Homologous veins as an arterial substitute: long-term results.

From 1968 through 1982, 129 homologous vein grafts were used in 91 patients in the following positions: 75 in the femoropopliteal, tibial, or peroneal artery; 38 in the aortocoronary artery; 13 in the aortopulmonary artery; and one each in the atrioventricular fistula, carotid-subclavian artery, and brachial-radial artery. In the lower extremity patency ranged from 0 to 121 months (mean 22.4 +/- 4.4 months). All grafts were performed for limb salvage, and 75% of the patients had undergone previous operations. Cumulative patency by the life-table method showed that while 50% of grafts occluded by 1 year, 60% of the remaining grafts continued to be functional for more than 5 years. Fifty percent of the aortocoronary bypass grafts studied were occluded at 1 year. Eight of the 13 systemic pulmonary artery shunts were patent at time of death, revision, or total correction. Multiple revisions and thrombectomies are required to maintain patency of homograft veins. The outcome is variable and unpredictable. The inconsistency is due to the antigenicity of the graft. If one is committed to the necessary efforts required to ensure long-term patency, the homologous saphenous vein is a suitable substitute when autogenous tissue is unavailable.

Experience with renal vein renin ratios in the identification of a pressor kidney.

The positive, preoperative recognition of a pressor kidney has many important ramifications, the most important being the ability to predict a reduction in blood pressure following surgical reconstruction or nephrectomy. One hundred forty hypertensive patients were selected for study for renal artery stenosis by measuring the differential plasma renin activity by either radioimmunoassay or bioassay. Bilateral renal vein renin determinations and renal arteriography were made consecutively in supine position and without stimulation of renin secretion. Unilateral or bilateral renal artery stenosis was found in 55 patients (39%). Twenty-eight of the 55 patients (51%) were treated surgically. Eighteen patients (64%) were cured of hypertension and seven (25%) were improved. All but one of the surgically treated patients had renal vein renin ratios of greater than 1.3 on the affected side over the unaffected or less-affected side. Increasing the ratio to greater than 1.5 or greater than 2.0 as a criterion for selection of patients for operation would not have decreased the failure rate. If used as the only criterion, increasing the ratios would have resulted in nonsurgical treatment of up to 50% of the patients cured or improved by surgery. Stimulation of renin secretion, although not used in this study, has been shown by others to more accurately identify a pressor kidney by increasing differential renal vein renin ratios. Although a combination of renin activity with renal plasma flow may lead to more accurate diagnosis, a careful clinical evaluation has not yet been replaced as the best method of selection of the patients for operation.

Neoplastic Paneth cells. Occurrence in an Adenocarcinoma of a Meckel's diverticulum.

Neoplasia is the least common complication of Meckel's diverticulum. A case of partial obstruction of the small intestine due to adenocarcinoma arising in a Meckel's diverticulum is presented. The noteworthy feature of this case is the presence of neoplastic Paneth cells in the tumor.

Renovascular occlusive disease. Results of operative treatment.

The blood pressure response to operative treatment in 502 patients with renal artery stenosis and coexisting hypertension was as follows: 51% cured, 15% improved, and 34% failure. The operative mortality was 5.9%. Patients with unilateral fibromuscular disease had a favorable blood pressure response (79.8%) more frequently than the patients with unilateral atherosclerosis (63.4%). In patients with bilateral stenosis, a favorable result occurred in 56%. The anatomic failure rate due to thrombosis of arterial reconstructions, as well as the operative mortality, varied considerably between institutions. If preoperative diagnostic studies demonstrated significant functional disparity between kidneys, and if the operation was anatomically successful, then approximately 80% of these patients were benefited by surgical intervention.