[Acetylsalicylic acid after iliac-femoro-popliteal interventions?]. / Acetyl-Salicyl-Säure (ASA) nach iliako-femoro-poplitealen Eingriffen?

To determine whether acetyl salicylic acid (ASA) in a daily dose of 1500 mg versus untreated controls is effective in patients with peripheral arterial disease a prospective randomized but not placebo-controlled one single centre trial was undertaken. Patients were assigned to one of two groups by means of multi-dimensional contingency tables whereas the risk factors age, sex, height, body weight, diabetic metabolic state, hypertension, history of myocardial infarction, smoking habits and preoperative clinical status according to the Fontaine classification where found in the state of balance. 298 patients with arterial occlusions in the iliaco-femoro-popliteal level were recruited during 1971-1974, the primary end points were probability of patency and probability of survival. In regard as well as to the probability of patency (p less than 0.56 Breslow, p less than 0.66 Mantel) as to the probability of survival (p less than 0.10 Breslow, p less than 0.70 Mantel) no statistical significant difference was detected. In conclusion ASA, in the doses administered here, was unable to improve patency or prolong patient survival, an outcome, which is at variance with results obtained by others.

[Professional organ procurement as a prerequisite for attaining the necessary transplantation frequency: experiences with organ distribution at the transplantation center in Vienna]. / Professionelle Organgewinnung als Voraussetzung zum Erreichen der notwendigen Transplantationsfrequenz: Erfahrungen mit der Organspende am Transplantationszentrum Wien.

In the years 1965 to 1988 one or more organs were harvested for the purpose of transplantation from 649 brain dead organ donors reported to the Vienna transplantation centre. Based on a 1982 law regulating organ donation a large number of initiatives aiming at the improvement of the organ procurement system have taken place. In particular, the introduction of a decentralized donor guidance and organ retrieval system, a few information campaigns, as well as the introduction of full-time transplantation coordinators have significantly increased the number of organ donors. This development has made the Vienna transplantation centre one of the largest centres in Europe and has recently resulted in the achievement of a virtual balance between the increase of patients on the waiting list and the growth of the rate of transplantations performed. If this organ procurement policy is consistently continued in the years to come, there is a good chance of ensuring sufficient supply of organs for all patients on waiting lists, at least within the Viennese area.

Primary hepatic cancer--the role of limited resection and total hepatectomy with orthotopic liver replacement.

Between 1977 and 1986, 172 patients with primary hepatic cancer were treated at the Department of Surgery I, University of Vienna Medical School. In 76 cases (80%) males, 20% females), cirrhosis of the liver was also present. Ninety patients underwent curative surgery (hepatic resection in 64, and liver transplantation in 26 cases). There were no early tumor stages. Forty-five large tumors were confined to one lobe, 42 involved both lobes, 3 even invaded adjacent structures, the majority (74%) being hepatocellular carcinomas. Forty-four of the 64 liver resections were performed in patients with otherwise normal livers (mortality 18%), while 20 patients had associated liver cirrhosis. In view of the extremely high mortality rates after extended liver resection, only limited local resections have been performed in cirrhotic malignancies since 1982 (mortality 25%). Perioperative mortality (25% overall) was due mainly to hepatic failure and sepsis; non-fatal complications occurred in 12 patients (26%). Seventeen of the 26 liver transplants were cirrhotic hepatomas. Nine deaths (34%) were caused by technical problems (graft failure, clotting disorder after massive transfusion) and systemic infections. The outcome for the patient after the immediate postoperative period was determined by tumor regrowth (residual liver tissue, graft, distant metastases) in both groups (median life expectancy 18.4 months after radical liver resection and 18.6 months after liver transplantation). Surgery is the only alternative for these patients (50% survival of untreated hepatoma: 2.6 months), improving both their quality of life and survival. We believe that in carefully selected candidates with non-resectable tumors liver replacement may be a useful alternative.

Aorto-Y-bifurcation graft: Dacron versus PTFE. Preliminary results of a randomized prospective study.

A randomized prospective study comparing PTFE-Y and Dacron-Y-grafts with regard to function rate, morphology, hemodynamic differences along the proximal anastomosis and body of the graft, complications and quality of material was performed. Between March 1983 and February 1987, 112 patients were admitted to the study. Randomization including the criteria of age, sex, indication to operation (chronic occlusive disease, aneurysm) run-off, diabetes, nicotine consumption and operative approach (transperitoneal, retroextraperitoneal) followed the methods of adaptive randomization developed by Pocock and Simon and was well balanced. Function rate and complications as well as morphological alterations showed no significant differences in either group. During a mean observation period of 24 months, Group I yielded a 97% and Group II a 95% function rate (Kaplan-Meier). In all patients but one in each group with limb graft occlusions (n = 5) function was regained by successful thrombectomy and profundaplasty. With respect to Doppler ultrasound differences in flow pattern, in four patients with enlarged proximal side-end anastomosis and adequate--not to large--incision is recommended performing the proximal anastomosis.

[Multiple transplantation of the kidney as a risk factor]. / Die Mehrfachtransplantation der Niere als Risikofaktor.

The influence of match, immunological therapy, age of the recipient and sex has been analysed by graft survival in 91 patients receiving a second kidney graft. Effects of these risk factors in first kidney grafts are not demonstrable in second grafts with the exception of cyclosporin which also produces better second graft survival. The main active risk factor for second transplants is endurance of function of the first graft. Function of the first graft over a period exceeding 1 year gives a significantly better second graft survival rate than function lasting less than one year.

[Effect of risk factors on early and long-term regional results following kidney transplantation]. / Der Einfluss von Risikofaktoren auf regionale Früh- und Langzeitergebnisse nach Nierentransplantation.

An observational study by multifactorial statistical analysis was undertaken on 785 kidney transplants. Risk factors in first transplants for primary non-function are cold ischaemic time, donor centre and acute rejection, with a non-function rate of 8% and a delayed function of 37%. Risk factors for transplant survival are bad match, no preoperative transfusions, age of recipient below 40 years, male sex, diabetes, conventional immunosuppressive therapy and cadaver donors. Donor centre and delayed primary function have no influence on long-term kidney function. The analysis revealed additive effects of various risk factors. This has to be taken into account in recipient-selecting policy.

The influence of anticoagulant treatment on the probability of function in femoropopliteal vein bypass surgery: analysis of a clinical series (1970 to 1985) and interim evaluation of a controlled clinical trial.

During the years 1970 to 1985, 463 patients with obliterative atherosclerosis at the femoropopliteal level underwent elective surgery. The operation performed was an autologous saphenous vein bypass using the reversed technique. The vascular surgical treatment was documented in reasonable detail (both baseline and follow-up) in accordance with the documentation system of the Austrian Society of Vascular Surgery. On-line data entry with use of SAS data-base management software was used. The patency curves were estimated in accordance with the Kaplan-Meier method; possible differences were checked by means Breslow's and Mantel's tests. The preoperative clinical status (claudicants, n = 200; limb salvage, n = 263) influenced the postoperative results in a statistically significant manner (Breslow p less than 0.01; Mantel p less than 0.03). All the other risk factors analyzed (site of distal anastomosis above versus below the knee, n = 231, and n = 232, respectively; Breslow p less than 0.58, Mantel p less than 0.58. Presence [n = 122] or nonpresence [n = 341], of diabetes mellitus [Breslow p less than 0.77, Mantel p less than 0.68]; smoking habits [nonsmokers, n = 93, smokers n = 370, Breslow p less than 0.68, Mantel p less than 0.69;]) did not reach statistical significance. Anticoagulant treatment (n = 101) had no effect (Breslow p less than 0.93, Mantel p less than 0.72), even when the therapy was restricted to cases with disease at advanced clinical stages (stages III, IV; n = 50; Breslow p less than 0.55, Mantel p less than 0.95). On the basis of these analyses, a prospective trial was initiated in 1979. Eighty-eight patients were studied; those in group I (n = 42) received dicumarol, and those in group II (n = 46) were controls who did not receive anticoagulant treatment. At present, the median follow-up time is at 30 months. Treatment with dicumarol favorably influenced graft patency (Breslow, p less than 0.03, Mantel p less than 0.07; one-tailed tests). The patients' preoperative clinical status affected the results of surgery (Breslow p less than 0.03, Mantel p less than 0.02; one-tailed tests). In relation to the preoperative clinical status, a therapeutic effect was observed in stages III and IV (n = 45; Breslow p less than 0.03, Mantel p less than 0.07; one-tailed tests), while no effect of therapy was demonstrable in claudicants (n = 43; Breslow p less than 0.3, Mantel p less than 0.4; one-tailed tests).(ABSTRACT TRUNCATED AT 400 WORDS)

The place of profundaplasty in the surgical treatment of superficial femoral artery occlusion.

One-hundred and sixty-three patients in whom an isolated profundaplasty was performed as treatment for superficial femoral artery occlusion were evaluated for postoperative improvement, taking into consideration the degree of stenosis of the profunda origin and the patency of peripheral vessels. One-hundred and eleven (68.1%) patients achieved clinical improvement. Fifty-two patients had to undergo amputation (27 below the knee and 19 above the knee) or distal reconstruction (6 patients) because of unrelieved ischaemia. In patients with Fontaine stage II and III disease (89% and 70% respectively) improvement was observed more often than in those with stage IV disease (53%). Half of the patients had an increase of the resting systolic ankle-brachial arterial pressure index, but the rise was only slight (0.12 +/- 0.1). While radiological information of the presence and degree of a stenosis had little influence on the operative outcome stenosis at the origin of the profunda, when seen and described at operation, resulted in a more frequent improvement in the clinical state and systolic ankle-brachial arterial pressure index. A patent popliteal artery was not necessary for a favourable outcome but the number of patent tibial arteries was important. Whenever two tibial vessels were patent, relief was achieved in 75% of the cases: the existence of one patent tibial artery produced improvement in 64% but if all were occluded only 31% showed improvement. In cases of severe ischaemia, success following profundaplasty is limited and the results are often inadequate. If at least one tibial artery is patent, the alternative is a femoro-crural reconstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevention of nephrotoxic cyclosporine peak concentrations by daily drug division in 3 equal oral portions.

Nephrotoxicity is the main side effect of cyclosporine therapy. In this study 2 groups consisting of 6 kidney transplant recipients were investigated. The oral cyclosporine daily dose was in the first group 13 mg/kg, in the second 11 mg/kg, respectively. In both groups, the daily dose was divided on the first day of investigation in 2 equal portions given at an interval of 12 hours. On the second day, the same dose was divided in 3 equal portions given at an interval of 8 hours. After cyclosporine administration twice a day very high blood cyclosporine peak concentrations (two to three times higher than the therapeutic range) were measured. These potential nephrotoxic cyclosporine concentrations could be prevented by cyclosporine application in 3 equal portions. A reduction of the daily dose in the early period after kidney transplantation to a starting daily dose of 12 mg/kg or even 10 mg/kg can be recommended.