Nathan P. Couch

PROLONGED SURVIVAL OF SKIN HOMOGRAFTS IN UREMIC PATIENTS

In the studies by Hume el al.’ on the functional survival of renal homotransplants in patients with chronic renal insufficiency, it was observed that the period of homotransplant function in 4 of 9 recipients ranged from 5 to 25 weeks. The course of the renal homotransplant in the normal dog contrasts with this wide range and long duration of the period of functional survival of renal homotransplants in the uremic patient. Irrespective of the manner in which the donor and/or recipient have been modified, including procedures known to suppress antibody formation, functional survival of the renal homotransplant in the dog seldom exceeds 1 week. Since there has been no uniformly successful experimental counterpart of chronic renal insufficiency in the dog, no information is presently available on the renal homotransplant function in the dog under these circumstances. In man, when the recipient does not have a chronic renal insufficiency, as exemplified by the case of Michon et aE.,2 the renal homotransplant functions well for about 3 weeks and then ceases to function rather abruptly, with the homotransplant showing the same morphologic pattern of rejection seen in the dog. This pattern has been interpreted as a morphologic representation of an antigen-antibody reaction; the immune response of the recipient to the renal homotransplant is believed to be the basis for the rejection. A delayed rejection or prolonged acceptance, therefore, may well represent an impaired immune response. Homotransplantation studies by Dempster3 and Simonsen4 have established a close antigenic relationship between the kidney and the skin. Should this relationship apply in man, one would expect the uremic recipient, if the prolonged functional survival is a manifestation of an impaired immune response, likewise to show a prolonged survival of skin homografts. I t was on this basis that the study to be described was undertaken. The first group of patients studied had chronic renal insufficiency with uremia that ranged from 4 months to 6 years in duration (TABLE 1). It may be noted that a variety of chronic lesions is represented, with uremia a common denominator. Skin homografts were accompanied by skin autografts in each case. The grafts were approximately square with an area of 3 to 4 sq. cm. The bed of the recipient site was subcutaneous tissue, and the grafts were full thickness. Biopsies from the homograft and the autograft were obtained simultaneously. Tissues were fixed in buffered 10-per cent formalin and processed through a modified Bouin solution. Hematoxylin and eosin, periodic acid-Schiff, Verhoeff-van Gieson, reticulum, and Feulgen stains were used. TABLE 2 summarizes the data on the recipient, donor type of homograft, the time interval to biopsy, and the estimate of the degree of homograft survival. “Pure” refers to grafts obtained from normal donors, “cortisone” to grafts from

What is the proper role of polytetrafluoroethylene grafts in infrainguinal reconstruction

Polytetrafluoroethylene grafts have been used extensively for infrainguinal vascular reconstruction either as the conduit of choice or as a substitute when saphenous vein is unavailable. Although numerous studies have shown satisfactory early patency rates, the long-term efficacy of these grafts in a large number of patients for specific indications and in various positions has been less well defined. From 1977 to 1987 we used four PTFE grafts from three different manufacturers to perform 300 infrainguinal reconstructions on 240 patients on our vascular service. The indications for surgery were disabling claudication in 28% and limb salvage in 72%. The 30-day operative mortality of 1% was not different from the 1.4% associated with infrainguinal autogenous vein grafting. The 5-year cumulative patency rate achieved with all infrainguinal polytetrafluoroethylene grafts was 35%, significantly higher for grafts placed for claudication (57%) than those placed for limb salvage (24%). There were no significant differences between the above-knee and below-knee locations for distal anastomoses regardless of indication, but femoropopliteal grafts provided significantly higher 5-year patency (37%) than infrapopliteal grafts (12%). Comparison of the 5-year patency rates among the three manufacturers of polytetrafluoroethylene grafts showed no significant differences. Fifty-four polytetrafluoroethylene grafts that failed underwent 67 revisions after catheter thrombectomy or thrombolysis, which resulted in a minimal 11% 5-year patency rate. Based on this experience, it is concluded that infrainguinal polytetrafluoroethylene prostheses provide significantly inferior results when compared with autogenous reconstruction.

The high cost of low-frequency events: the anatomy and economics of surgical mishaps.

Abstract We conducted a one-year prospective survey to identify adverse outcomes due to error during care in the field of general surgery. We identified 36 such cases among 5612 surgical admissions to the Peter Bent Brigham Hospital, but in 23 cases the initiating mishap had occurred in another hospital before transfer. In two thirds of the cases the mishap was due to an error of commission: an unnecessary, defective, or inappropriate operative procedure. Twenty of these patients died in the hospital, and in 11 death was directly attributable to the error. Five of the 16 survivors left the hospital with serious physical impairment. A satisfactory outcome was achieved in only 11 cases (31 per cent). The average hospital stay was 42 days, with the duration ranging from one to 325 days; the total cost for the 36 patients was

Natural history of the leg amputee

1,732,432. We suggest that all hospitals develop comprehensive methods to identify and prevent these costly and unnecessary events. (N Engl J Med. 1981; 304:634–7.)

A comparison of in situ and reversed saphenous vein grafts for infrainguinal reconstruction

For 173 patients undergoing major leg amputations, the operative mortality was 13 per cent. The ratio of below-knee (BK) to above-knee (AK) amputations was approximately unity. Of the 150 patients who survived amputation, 93 were given prostheses. Amoung the latter group, 76 per cent of the unilateral AK amputees and 90 per cent of the unilateral BK amputees had a successful rehabilitation. For those patients who had to be converted from BK to AK unilateral amputations, 40 per cent experienced successful rehabilitation, and for those who had either bilateral BK or bilateral mixed amputations, 45 per cent were successful. The most common contraindications to granting prostheses were debility and dementia. The mean time interval from first amputation to latest observation was 3.5 years (range, 5 weeks to 13.5 years). At three years 49 per cent of the patients survived and at five years 31 per cent survived. Despite major impediments, satisfactory rehabilitation is accomplished frequently enough to justify optimism for a considerable number of geriatric amputees.

Coronary artery disease in patients requiring abdominal aortic aneurysm repair. Selective use of a combined operation.

Despite the recent popularity of the in situ saphenous vein graft for infrainguinal arterial reconstruction, considerable doubt exists as to whether this approach offers any real advantage over conventional reversed vein grafts. Therefore we have reviewed our experience with 675 infrainguinal vein grafts undertaken during the past 10 years. There have been no substantial modifications in the technique used for 535 reversed vein grafts over the 10-year period. During the past 3 years, 140 in situ vein grafts have been carried out with the Leather valvulotome used to incise the venous valves. Life-table analysis of 449 femoropopliteal reversed saphenous vein grafts demonstrated 1- and 3-year cumulative patency rates of 81% and 73%, respectively, and a 5-year patency rate of 63%. Seventy-five femoropopliteal in situ bypasses demonstrated a patency rate of 85% at both 1- and 3-year intervals. Cumulative patency rates for 86 femoroinfrapopliteal reversed saphenous vein grafts were 64% and 62% at 1 and 3 years, respectively. Comparable patency rates for 65 infrapopliteal in situ saphenous vein grafts remained stable at 87% for 3 years. Fifteen of the in situ bypasses were anastomosed to vessels at the ankle or foot level, whereas none of the reversed bypasses was carried that far distally. This experience with both in situ and reversed techniques on one service by the same surgeons demonstrates a clear superiority of the in situ saphenous vein graft for infrapopliteal reconstruction at the 3-year interval.

The reduction of mortality of abdominal aortic aneurysm resection

The chief cause of operative mortality after abdominal aortic aneurysm (AAA) repair is myocardial infarction. For this reason, routine coronary angiography followed by prophylactic coronary artery bypass grafting (CABG) prior to AAA repair has been recommended by some surgeons. We report here the results of the selective use of a combined operation. Two hundred twenty-seven patients had elective or emergency repair of nonruptured AAA on our service from 1972 to 1983. Prior to surgery, all patients underwent careful clinical evaluation for the presence of coronary artery disease (CAD) and were classified into the following: group I (n = 121), no clinical evidence of CAD, 53%; group II (n = 96), clinical evidence of stable CAD, symptomatic or asymptomatic, 42%; group III (n = 10), unstable CAD, five per cent; Group IIIa (n = 4), asymptomatic AAA; and group IIIb (n = 6), symptomatic AAA. Seven patients ultimately assigned to group II underwent stress electrocardiogram (ECG) and eight group II patients had coronary angiography before surgery. All patients in groups I and II underwent elective or urgent repair of their AAA without CABG. Prior to surgery, these patients were managed with placement of a pulmonary artery catheter and incremental volume loading to construct a left ventricular performance curve as a guide to surgical fluid replacement. All were carefully monitored for at least 48 hours after surgery in an intensive care unit. Four patients (group IIIa) with unstable CAD and asymptomatic AAA underwent CABG followed by elective AAA repair within six months. Six patients (group IIIb) with unstable CAD and symptomatic AAA underwent combined open heart surgery (CABG and, in one patient, valve replacement) and AAA repair as a single operation. There was no operative mortality in group III patients. Thirty-day operative mortality for the entire group of 227 patients was 1.3% (three deaths), with only one death from a myocardial infarction (0.4%). While there is clearly a high incidence of CAD in patients with AAA, the present results indicate that these individuals can be managed with low risk by a selective approach based upon clinical assessment of their CAD. Our experience further demonstrates that patients with unstable CAD and symptomatic AAA may have both lesions safely repaired as a single operative procedure.

Early carotid endarterectomy in patients with small, fixed neurologic deficits

The reasons for improvement in mortality after abdominal aortic aneurysmectomy in 144 consecutive patients are assessed. Elective aneurysmectomy carried a mortality of 5.7 percent. The deaths were all attributable to myocardial infarction occurring in patients with known coronary artery disease.

Renal vein renin activity in the prognosis of surgery for renovascular hypertension

Patients who have sustained a large hemispheric stroke are not candidates for early carotid endarterectomy, but there is less agreement regarding the role of carotid endarterectomy in patients with small, fixed neurologic deficits. Accepted practice in many centers is to wait 4 to 6 weeks after the onset of the deficit before proceeding with carotid endarterectomy because of the fear that early revascularization will increase the size of the infarct. Earlier endarterectomy, however, in patients with significant residual ipsilateral carotid territory at risk may prevent repeated infarctions. For the past 5 years our approach to patients with a small stable stroke and significant stenosis (greater than 75%) has been prompt ipsilateral endarterectomy. Of the 337 carotid endarterectomies at our institution since 1979, a subset of 28 patients with hemodynamically significant carotid lesions presented with a small, fixed stroke. The period of time between the appearance of the stroke and carotid endarterectomy averaged 11 days, but 53% of patients were operated on within 7 days of the onset of symptoms. Selective shunting based on intraoperative EEG monitoring was utilized and 40% of the 28 patients required shunts. Operative mortality consisted of one death from a pulmonary embolus, and no patient sustained a new postoperative deficit. Long-term follow-up was available for 96% of patients over a mean of 2 years. During this time two new neurologic events occurred: one fatal stroke and one transient deficit. This experience indicates that patients with small, fixed neurologic deficits who continue to have carotid territory at risk may safely undergo carotid endarterectomy without waiting 4 to 6 weeks.

Abdominal aortic aneurysm repair in patients with preoperative renal failure

Abstract Twenty-four hypertensive patients underwent corrective surgery for renal hypertension. The postoperative follow-up period was one year or more in all. In twelve patients the results were classified as excellent (five patients) or good (seven patients). Type of surgery (nephrectomy, thirteen patients; vascular repair, eleven patients) was not a factor in the clinical results. Renal vein renin activity ratio and absolute renal vein renin activity from the involved kidney provided the most accurate means of predicting surgical results. The ratio correctly predicted the surgical result in eleven of fourteen patients, and the absolute level correlated correctly in all but one of fourteen patients. Divided ureteral function tests did not distinguish between patients whose condition was and was not improved by surgery, and the intravenous pyelogram, although adequate for screening for the presence of functional renovascular disease, included a high proportion of false-positive tests. Aortography, although revealing the arterial stenosis in all instances, emphasized the need for confirmation of the functional significance of the lesion since half the patients with stenosis did not respond to surgery. On the basis of our experience, renal vein renin determinations appear to be a highly reliable means of selecting patients for corrective renal surgery.