Outcome for patients with carotid stenosis undergoing carotid endarterectomy, the cerebral condition followed by extra/intracranial ultrasound examinations.

Seventy-six patients undergoing carotid endarterectomy were studied to estimate the effect of operation, evaluate the accessible methods of examination and disclose the complications owing to the operation. In addition, the hypothesis that the pulsatility index in MCA measured by the Doppler method could disclose severe ischemia and risk of complications during endarterectomy was tested. The study was a prospective study of patients operated at the University Hospital in Odense in the years 1991-1996. Data collected included demographics, operative indications, complications, follow-up extra/transcranial Doppler examinations, cerebrovascular reactivity investigations, recurrent symptoms and deaths. Concerning the carotid stenosis, a fairly good correlation was found between the results of extracranial Doppler examinations, Duplex and carotid angiography. Serious complications after surgery were few. One patient, who had a coronary by-pass operation consecutive to the endarterectomy, died 3 weeks after the operation, owing to a hematothorax. Five patients (7%) suffered a stroke. Only 2 patients needed rehabilitation, and they came out with minor disturbances in the use of a hand. Recurrent stenosis in excess of 69% emerged in 3% of the patients. All were hemodynamically insignificant. One patient had a new TIA during the observation time of 3-60 months. After the operation she had a thrombosis in the operated carotid artery. Thus our results, a perioperative stroke rate of 7% and a mortality rate of 1%, are in line with the average results in multicenter trials. In addition a PI below 0.60 in the MCA seemed to be a warning of the risk of postoperative cerebral hyperemia.

Development of anti-OKT3 antibodies after OKT3 treatment.

The development of IgG and IgM anti-OKT3 antibodies the first 90 days after start of OKT3 treatment for acute cellular rejection was determined by ELISA in 25 consecutive renal transplant patients. The ELISA positive sera were then tested for neutralizing OKT3 antibodies by immunofluorescence inhibition assay utilizing the FACScan. The number of IgM positive patients was highest, four (16%) after 10 days of treatment and then declined. The highest number of patients, thirteen (56%) with IgG antibodies was found after 60 days. Sera with only IgM antibodies or with low IgG titers (< 1:100) did not neutralize OKT3. Five patients (20%) developed neutralizing antibodies. All of these patients had received OKT3 during an earlier transplantation. In four of these patients, the ACR had been reversed successfully before the development of antibodies, and in the last patient the ACR was reversed by a second course of Minnesota-ALG and increasing the dose of Cyclosporine. Monitoring the development of neutralizing anti-OKT3 antibodies is valuable in patients who have previously received OKT3 treatment.

Analysis of the inflammatory leucocyte mobilization in 838 fine needle aspiration biopsies in non-rejecting (day 1-90) kidney grafts and 465 biopsies in grafts before, during and after acute cellular rejection.

A total of 1303 fine needle aspiration biopsies (FNABs) were performed in all 105 kidney transplanted patients at our institution during 1990-1992: 838 were in patients who never had an acute cellular rejection (ACR), and 465 were in patients who had experienced an ACR; 393 of these FNABs were performed in first rejections and 72 in second rejections. The immunosuppressive protocol included monotherapy with cyclosporin A and an initial, additional course of Minnesota-ALG during the first ten days after transplantation (Tx). OKT3 was first-line antirejection therapy accompanied for a short period with prednisolone and azathioprine to oppose the development of anti-OKT3 antibodies. FNABs were taken each day for the first three days after Tx, then twice a week for the first month, and then at each visit to the outpatient clinic for the next three months. In non-rejecting grafts the total corrected increment (median) of the inflammatory response (TCI) increased from 1 to a maximum of 3.5, 17-21 days after Tx followed by a slight decrease. The inflammatory response was mainly due to non-activated lymphocytes. In the rejecting grafts the TCI (median) increased from three days before ACR to a maximum of 7 on the day of ACR, followed by a decrease when OKT3 treatment was started. The infiltrating cells were activated lymphocytes, other lymphocytes and, in smaller amounts, macrophages and monocytes.

[Femoro-crural reconstruction in Denmark 1983-1987]. / Femoro-krurale rekonstruktioner i Danmark 1983-1987.

From 1983 to 1987, 293 femoro-crural bypasses were performed in eight centers for vascular surgery in Denmark. The activity increased in the period from 15 to 135 bypasses per year. The increase took place particularly 1986, when the in situ saphenous vein bypass was introduced in Denmark. A total of 203 bypasses were performed at the University Hospital of Copenhagen, Rigshospitalet: 108 in situ bypasses, 51 bypasses with arterial protheses and 44 bypasses using reversed vein. The cumulated graft patency after one year was 76% for the in situ bypasses, 26% for the bypasses with arterial protheses and 32% for reversed vein. The cumulated limb survivals after one year were 90%, 66% and 63%, respectively.

Teratomas of the mediastinum.

Mediastinal teratomas are rare, constituting only 8-13% of tumours in this region. Teratomas often contain structures from all three germ layers, and 15-20% are malignant. A report is presented of eight patients operated on in 1978-1985 for mediastinal teratoma histologically classified as benign. Radical excision was performed in seven cases, but one tumour could not be radically removed because of infiltrative growth into vital structures, and the patient died 9 months postoperatively. In the other seven cases, including four with unusually rapid and dramatic tumour development, no signs of recurrence have appeared.

Hemodynamic factors as a cause of vascular surgery failures in diabetics.

Thirty-six legs in thirty-three diabetic patients with ischemia at rest and multiple level arterial disease were studied preoperatively. Direct intraarterial femoral and popliteal artery blood pressures were measured together with indirect arm and foot blood pressures. Based on the systolic segmental pressure gradients it was predicted preoperatively whether it was necessary to make a one- or two-level reconstruction. The ankle pressure measured one month postoperatively correlated well with predicted values. Of the seventeen occlusions within the observation time hemodynamic factors played an important role in eleven cases. In the femoro-crural segment one occluded in which an iliac stenosis with a pressure gradient of 28% had been disregarded. In the femoro-popliteal above knee segment four occlusions occurred in cases where the postoperative ankle pressures were less than 80% of the preoperatively predicted value, suggesting stenosis at the anastomosis. A popliteal to ankle gradient of 39% was measured preoperatively in the fifth case which occluded 2 months postoperatively. In the aortofemoral segment five occlusions occurred all having femoral to ankle pressure gradients exceeding 40% of femoral artery pressure. Retrospectively, seven of the failures might have been prevented by two-level reconstructions and four failures by a secondary arterioplasty.