Resection of renal cell carcinoma with vena cava extension using circulatory arrest.

Resection of renal cell carcinoma with extension into the inferior vena cava can result in massive blood loss, incomplete removal of the tumor, and systemic dissemination of malignant cells. A case is presented in which circulatory arrest with total body exsanguination permitted relatively safe resection in a bloodless operative field.

A unique inlet [the ascending aorta] for extra-anatomic bypass of infected arterial prostheses.

Infection is the most dreaded complication associated with implantation of a prosthetic arterial graft. The reported incidence of primary graft infection varies from 1.3% to 6.0%, with a mortality rate from this complication as high as 75%. Although remote bypass followed by complete removal of the infected prosthesis has proven to be a satisfactory method of treatment, in certain instances remote bypass alone is not feasible and other modes of surgical treatment must be employed. Such conservative methods of management of infected aorto-iliac-femoral prosthesis sometimes irradicate infection. The only certain cure, however, is obtained by totally removing the graft. And the success of extra-anatomic axillofemoral techniques has led to its extended use. The addition of a cross-limb on an axillo-unilateral femoral graft to form an axillobilateral femoral graft was described by Sauvage and Wood, reasoning that the higher flow rate in the axillary limb of the axillobilateral femoral graft would result in an improved patency rate compared with that of axillounilateral femoral grafts. Additionally, both medial (obturator foramen) and lateral extra-anatomic remote bypass of infected femoral prosthesis have been used, successfully. The current case illustrates the complexity of management, once sepsis occurs. It further focuses on groin, retroperitoneal and bilateral axillo-femoral tract infection with prolonged (apparently innocuous) graft exposure and finally points out the utility of the ascending aorta as an alternative extra-anatomic inlet to perfuse the lower extremities.

Laser assisted balloon angioplasty in peripheral vascular surgery: a preliminary report.

Laser/balloon thermal angioplasty has proven to be a valuable adjunct in our management of peripheral vascular disease. The initial trials have produced a 77% success rate, a 3% incidence of complications, and no morbidity. Patient acceptance has been high and the return to prior activities in less than 1 week is an appreciated advantage. Laser/balloon angioplasty expands the armamentarium of the vascular surgeon and makes possible broader applications of standard vascular surgical techniques.

Significance of asymptomatic biliary tract disease in heart transplant recipients.

Biliary disease in conjunction with heart transplantation was encountered in 13 of 33 patients: in the past history (three patients), at pretransplant evaluation (nine patients), and appearing de novo after transplantation (one patient). Four patients with asymptomatic cholelithiasis underwent transplantation: biliary complications requiring emergency and/or urgent surgery occurred in all, with two deaths. Potentially complicating factors included (1) untoward effects of steroids on tissue healing and infection and (2) interaction between liver dysfunction and/or external bile loss and cyclosporine metabolism. Therapeutic lessons learned from this experience involve (1) selection of monoclonal antibodies over methylprednisolone for rejection control, (2) return of drained bile to the gastrointestinal tract, and (3) careful cyclosporine level and dosage monitoring. Five candidates with asymptomatic cholelithiasis underwent elective pretransplant biliary surgery; despite their compromised heart function, all patients had an uncomplicated postoperative course. We conclude that asymptomatic biliary disease is frequent in transplant candidates, can lead to serious morbidity and/or mortality after transplantation, and ideally can and should be treated before transplantation.

Vein graft arteriovenous fistula for long-term venous access in a heart transplant recipient lacking superficial veins: a case report.

Construction of a (radial artery) saphenous vein graft arteriovenous fistula for blood sampling after heart transplantation is presented as a solution to the problem of a patient with poor or sclerosed superficial arm veins. Satisfactory experience with one patient over a 12.5 month follow-up is presented.

Angina during hemodialysis. Treatment by coronary bypass graft.

In a 52-year-old man with chronic renal failure, severe angina occured when he was receiving hemodialysis. A double coronary bypass graft was performed, providing complete relief.