Chronic abdominal aortic occlusion(CAO) is a rare entity and poses a particular management challenge. It shows a spectrum of clinical presentations due to chronic progression and suprarenal thrombus progression. Ongoing debate over the proximal thrombus propagation leading to renal and mesenteric artery occlusion results in controversy regarding the need of in-line aortic reconstruction with proximal thromboendarterectomy(TEA). To evaluate the management and surgical outcome of chronic abdominal aortic occlusion, a retrospective study of 24 patients surgically treated for angiographically documented CAO between September, 1986 and September, 1997 was conducted. Male to female ratio was 22:2 with a mean age of 56.8 years(range: 33~71 years). Mean follow-up period was 55.0 months. All patients presented with sympoms of vascular insufficiency of lower limbs including claudication in 10(41.7%), rest pain in 11(45.8%) and tissue loss in 3(12.5%). Impotence was present in 59.1% in men. Location of aortic occlusion was distributed in juxtarenal and above(11, 45.8%) and infrarenal(13, 54.2%). Associated visceral arterial involvement included 18 inferior mesenteric artery(IMA) occlusion, 8 renal artery(RA) stenosis and 1 superior mesenteric artery(SMA) occlusion. Infrainguinal arteries were involved in 11 patients(45.8%) including 9 superficial femoral artery obstruction. Aortobifemoral bypass(AoBF) grafts were implanted all but one case, which was treated with an axillobifemoral bypass(AxBF). In AoBF, proximal thrombectomy or thromboendarterectomy was performed and, in most cases, end to end anastomosis is favored in proximal anastomosis due to possibility of proximal thrombus propagation. Concomitant visceral revascularizations were performed in selected cases(2 renal, 2 IMA) with inflow procedures. The operative mortality rate was 4.2%(1/24) and the perioperative morbidity rate was 37.5%. AoBF inflow procedures yielded 1, 5-year primary patency rate of 95.5% and 89.1%, respectively. The one AxBF graft was occluded graft at 26 days after surgery. Two patients died and the 5-year survival rate for AoBF was 95.7%. There was no statistical change in renal function between pre- and postoperative periods. Follow-up renal dysfunction(serum creatinine levels>2.0 mg/dl) was documented in two patients, and one patient developed acute renal failure requiring dialysis. Aortobifemoral bypass following proximal thromboendarterectomy is the optimal treatment modality with high patency rate in chronic abdominal aortic occlusion. Visceral artery reconstruction in clinically significant stenosis and judicious attention for prevention of renal damage in pararenal thrombectomy under suprarenal clamping are helpful for better outcome in chronic abdominal aortic occlusion.
Acute Kidney Injury ; Arteries ; Constriction ; Constriction, Pathologic ; Creatinine ; Dialysis ; Endarterectomy ; Erectile Dysfunction ; Female ; Femoral Artery ; Follow-Up Studies ; Humans ; Lower Extremity ; Male ; Mesenteric Arteries ; Mortality ; Postoperative Period ; Retrospective Studies ; Survival Rate ; Thrombectomy ; Thrombosis ; Transplants

BACKGROUND: This study investigated the protective mechanism of Prostagladin E1 (PGE1) against intimal hyperplasia after vein interposition grafts in rabbits. It has been demonstrated that active oxygen species contribute to vascular smooth muscle cell growth via early cell cycle gene activation. We attempted to study whether PGE1 had an effect on the inhibition of the oxidative stress injury index (8-OHdG, MDA). METHODS: Forty-eight jugular vein grafts were inserted into the carotid arteries of male hyperlipidemic New Zealand white rabbits, which were divided into 2 groups (saline group and PGE1 group). Saline and Prostaglandin E1 (0.1 microgram/kg/min) were administered as a continuous infusion for 2 hours every day from just before graft interposition to harvest. The vein grafts were harvested at 6 hour, 1 day, 1 week, and 2 week after grafting and rapidly stored in liquid nitrogen ( 70oC). 8-OHdG was measured by using high performance liquid chromatography coupled with electrochemical detection (HPLC-EC), and malondialdehyde (MDA) was measured by using thiobarbituric acid (TBA) assay. PC 10 index and intimal thickness of the grafts were measured with a computer digitalized image analyzer. RESULTS: There was no difference in 8-OHdG levels between the saline and the PGE1 groups. PGE1 had more inhibitory effect on the MDA level as an oxidative stress injury index, but its action was restricted to 1 day. A morphometric analysis and an immunohistochemical study showed that the PGE1 group had more suppressive effects both in intimal thickeness and proliferating cell nuclear antigen (PCNA) expression than the saline group (p<0.05). CONCLUSION: These results suggest that PGE1 is effective in preventing intimal hyperplasia after vein interposition grafts in rabbits and may play a role in inhibiting oxidative stress injury.
Alprostadil ; Carotid Arteries* ; Chromatography, Liquid ; Genes, cdc ; Humans ; Hyperplasia ; Jugular Veins ; Male ; Malondialdehyde ; Muscle, Smooth, Vascular ; Nitrogen ; Oxidative Stress* ; Proliferating Cell Nuclear Antigen* ; Rabbits ; Reactive Oxygen Species ; Transplants* ; Veins*

Acute rejection in renal transplantation is a major risk factor threatening the longterm graft survival. Acute rejections refractory to conventional anti-rejection therapy using steroid pulse or antilymphocyte preparations occur in minority, preceding to progressive deterioration of renal function and graft loss. Recent reports showed that tacrolimus rescue therapy in this refractory rejections has converted rejection process. In order to evaluate the clinical outcome of tacrolimus rescue therapy in refractory rejections, we performed a retrospective study. Since April 1997, we performed tacrolimus rescue therapy intent-to-treat for steroid- or OKT3- resistant rejections in 5 patients. All rejections were histologically confirmed according to Banff criteria. As conventional antirejection therapy, steroid pulse therapy (solumedrol 500~1000 mg iv for 3 days) or OKT3 therapy (5 mg/day for 14 days) was performed. The outcome of the rescue therapy is classified into three categories by the change of serum creatinine level or the histologic findings; Improvement-return of serum creatinine level (sCr) to or below the prerejection baseline (nadir) level, Stabilization-arrested sCr increase, Failure-progressive deterioration of renal function, or graft loss. All were men and the mean age was 38 years. Living related- & unrelated-donor transplantation were 2 and 3 cases respectively. Immunosuppression were done with CsA Pd+ (3) or CsA+ Pd+ AZA (2). Acute rejection grades according to Banff criteria were mild (2) or moderate (3). The mean interval between transplantation and tacrolimus conversion was 54.4 days. The outcome was as follows; improvement 2 cases, stabilization 1 case and failure 2 cases. During 3~10 months followup PTLD occured in 1 case, treated with graft nephrectomy and no other complications in other 4 cases. In conclusion, we can convert ongoing refractory rejections to steroid and OKT3 therapy by tacrolimus rescue therapy in 60% (3/5) successfully. Although longterm followup result is necessary to confirm the efficacy and safety of the tacrolimus rescue therapy, the result of this early trial is so good that we may try tacrolimus in refractory rejections for rejection reversal.
Creatinine ; Follow-Up Studies ; Graft Survival ; Humans ; Immunosuppression ; Kidney Transplantation* ; Male ; Muromonab-CD3 ; Nephrectomy ; Retrospective Studies ; Risk Factors ; Tacrolimus* ; Transplants

PURPOSE: Although progenitor cells may contribute to intimal hyperplasia (IH) after arterial injury, positive contribution of IH is variable with type of injury or cells. This study was designed to examine whether differentiated muscle derived stem cells (MDSC) attenuate IH in rat. METHODS: MDSCs were retrieved using preplate techniques from rat calf muscle and MDSCs (preplate 6th culture fraction, pp6) were exposed to VEGF (50 ng/ml) for endothelial differentiation prior to injection. Male rats were divided into two groups (cell treated vs. control) and underwent carotid balloon injury with 2-Fr catheter. The virus containing Green fluorescent protein (GFP) gene was transfected into cells for monitoring. Cells (5x10(6)) were indwelled into carotid artery for 30 minutes after injury and then blood flow was restored. Arteries were harvested at various intervals (1, 2 and 4 weeks) after injury. The intima to media thickness ratio (IMTR) was calculated with morphometric analysis. RESULTS: Endothelial surface markers such as VE-CADHERIN were strongly expressed on differentiated MDSCs. At 4 weeks after injury, IH was predominantly observed in control group compared to cell treated group. The intensity of GFP was strongly observed at 1 week and declined at 4 weeks in carotid artery wall at MDSC group. CD31(+) endothelial cells were observed at MDSC group compared to control. The mean IMTR in cell treated groups were significantly lower than control at 2 weeks (P=0.005) and 4 weeks (P< or =0.001). CONCLUSION: Our study demonstrates that MDSCs therapy promotes re-endothelialization and leads to attenuation of IH after balloon injury in rat.
Animals ; Antigens, CD ; Arteries ; Cadherins ; Carotid Arteries ; Catheters ; Endothelial Cells ; Humans ; Hyperplasia ; Male ; Muscles ; Rats ; Stem Cells ; Vascular Endothelial Growth Factor A ; Viruses

Iliofemoral vein thrombosis is a serious disease causing major morbidity, such as phlegmasia alba dolens, phlegmasia cerulea dolens, fatal pulmonary embolism, and post-thrombotic syndrome. Systemic anticoagulation therapy with heparin and coumadin often shows no effect and thrombectomy often results in poor long term patency due to recurrent thrombosis. Some recent studies have reported good results by catheter-guided thrombolysis therapy (CGTT) in iliofemoral vein thrombosis. Authors have experienced a good result by CGTT in an old (aging 7 weeks) iliofemoral vein thrombosis. (Case) A 21 years-old female patient with diffuse edema of left thigh and leg was admitted in SNUH. Her parents notified her abnormal gait at the age of three, but no treatment was done. In Jan. 1998, she was diagnosed as spastic diplegia due to cerebral palsy and underwent orthopedic surgery (semitendinosus tendon transfer) at other hospital. After long leg cast for 6 weeks, swelling of her left thigh developed, which waxed and waned. Seven weeks thereafter, she was diagnosed to have left iliofemoral vein thrombosis and transferred to our hospital. After initial evaluation and systemic heparin therapy, we performed CGTT via left popliteal vein puncture. After successful passage of guidewire, serial balloon dilatation and intra-clot urokinase infusion was done. Total 3.5 million units of urokinase was infused for 28 hours with simultaneous intravenous heparin. Despite of some residual thrombi, the venous flow of iliofemoral vein was restored with no complication and her symptom has much improved. Patent venous flow was detected at 6 months follow-up doppler examination.
Cerebral Palsy ; Dilatation ; Edema ; Female ; Follow-Up Studies ; Gait ; Heparin ; Humans ; Leg ; Orthopedics ; Parents ; Popliteal Vein ; Pulmonary Embolism ; Punctures ; Tendons ; Thigh ; Thrombectomy ; Thrombolytic Therapy* ; Thrombophlebitis ; Thrombosis* ; Urokinase-Type Plasminogen Activator ; Veins* ; Warfarin ; Young Adult

Effectively functioning arterio-venous fistula (AVF) is so important as to be called a lifeline of the patient with end stage renal disease by maintaining hemodialysis. Not infrequent development of complications of AVF is a major cause of patient's admission and medical cost. Rescue therapy of complicated AVF had several advantages; delay or prevention of new AVF formation, prevention of temporary percutaneous central vein cannulation, and maintenance of psychologic stability. PURPOSE: In order to analyse the patterns of AVF complications and the short- and long-term results of rescue therapy, we made a clinical review retrospectively. PATIENTS & METHODS: We performed AVF in 1503 cases from Jan. 1986 to Dec. 1997. Among them, we performed 93 rescue therapies in 70 patients. Rescue therapy is defined to be a secondary procedure to correct complications while maintaining the primary anastomosis. Secondary procedures in immediate postoperative failure due to technical cause, such as improper selection of vein, were excluded. RESULTS: The most common indication of rescue therapy in 93 cases was thrombosis (78 cases, 83.9%), which is followed by aneurysm in 9 cases, venous hypertension in 2 cases, steal syndrome in 2 cases, high output cardiac failure in 1 case. Autogenous veins were used in initial operation in 55 cases and PTFEs in 38 cases. Early failure within 1 month after rescue therapy happened in 20 cases (21.5%). Complications occured in 4 cases, such as infection (2), brachial plexus injury (1), and arm edema. (1) Mean follow up duration was 3.9 months (1~123 months). Secondary patency rate after 3, 6, 12, 24 months were 70.3+/-3.97, 62.0+/-4.89, 50.6+/-5.85, 37.9+/-7.03% respectively. Secondary patency rate in successfully rescued patients excluding early failure within 1 month after rescue therapy were 91.5+/-3.11, 80.9+/-4.46, 68.9+/-6.15, 54.1+/-8.19%. CONCLUSIONS: Thrombosis or malfunction due to neointimal hyperplasia was the most common complication in AVF. Early and proper rescue therapy in complicated fistula could salvage the AVF. So careful and prompt evaluation of the inflow and outflow of the complicated fistula is necessary, and every effort to rescue the fistula should be made.
Aneurysm ; Arm ; Brachial Plexus ; Catheterization ; Edema ; Fistula* ; Follow-Up Studies ; Heart Failure ; Humans ; Hyperplasia ; Hypertension ; Kidney Failure, Chronic ; Polytetrafluoroethylene ; Renal Dialysis* ; Retrospective Studies ; Thrombosis ; Veins

Despite the wide acceptance of endovascular aneurysmal repair in patients with abdominal aortic aneurysm (EVAR), stringent morphologic criteria recommended by manufacturers may preclude this treatment in patients with AAA. The purpose of this study was to investigate how many patients are feasible by Zenith and Excluder stent graft system, which are available in Korea. Eighty-two AAA patients (71 men, mean age 70 yr) who had been treated surgically or medically from January 2005 to December 2006 were included. Criteria for morphologic suitability (MS) were examined to focus on characteristics of aneurysm; proximal and distal landing zone; angulation and involvement of both iliac artery aneurysms. Twenty-eight patients (34.1%) were feasible in Zenith stent graft and 31 patients (37.8%) were feasible in Excluder. The patients who were excluded EVAR had an average of 1.61 exclusion criteria. The main reasons for exclusion were an unfavorable proximal neck (n=34, 41.5%) and problem of distal landing zone (n=25, 30.5%). There was no statistical significance among gender, age or aneurysm size in terms of MS. Only 32 patients (39%) who had AAA were estimated to be suitable for two currently approved grafts by strict criteria. However, even unfavorable AAA patients who have severe co-mobidities will be included in EVAR in the near future. Therefore, more efforts including fine skill and anatomical understanding will be needed to meet these challenging cases.
Aged ; Aged, 80 and over ; Aortic Aneurysm, Abdominal/pathology/*surgery ; *Blood Vessel Prosthesis Implantation/methods ; Female ; Humans ; Male ; Middle Aged

PURPOSE: This study was designed to investigate whether vascular smooth muscle cells (VSMC) from the neointima showed any different response to antiproliferative agents, such as rapamycin or imatinib mesylate, compared to VSMCs from normal artery. MATERIALS AND METHODS: Intimal hyperplasia was made by carotid balloon in jury in male rats. Neointimal cells at 4 weeks after injury and normal VSMCs were extracted by enzymatic isolation method and cultured. Cell viability and proliferation were tested in VSMCs from injured left carotid artery and uninjured right carotid artery. Tests were repeated with rapamycin, imatinib mesylate or both in various concentrations. RESULTS: Rapamycin decreased cell viability only at a high concentration of 10(-5) M in uninjured VSMCs. Combined drugs decreased cell viability at a lower concentration of 10(-7) M in uninjured VSMCs, and at a higher concentration of 10(-5) M in neointimal cells. Overall, rapamycin showed cytocidal effects at a high concentration of 10(-5) M, whereas imatinib did not. Cell proliferation of neointima was significantly decreased along with the drug concentration. Cell proliferation of uninjured VSMCs was significantly decreased at higher drug concentrations. Combined drug therapy showed synergistic effects. Overall, neointimal cells are more susceptible to the antiproliferative effects of the drugs. CONCLUSION: Neointimal cells from the injured carotid artery are more susceptible to the antiproliferative effect of imatinib and rapamycin. Both drugs can be a used for the prevention of intimal hyperplasia, which could be investigated through further in vivo studies.
Animals ; Arteries ; Carotid Arteries ; Carotid Artery Injuries ; Cell Proliferation ; Cell Survival ; Drug Therapy ; Humans ; Hyperplasia ; Male ; Mesylates* ; Muscle, Smooth, Vascular* ; Neointima ; Rats ; Sirolimus* ; Imatinib Mesylate

Extra-anatomic bypass(EAB) is defined as bypass grafts that pass through a significantly different anatomic pathway than the natural blood vessles they replace. The two categorical reasons for doing this in aortoiliac occlusive disease are to avoid "hostile" intra-abdominal pathologic features and to avoid the high risk of transabdominal reconstruction in patients with serious visceral and systemic disease. To determine the application of this procedure, we reviewed retrospectively the characteristics and outcomes of 30 patients who underwent extra-anatomic bypasses during April, 1986 to April, 1997. Three EABs in brachiocephalic reconstruction were done including 2 carotid-subclavian bypass, 1 femoral-biaxillary bypass. 27 EABs in aortoiliac reconstruction were done including 22 femorofemoral bypass(FFB), 4 axillobifemoral bypass(AxBF). In the latter, EABs were used in older patients with medical comorbidities and contraindication to direct reconstructive procedures involving the abdominal aorta including aneurysms, graft infection, and trauma. One and five-year primary patency rates for entire EABs and FFB were 76.9%, 63.8% and 83.1%, 63.5%, respectively. In FFB, patients with limb- threatening ischemia proved to be inferior to those with claudication as measured by primary patency(p=0.013). Age(>65yr.), sex, smoking, medical comorbidities, duration of symtoms, preoperative angioplasty, use of externally supported graft did not influence primary patency in FFB. The 5-year patient survival rates for entire EABs and FFB were 70.4%, 67.9%. Limb salvage rates for entire EABs and FFB were 65.1%, 66.7% at 3 years. Our results suggest that strict selection of patients with limb-threatening ischemia and medical comorbidities may contribute inferior patency rate of EABs. To determine the application of EABs in aortoiliac reconstruction, the nature of intraabdominal pathology and operative risk with vascular surgeon's experience and judgement should be considered.
Aneurysm ; Angioplasty ; Aorta, Abdominal ; Comorbidity ; Humans ; Ischemia ; Limb Salvage ; Pathology ; Retrospective Studies ; Smoke ; Smoking ; Survival Rate ; Transplants

Patients with multilevel atherosclerotic disease represent a difficult surgical challenge. In the 5 decades that have relapsed since the introduction of initial methods of revascularization, a wide variety of the therapeutic options have been developed and advocated for management of aortoiliac disease. With the aid of dramatic advance of endovasular technique, various nonoperative catheter based endoluminal therapies have been accentuated in recent years by the explosive growth in vascular surgical procedures. A combination of iliac PTA and distal surgical revascularization would appeal to be a logical and potentially advantageous methods of revascularization in selected patients. This report is a retrospective review of 20 patients who were treated using a combination of lilac transluminal angioplasty and/or stent and infrainguinal reconstruction. They were 19 males and 1 female with an average of 69 years (range : 48 to 74 years). Follow-up period ranged from 1 month to 92 months( median : 28 months). These patients had cormorbid disease including heart disease (35%), hypertension(35%), diabetes mellitus(15%), hyperlipidemia(15%); 90% of the patients were smokers. Ten patients were treated for rest pain or tissue loss, while ten were treated for moderate or severe claudication. Distal operation included 7 femorofemoral bypass, 11 femoropopliteal(AK) bypass, 4 femoropopliteal(BK) bypass, 1 pop-tibial bypass. A mean resting iliac artery pressure gradient of 27.6+/-22.8 mmHg pre-PTA was reduced to 3.1+/-4.3 post PTA. Mean pretreatment ankle/brachial index of 0.36+/-0.28 increased to 0.80+/-0.16 after operation(P<.001). By Kaplan-Meier method, the 5-year primary patency rate of the distal surgical procedures was 72%. The procedures were well tolerated with no mortality and two complication occurred, but all were sucessfully corrected by stent insertion for intimal dissection and Urokinase infusion for thrombosis. Two patients underwent amputation due to preoperative wide skin ulcer and knee joint infection. We conclude that in selected patients, combined use of iliac PTA or stent insertion and distal surgical reconstructions is safe and effective modality for managing the patients with severe multilevel occlusive disease.
Amputation ; Angioplasty ; Angioplasty, Balloon ; Catheters ; Female ; Follow-Up Studies ; Heart Diseases ; Humans ; Iliac Artery ; Knee Joint ; Logic ; Male ; Mortality ; Retrospective Studies ; Skin Ulcer ; Stents ; Thrombosis ; Urokinase-Type Plasminogen Activator ; Vascular Surgical Procedures