weeks prior to transplant nephrectomy light microscopic examination of the allograft biopsy failed to show glomerulonephritis. Subsequent histopathology of the transplant nephrectomy specimen demonstrated a crescentic form of type I MPGN following withdrawal of cyclosporin A (CsA) and intense course or oral steroid therapy. The entity of recurrent type I MPGN in kidney transplantation is reviewed, and a possible protective role of CsA against rapidly progressive crescentic type I MPGN is explored.

Transforming growth factor-beta 1 serves as an autocrine inhibitor of human endothelial cell/lymphocyte adhesion.

Other investigators have shown that exogenously administered transforming growth factor-beta (TGF-beta) inhibits lymphocyte adherence to vascular endothelial cells (VEC). We examined the role of TGF-beta 1 as an autocrine mediator of lymphocyte adhesion to adult human VECs. VECs were harvested from eight saphenous or cadaveric iliac veins using 0.2% collagenase. Low-passage VECs in MCDB + 0.1% BSA were pretreated for 24 hr with monoclonal anti-TGF-beta 1 antibody (5 micrograms/ml), LPS (5 micrograms/ml), or IL-1 (10 U/ml). Adherence of fluorescently labeled lymphocytes to pretreated VECs was quantitated and results were expressed as relative adhesion compared to untreated control. Total mRNA from LPS- or IL-1-treated VECs was subjected to Northern analysis to determine relative TGF-beta 1 expression. Total TGF-beta 1 protein concentration in supernatants from LPS- or IL-1-treated VECs was determined by ELISA. Data (means +/- SEM) were analyzed by ANOVA with a Newman-Keuls posttest. Neutralizing endogenous TGF-beta 1 with anti-TGF-beta 1 antibody significantly increased adhesion of lymphocytes to VEC monolayers compared to control (125 +/- 3 vs 101 +/- 2%, P < 0.01, n = 8). The level of adhesion was equivalent to that seen with IL-1 stimulation (131 +/- 6%). Spearman correlation of lymphocyte adherence to IL-1- or LPS-treated VECs vs TGF-beta 1 mRNA expression or vs relative TGF-beta 1 protein concentration showed significant inverse relationships (r = -0.82, P < 0.001, and r = -0.87, P < 0.001, respectively). Endogenous TGF-beta 1's inhibitory effect on lymphocyte adhesion was blocked by a specific neutralizing antibody. VEC TGF-beta 1 mRNA expression and TGF-beta 1 production were inversely proportional to lymphocyte adhesion, suggesting down-regulation of TGF-beta 1 in response to proinflammatory cytokines. Together, these observations support the hypothesis that TGF-beta 1 has an autocrine inhibitory role in regulation of lymphocyte adhesion to VECs.

Gallstone umbilical sinus tract formation following laparoscopic cholecystectomy.

The use of laparoscopic techniques in general surgical procedures has increased dramatically in the past 6 years. A number of articles in the literature have described a multitude of complications arising from these techniques. We report the development of a draining umbilical sinus tract following laparoscopic cholecystectomy, arising as a result of gallstone fragmentation during gallbladder removal. Despite aggressive local treatment, there was no improvement in the condition of the umbilical trocar site, necessitating wide excision of the umbilicus and trocar site. Although subcutaneous abscesses from gallstone fragments have been reported in the literature, to our knowledge this is the first report in which the subsequent development of a sinus tract required a second operative procedure for resolution. In addition, we suggest several methods for the prevention of abscess or sinus tract formation following laparoscopic cholecystectomy.

Thrombolytic therapy and balloon catheter thrombectomy in experimental femoral artery thrombosis: effect on arterial wall morphology.

PURPOSE: To determine vessel wall architectural changes after lytic therapy and balloon catheter thrombectomy in experimentally thrombosed arteries. MATERIALS AND METHODS: Bilateral 5-cm femoral artery occlusions were created by ligation in 14 dogs. Two dogs served as controls, and 12 animals underwent balloon catheter thrombectomy on the left and lytic therapy with urokinase on the right either 24 hours (group 1, n = 6) or 7 days (group 2, n = 6) after creation of the occlusion. After treatment, the area of thrombosis was subjected to light and scanning electron microscopy. RESULTS: The IEL was intact in all lysed arteries. IEL fractures were present in 11 of 12 arteries treated with thrombectomy. For group 1 arteries, average luminal area after thrombectomy was 5.63 mm2 +/- 0.66 versus 1.94 mm2 +/- 0.7 after lytic therapy (P < .007). Mean control artery luminal area was 2.86 mm2 +/- 0.52. Similar differences were found in group 2 arteries. With lytic therapy, scanning electron microscopy grading revealed surfaces to be intact in group 1, but moderate injury was exhibited in group 2. All arteries treated with thrombectomy had severe injury. CONCLUSIONS: Lysis of acute thrombi (group 1) preserved arterial wall architecture, with an intact IEL and no endothelial injury. Lysis of chronic thrombi (group 2) was associated with mild to moderate injury. Catheter thrombectomy caused severe injury regardless of the time of intervention. These results may help explain the poor long-term patency observed after these interventions.

Successful identification of acute renal allograft rejection with duplex ultrasonography.

Duplex ultrasonography has met with variable accuracy in identifying acute renal allograft rejection. These published studies have focused on using mathematical indices. We have applied duplex ultrasonography differently by insonating the site of rejection, i.e. renal cortex, to identify by subjective analysis the changes of the velocity spectral patterns. This subjective analysis method was compared to the mathematical indices of diastolic/systolic ratio and pulsatility index in 126 episodes of clinical acute renal allograft rejection which all had biopsy correlation. This present study represents the largest published experience with duplex ultrasonography and renal transplant rejection. Subjective analysis of velocity spectral patterns (SUBJ) resulted in sensitivity of 87%, specificity of 94% and overall accuracy of 88%. This technique was statistically better than the diastolic/systolic ratio (DSR) sensitivity of 40%, specificity of 72% and overall accuracy of 49%, or the pulsatility index (PI) sensitivity of 47%, specificity of 75% and overall accuracy of 55%. The superior results of the subjective analysis technique of duplex ultrasonography to identify acute renal allograft rejection suggests that this diagnostic approach has sufficient accuracy to avoid invasive allograft biopsies.

Extracorporeal shock wave lithotripsy in the renal transplant patient: a case report and review of literature.

Renal allograft lithiasis is a rare complication of renal transplantation, which in the past has required various invasive procedures for adequate stone fragmentation and dissolution. Noninvasive techniques such as extracorporeal shock wave lithotripsy (ESWL) can now be extended to the renal transplant patient. Five cases have been previously reported in which ESWL was used effectively for dissolution of renal allograft calculi. We now report a 6th case in which a calculus, initially identified 2 weeks after renal transplantation, was effectively fragmented 3 years later using ESWL. Based on our experience and the reviewed composite experience in the literature, ESWL is a safe therapy for renal allograft calculi.

Histologic resolution of documented hemosiderosis in a renal transplant recipient. A case report.

A 33-year-old cadaveric renal transplant recipient showed complete histologic resolution of hemosiderosis by liver biopsies obtained pre- and post-transplantation. Although there have been reports in the past of progression of hemosiderosis to hemochromatosis to severe liver failure in the renal transplant population, the correlation has never been clear. This is the first case report of complete resolution of hemosiderosis as documented histologically by liver biopsies in a cadaveric renal transplant recipient.

Arterial reconstruction of the pancreatic allograft for transplantation.

The shortage of organs is particularly acute in whole pancreas transplantation, because the liver and pancreas often share a common arterial supply, making combined procurement of both organs difficult. A previously described technique of simultaneous whole liver and pancreas procurement depended on "classic" hepatic arterial anatomy, which is present just over half the time. We describe herein our experience with three Y-reconstructions of the splenic and superior mesenteric arteries of the pancreatic allograft using donor allograft internal and external iliac arteries. In situ Doppler ultrasound examination of the pancreatic allograft after surgery demonstrated a patent reconstruction without evidence of stenosis or turbulent flow patterns. We believe this reconstruction is a safe, alternative method to provide arterial flow to the whole donor pancreas.

Cholecystectomy in the potential heart transplant patient.

The management of cholelithiasis with gallstone pancreatitis in the heart transplant candidate is a difficult problem. Biliary tract surgery in the heart transplant candidate presents an additional set of clinical risks in view of extensive heart disease. We report the cases of three patients with symptomatic cholelithiasis with gallstone pancreatitis who were successfully operated on while awaiting cardiac allografts. Each patient was preoperatively prepared with (1) a lumbar epidural catheter for postoperative pain control with epidural opioids, (2) a balloon-tipped (Swan-Ganz) catheter and arterial line for perioperative monitoring, and (3) an intraaortic balloon pump for circulatory support with full heparinization after epidural catheter placement. In addition, preoperative optimization of cardiovascular function with pharmacologic agents was carefully achieved for 6 to 12 hours before surgery. All three patients had stable intraoperative courses, with less than a 300 ml blood loss. Their postoperative outcomes were without surgical complication. We think that biliary tract surgery may be safely accomplished in the heart transplant candidate with careful, appropriate preparation and meticulous surgical technique. We also present our management algorithm for heart transplant patients with cholelithiasis before and after operation.

Cyclosporine inhibits the development of medial thickening after experimental arterial injury.

Vascular proliferative lesions may occur after arterial injury and consist of inflammatory cells and proliferating smooth muscle cells. We studied the effect of cyclosporine on modulating the response to experimental arterial injury in rats. Arterial injury was created in 90 rats by rotating a 1 mm coronary dilator in the right common iliac artery. After treatment with parenteral cyclosporine 2 mg/kg/day or 5 mg/kg/day, or with saline solution, right and left iliac arteries were perfusion fixed and cross sectioned. The thickness of the tunica media was measured, and the groups were compared with a Student's t test. In the control groups the injured iliac artery had significant medial thickening when compared to the noninjured (p less than 0.05) from 1 to 42 days after injury. Injured arteries treated with cyclosporine 2 mg/kg/day for 14 days showed significantly less medial thickening when compared to controls (p less than 0.01). Cyclosporine 5 mg/kg/day for 14, 28, and 42 days showed a significant inhibition of medial thickening (p less than 0.05) for each time period. These results show that cyclosporine affects the response to experimental arterial injury by inhibiting the development of medial thickening. The most consistent effects were seen with a cyclosporine dose of 5 mg/kg/day for 2 to 6 weeks. These data also provide further evidence that immunologic mechanisms may modulate vascular proliferative lesions.

Experience with the double lumen Silastic catheter for hemoaccess.

Transvenous access for acute hemodialysis has advanced recently with the introduction of a double lumen Silastic (silicone rubber), Dacron-cuffed (polyester) catheter (Quinton PermCath), which has a better patient acceptance than the stiff Teflon (polytetrafluoroethylene) catheters. We present our experience with 53 PermCath catheters placed in 49 patients (eight to 80 years old). Twenty-two catheters were used for initiation of dialysis, 17 as a bridge to permanent hemoaccess, two as a bridge to peritoneal dialysis and 12 for chronic hemoaccess. We have achieved better success with insertion of catheters through the jugular system (external in 22 instances and internal in 30) by cutdown with fluoroscopic positioning of the catheter tip at the second to third intercostal space. Arterial port alignment was toward the center of the vena cava to reduce sucking against the caval wall during dialysis. No catheter failed to function with this positioning technique. Average catheter use was 84 days with a range of one to 573 days. Catheter thrombosis occurred 40 times in ten patients and was treated successfully in all with the infusion of streptokinase or urokinase. Four patients received chronic warfarin for repeated clotting. Four patients had catheter sepsis that resolved with removal of the catheter and administration of antibiotics. We conclude that the PermCath is an improved means for hemoaccess with a low complication rate. Our key to successful functioning of the PermCath is careful fluoroscopic positioning of the catheter tip.

A rational approach to recurrent carotid stenosis.

To further characterize the incidence and morbidity of recurrent carotid stenosis, we reviewed 184 consecutive carotid endarterectomies performed in a university hospital between August 1983 and January 1988, in patients followed after operation with serial duplex ultrasonography. Recurrent stenosis of greater than 50% diameter reduction developed in eleven arteries (6.0%) at a mean interval of 10.2 +/- 7.8 months. Three of the eleven (1.6% of the total) had associated transient ischemic attack, and none had strokes. Restenosis was significantly more frequent in diabetic patients than in nondiabetic patients (13.3% vs 4.5%; p less than 0.05); and among patients whose primary stenoses had been symptomatic compared to asymptomatic (11.0% vs 1.5%; p less than 0.02). No statistically significant association with restenosis could be established for gender, hypertension, or smoking. Completion angiography and/or Doppler spectral analysis had been performed, and results were normal at the primary operation in 10 of the 11 patients. Only six of 184 arteries (3.3%) had vein patch closure, but none of these restenosed. Uneventful reoperation with patch closure was performed in three patients with transient ischemic attacks and two with preocclusive restenoses. Lesions were myointimal hyperplasia in four and atheroma in one. Three of the unoperated restenoses have shown regression on duplex scanning, but a fourth progressed to asymptomatic occlusion. Carotid restenosis is uncommon, even without routine use of vein patch angioplasty. Reoperation should be reserved for patients with associated symptoms or greater than 80% restenosis.

Evaluation of pancreatic allograft circulation using color Doppler ultrasonography.

In conclusion, color flow Doppler ultrasonography is a safe, noninvasive method to study perfusion in the pancreatic allograft. In trained hands, reproducibly quantitative measurements can be made of the circulation in the transplanted pancreatic allograft. With further experience, it is our hope that spectral analysis will elucidate rejection as it has for us with kidney transplants. Because the technique is noninvasive, it has a high degree of patient acceptance.