Angioplasty and stenting of arterial stenosis affecting renal transplant function.

PURPOSE: To evaluate the efficacy of percutaneous angioplasty and stenting in cases of artery stenosis of the transplanted kidney or proximal iliac artery stenosis causing transplant dysfunction and/or increase of the arterial blood pressure. MATERIALS AND METHODS: Between January 1999 and June 2007, we evaluated 24 patients who had undergone renal transplantation and subsequently were diagnosed with refractory hypertension and transplant dysfunction for signs of possible renal transplant artery stenosis. Color Doppler ultrasonography and magnetic resonance angiography preceded the intrarterial angiographic investigation, with false-negative results in 18.2% and 13.6% of patients, respectively. In 2 of the 24 patients, angiography did not reveal arterial stenosis affecting the transplanted kidney. Two patients had severe ipsilateral iliac artery stenosis and the remaining 20 had transplant artery stenosis. Successful angioplasty and stenting were performed in these 22 patients. RESULTS: The method was technically feasible in 100%. The procedure-related morbidity was 0%. During the follow-up period (range: 3 to 104 months), two patients died with normal transplant function, two suffered transplant failure, and the remaining 18 still have normal transplant function and easily controlled hypertension. CONCLUSION: Percutaneous angioplasty and stenting in cases of arterial stenosis affecting the renal transplant function are safe and effective procedures. Even more, the strong clinical suspicion must lead to angiographic investigation regardless of the results of other imaging approaches.

Biopsy-related hemorrhage of renal allografts treated by percutaneous superselective segmental renal artery embolization.

INTRODUCTION: Biopsy-related vascular injuries in renal transplants are rare, but they can lead to dramatic clinical symptoms prompting immediate treatment. Transcatheter embolization is a minimally invasive technique used to treat some forms of arterial bleeding. This study evaluated the efficacy of this technique in iatrogenic biopsy-related vascular lesions in renal allografts. MATERIALS AND METHODS: Over the last eight years, six patients with severe renal hemorrhage were admitted to the angiography department of our hospital for evaluation and possible further treatment. All of them had a history of previous biopsy of a transplanted kidney. They all presented with clinical signs of hemodynamic instability. Angiographic investigation of the kidneys preceded further intervention in all cases. All underwent hyperselective embolization of the specific bleeding vessel with the use of microcoils and/or gelfoam particles. RESULTS: Successful embolization of the feeding artery could be performed in all patients. Superselective segmental renal artery embolization had a successful outcome concerning a steady renal function and a stable clinical course. No complications occurred. CONCLUSION: Transcatheter embolization is a safe and efficient endovascular technique to treat biopsy-related vascular injuries in renal transplants. Immediate clinical success and significant benefit in renal function can be obtained, and the longevity of the allograft after successful embolization mainly depends on the natural outcome.

Screening of patients after colectomy: virtual colonography.

BACKGROUND: Virtual colonography is a powerful new method of imaging the entire colon and is useful to assess polyps and diagnose colon cancer. We evaluated virtual colonography in the postoperative screening of patients who had colon cancer. METHODS: Fifty-three patients were examined with virtual colonography 12 to 48 months postoperatively. Forty-four patients had received segmental colectomy with restoration of the gastrointestinal tract, and nine patients underwent abdominoperineal resection and permanent colostomy. After proper cleaning of the colon and distention with air, spiral computed tomographic examination of the abdomen with a slice thickness of 5 mm (table speed [TS] 10 mm, reconstruction interval [RI] 2.5 mm) was performed in the supine and prone positions (including intravenous contrast medium infusion). Images were transferred to a separate workstation (Philips Easy Vision) for postprocessing, three-dimensional rendering, and endoluminal viewing. RESULTS: Eleven recurrences (16.41%) were identified in 10 patients by virtual colonography, but one recurrence was missed. Conventional colonoscopy was incomplete in six cases, and two patients with colostomy refused colonoscopy. In these eight cases (15%), virtual colonoscopy was completed without problems. A second tumor in one patient who had received abdominoperineal resection was demonstrated by virtual colonography, but conventional colonoscopy failed to demonstrate the lesion. Liver metastases were identified in only one patient. CONCLUSIONS: Virtual colonography seems to provide a good alternative in the follow-up of patients after colectomy. The technique is effective in the diagnosis of locoregional recurrences and distant metastases and is well accepted by patients, and results are equal to those of the conventional colonoscopy.

Endovascular repair as first-choice treatment of iliac pseudoaneurysms following renal transplantation.

Pseudoaneurysms of the arterial anastomosis are rare complications of renal transplantation. We report three cases of patients with extrarenal pseudoaneurysms and describe their treatment by endovascular placement of covered stents. Two of these aneurysms were due to vascular infections by fungi. An 8-week antifungal therapy proved to be successful in preventing the risk of fungal infection of the graft material in both patients. All three of our grafts remained open 2 months to 3 years after their placement with no evidence of stenosis or infection.

Prolonged ureteral stenting in obstruction after renal transplantation: long-term results.

BACKGROUND: Renal transplantation is an effective treatment for end-stage renal disease. Ureteral stenosis is the most frequent urologic complication. We report our long-term follow-up results concerning endourologic treatment of ureteral obstruction after renal transplantation. METHODS: Between May 1997 and September 2000, 15 patients with renal transplant obstructive uropathy were managed with percutaneous nephrostomy and prolonged ureteral stenting. RESULTS: Percutaneous nephrostomies were performed successfully in all 15 kidneys. In 13 patients, antegrade ureteral stenting was attempted, which was successful in 11 patients (85%). After prolonged ureteral stenting (mean duration 15 months), the stent was removed in all patients, 90% of whom had no recurrence. During follow-up (36 to 71 months; mean 51), urea, creatinine, sodium, and potassium determinations and ultrasound scans were performed. Success was defined as a reduction in hydronephrosis. No major complications were observed. CONCLUSIONS: Modern endourologic procedures have replaced open reconstructive surgery in most patients with ureteral obstruction after renal transplantation, because they may offer a definitive treatment with low morbidity.

Video-assisted transcervical thymectomy.

BACKGROUND: The optimal surgical approach for complete removal of the thymus gland has long been debated. In this report, the excision of the entire gland through a transcervical incision using video-assisted techniques is described. METHODS: Ten patients, including one with thymoma and myasthenia gravis, underwent surgery via the transcervical approach. After standard dissection up to the level of the innominate vein and ligation of the thymic vessels, a laparoscope was inserted into the mediastinum. In the patient with thymoma, the operation was completed by a small incision in the third intercostal space. RESULTS: No perioperative mortality or long-term morbitity was observed. The mean hospital stay was 69.6 h. After a mean follow-up period of 63.8 months, eight patients displayed complete remission, whereas one continued to receive minimal medication. The patient with thymoma showed considerable improvement, but remained on same medical regimen No complications were seen throughout the study. CONCLUSION: Video-assisted thymectomy improves effectiveness of the transcervical approach for thymectomy with a minimum of trauma and excellent results.

Percutaneous insertion of metallic endoprostheses in the biliary tree in 66 patients: relief of the obstruction.

BACKGROUND: We evaluated the efficacy of percutaneous transhepatic insertion of metallic endoprosthesis in 66 patients with biliary obstruction. METHODS: From September 1994 through September 2002, 97 patients with obstructive jaundice attended the radiology department of our hospital; 92 had malignancy and five had benign obstruction (age range, 29-92 years; mean age, 68.3 years). In three patients, findings of percutaneous cholangiography did not indicate further access. Eighty-six metallic stents were implanted in 66 of the 94 remaining patients, and the other 27 patients were treated with percutaneous biliary drainage: external drainage in 21 patients to assist in subsequent operations and combined internal and external drainage in six patients. In one patient we performed percutaneous balloon dilatation of the stenosis of the choledochjejunal anastomosis. Hemobilia occurred in one patient and required embolization of the right hepatic artery. In nine patients (13.6%), a new procedure was used after 40 to 278 days (mean, 129 days) because of occlusion of the endoprosthesis. RESULTS: Clinical improvement and decrease in serum bilirubin level were achieved in 61 of the 66 patients (92.4%). The survival time in patients with malignancy ranged from 6 to 485 days (mean, 139 days). No intervention-related death occurred. Except for the aforementioned hemobilia, one case of biloma occurred and required immediate percutaneous drainage. CONCLUSION: Percutaneous transhepatic insertion of metallic stents was an efficient and secure method to treat biliary obstruction, particularly in malignant inoperable cases.

A new rare allele at the CGG repeat polymorphism in the first intron of human c-H-ras gene.

We have examined a region in the first intron of the human c-H-ras gene containing a CGG repeat. This region was previously shown to be variable in length. The length variation was attributed to the presence of the CGG repeat after estimation of its electrophoretic mobility. In the present report we have characterized in detail this region by PCR-RFLP and automated sequencing, in a total of 102 histologically normal tissues from unrelated individuals affected by lung and breast cancer. Four alleles were detected and analysis of their internal sequence showed that the length alterations of this region were due to the presence of 5, 6, 8 and 9 CGG triplets respectively. The last three occur most often (44.1%, 34.8%, 20.6% respectively) and coincide with three previously reported alleles (Riggins et al, Hum Mol Genet 9: 775, 1992). The fourth allele consisting of 5 repeats is a rare one (0.5%), whilst alleles with 7, and a previously reported one suggested to comprise 11 repeats (1%) were not present in our cohort. This polymorphism coincides in position with an element that was previously shown to possess regulatory activity.