Effects of ginsenoside Rg2 on human neuronal nicotinic acetylcholine receptors

Ginseng saponins, major active components of ginseng root used by folk medicine in the treatment of various diseases, produce multiple pharmacological responses having many effects on the central and peripheral nervous system. Specifically, ginsenoside Rg(2) has been shown to block the nicotinic acetylcholine receptors in bovine chromaffin cells. We have studied the effect of Rg(2) on different types of human neuronal nicotinic acetylcholine receptors (nAChRs), both homomeric and heteromeric, expressed in Xenopus oocytes. Rg(2) did not affect the acetylcholine (ACh)-induced currents in alpha(7) human receptors, however Rg(2) affected the peak currents, and mainly the desensitization of heteromeric receptors alpha(3)beta(4), alpha(3)beta(2), alpha(4)beta(4), and alpha(4)beta(2). Both effects, a diminution of peak current and an increase of desensitization, are dose-dependent and are very similar for all the receptors. The mechanism of action has been studied in more detail in alpha(3)beta(4) and alpha(4)beta(2) receptors where we found a negligible shift in the ACh dose-response curves and a persistence of the Rg(2) effects at high ACh concentrations, indicative of a noncompetitive antagonism. A lack of voltage dependence on the reduction of the peak currents induced by ACh also suggests that Rg(2) does not act as an open channel blocker of human nAChR. The results indicate that Rg(2) acts specifically on heteromeric human nAChRs modulating their desensitization and suggest a possible mechanism by which this saponin contributes to the multiple therapeutic effects of ginseng.

Effects of ginsenosides, active components of ginseng, on nicotinic acetylcholine receptors expressed in Xenopus oocytes

We investigated the effects of ginsenosides, the active ingredient of ginseng, on neuronal or muscle-type nicotinic acetylcholine receptor channel activity expressed in Xenopus oocytes after injection of cRNA encoding bovine neuronal alpha3beta4, alpha7 or human muscle alphabetadeltavarepsilon subunits. Treatment with acetylcholine elicited an inward peak current (I(ACh)) in oocytes expressing nicotinic acetylcholine receptor subtypes. Cotreatment with ginsenoside Rg2 and acetylcholine inhibited I(ACh) in oocytes expressing with alpha3beta4 or alphabetadeltavarepsilon but not in oocytes expressing alpha7 nicotinic acetylcholine receptors. The inhibition of I(ACh) by ginsenoside Rg2 was reversible and dose-dependent. The half-inhibitory concentrations (IC50) of ginsenoside Rg2 were 60.2+/-14.1 and 15.7+/-3.5 microM in oocytes expressing alpha3beta4 and alphabetadeltavarepsilon nicotinic acetylcholine receptors, respectively. The inhibition of I(ACh) by ginsenoside Rg2 was voltage-independent and noncompetitive. Other ginsenosides besides ginsenoside Rg2 also inhibited I(ACh) in oocytes expressing alpha3beta4 or alphabetadeltavarepsilon nicotinic acetylcholine receptors. The order of potency for the inhibition of I(ACh) was ginsenoside Rg2>Rf>Re>Rg1>Rc>Rb2>Rb1 in oocytes expressing alpha3beta4 nicotinic acetylcholine receptors and was ginsenoside Rg2>Rf>Rg1>Re>Rb1>Rc>Rb2 in oocytes expressing alphabetadeltavarepsilon nicotinic acetylcholine receptors. These results indicate that ginsenosides might regulate nicotinic acetylcholine receptors in a differential manner and this regulation might be one of the pharmacological actions of Panax ginseng.

Effects of benzothiazepines on human neuronal nicotinic receptors expressed in Xenopus oocytes

1. We have investigated the effect of diltiazem and its newly synthesized derivative (+,-)-trans-3-acetoxy-8-chloro-2,3-dihydro-5[2-diisopropylamine)ethyl]-2-(4-methoxyphenyl)-1,5-benzothiazepin-4-(5H)-ona hydrochloride (JAC-65) on several recombinant human neuronal nicotinic acetylcholine receptors (nAChRs) expressed in Xenopus oocytes. 2. At 3 microM, both drugs have little effect on the maximal currents evoked by brief pulses of acetylcholine (ACh) in five subtypes of nAChRs (alpha7, alpha3beta2, alpha4beta2, alpha3beta4, and alpha4beta4), showing little selectivity among subtypes. 3. However, both drugs accelerate the decay of the ionic currents evoked upon continuous stimulation of ACh, being this effect larger with JAC-65, and in beta4*-nAChRs. Such an effect was dependent on the concentrations of both the drug and of the agonist used, and showed the characteristics of a non-competitive antagonism. 4. We have further investigated the effect of both drugs when combined with submicromolar concentrations of nicotine, such as those present in plasma of cigarette smokers, and found that JAC-65, but not diltiazem, is able to greatly enhance the desensitizing effect of these low concentrations of nicotine, specially in beta4*-nAChRs. 5. Experiments in alpha4beta4-nAChRs failed to show voltage dependence of the action of JAC-65. Moreover, recovery from desensitization followed the same time course regardless of the presence of the drug, suggesting that the main mechanism of action of JAC-65 does not involve open channel block. 6. In summary, both drugs, diltiazem and JAC-65, seem to act through a non-competitive mechanism, accelerating the decay of the ionic currents, being JAC-65 more effective than diltiazem at the concentrations used in beta4*-nAChRs. Thus, the differences between both benzothiazepines when measuring various parameters suggest that their mechanisms of action could be slightly different. This would require further investigation.

Cisplatin-induced peripheral neurotoxicity in rats reduces the circulating levels of nerve growth factor

The pathogenesis of the neurotoxicity of most antineoplastic drugs is unknown. Recent reports suggest that changes in the circulating levels of nerve growth factor (NGF) might be related to the dorsal root ganglia sensory neuron damage induced by cisplatin (CDDP), the first member of a family of widely used and very effective platinum-derived anticancer agents. Using a well-characterized model of CDDP neurotoxicity, we demonstrated that the NGF circulating level decreased during chronic CDDP administration in close accordance with the clinical course and returned to normal levels after recovery from the neurotoxic damage. Moreover, these changes were restricted to NGF and did not involve other trophic factors of the same neurotrophin family. Our findings are in agreement with previous in vitro and in vivo results and further suggest that NGF plays a specific role in the course of CDDP-induced primary sensory neuron damage.

Immunomodulating effects of extracorporeal photochemotherapy in rat experimental allergic encephalomyelitis

Experimental allergic encephalomyelitis (EAE) is a well-established model of human multiple sclerosis that is commonly used to evaluate the possible effectiveness of new treatments in this disease. Extracorporeal photochemotherapy (ECP) is an immunomodulating procedure currently used in several non-neurological diseases that, like multiple sclerosis, are likely to be due to T-cell-mediated autoimmunity. In this study we examined the effect of ECP using the EAE paradigm in the Lewis rat. In our model, ECP induced a significant modulation in peripheral blood T-cell distribution, changes which are typical of EAE. Remarkably, this effect was closely correlated with the clinical and pathological results, which showed reduced severity of the disease in the ECP-treated EAE animals vs. the EAE alone rats. We conclude that ECP induces modifications in the immunological events that occur during the course of EAE in rats, thus giving support to the hypothesis that it could be used in the treatment of multiple sclerosis.

Retroesophageal subclavian artery aneurysm arising from Kommerell's diverticulum

This report describes a novel technique used for management of retroesophageal subclavian artery aneurysm arising from Kommerell's diverticulum. The procedure consists of endoaortic exclusion of the aneurysmal neck, using a prosthetic patch after sternotomy during circulatory arrest, and antegrade cold blood cerebroplegia. The advantages of this technique are avoidance of hemorrhagic complications during clamping of the aneurysmal neck, limiting of the extent of dissection of the aortic arch, and elimination of the risk of inadvertent left recurrent nerve paralysis. Antegrade cold blood cerebroplegia provides good cerebral protection and decreases the duration and consequences of extracorporeal circulation.

The current and effective use of the dynamic axial fixator in the treatment of exposed fractures of the leg

The authors observed rapid, practical, effective, and excellent tolerance in the use of the Orthofix dynamic axial fixator in the treatment of leg fractures. Good, stable reduction performed in an emergency situation, with respect for tissues that had been exposed to trauma, with fragments in compression when possible, and correct postsurgical management using early dynamization, are the goals to be attained for the physiological development of the bone callus.

Phenotypic expression of familial hypobetalipoproteinemia in three kindreds with mutations of apolipoprotein B gene

We report the clinical phenotype in three kindreds with familial heterozygous hypobetalipoproteinemia (FHBL) carrying novel truncated apolipoprotein Bs (apoBs) of different sizes (apoB-8.15, apoB-33.4 and apoB-75.7). In D.A. kindred, we found three carriers of a C-deletion in exon 10 leading to the synthesis of apoB-8.15 not detectable in plasma. They showed steatorrhea and fatty liver. In N.L. kindred, the proband is heterozygous for a nonsense mutation in exon 26, leading to the formation of apoB-33.4. He had premature cerebrovascular disease and fatty liver; two apoB-33.4 carriers in this kindred showed only fatty liver. In B.E. kindred, the proband is heterozygous for a T-deletion in exon 26, which converts tyrosine at codon 3435 into a stop codon, resulting in apoB-75.7. The proband, a heavy alcohol drinker, had steatohepatitis, whereas his teetotaller daughter, an apoB-75.7 carrier, had no detectable fatty liver. This study suggests that: i) fatty liver invariably develops in FHBL carriers of short and medium-size truncated apoBs (< apoB-48), but its occurrence needs additional environmental factors in carriers of longer apoB forms; ii) intestinal lipid malabsorption develops only in carriers of short truncated apoBs, which are not secreted into the plasma; and iii) cerebrovascular disease due to premature atherosclerosis may occur even in FHBL subjects.

Multiple roles of the conserved key residue arginine 209 in neuronal nicotinic receptors

We have examined the role of a highly conserved arginine (R209), which flanks the M1 transmembrane segment of nAChRs, in the biogenesis and function of neuronal nAChRs. Point mutations revealed that, in alphaBgtx-sensitive neuronal alpha7 nAChRs, the conserved arginine is required for the transport of assembled receptors to the cell surface. By contrast, R209 does not play any role in the transport of assembled alpha-Bgtx-insensitive neuronal alpha3beta4 nAChRs to the cell surface. However, a basic residue at this position of alpha3 and beta4 subunits is necessary for either synthesis, folding, or assembly of alpha3beta4 receptors. Moreover, electrophysiological experiments revealed that in alpha3beta4 receptors the conserved arginine of the alpha3 subunit is involved in either coupling agonist binding to the channel or regulating single channel kinetics.

Internal fixation by bundle nailing in the elderly patient

Between November 1992 and July 1999, a total of 27 fractures and 1 non-union, including 15 tibias, 8 femurs, and 5 humeri in geriatric patients were treated using Marchetti-Vicenzi bundle nail internal fixation. Reaming of the medullary canal was never used in any of the fractures, while it was used in the case of non-union. The results suggest that flexible intramedullary nailing provides adequate stability and is responsible for earlier weight-bearing, facilitating bone healing and early functional recovery in the elderly patient. Automatic distal locking allows for a reduction in the amount of time required for surgery.

Value of stent placement during percutaneous transluminal angioplasty of the iliac arteries

BACKGROUND

To determine the benefits of stents during percutaneous transluminal angioplasty (PTA) of the iliac arteries. Retrospective analysis of our 10-year surgical experience with iliac PTA from 1988-1997 permitted comparison of results during two consecutive periods: an initial period (1988-1992), during which stents were never used, followed by a second period (1992-1997), when stenting was performed on indication.

METHODS

From January 1988 to October 1997, 287 iliac PTA procedures (158 common iliac arteries, 129 external iliac arteries) were performed on 250 patients. Thirty-seven patients had two iliac lesions that were treated simultaneously. Indications for PTA included stenosis (270 cases) and chronic occlusion (17 cases). Thirty-one patients (12.4%) underwent infra-inguinal bypass in addition to PTA owing to the existence of arterial lesions at two levels. Two consecutive patient groups were defined: Group I consisted of 75 patients who underwent 86 iliac PTA procedures between January 1988 and May 1992 without stent placement; Group II consisted of 175 patients who underwent 201 iliac PTA procedures between June 1992 and October 1997, when selective stenting was performed. A total of 55 stents (35 in the common iliac artery, 20 in the external iliac artery) were placed in Group II during PTA due to unsatisfactory immediate results (dissection, residual stenosis) or occlusion.

RESULTS

There was no 30-day mortality. There were 15 immediate failures of PTA: 8 in Group I (10.7%) and 7 in Group II (4%). The cumulative initial success rate was 94%. Follow-up ranged from 3 months to 102 months (mean 37 months). The cumulative primary patency rate at 4 years was 62% (58% in Group I, 64% in Group II). The cumulative secondary patency rate at 4 years (including patients who subsequently underwent repeat angioplasty procedures) was 72% (68% in Group I, 74% in Group II).

CONCLUSIONS

Stents were an effective means for treatment of initial failures of PTA in patients with iliac artery occlusive disease. However, there were no significant differences in the long term results between PTA alone and PTA with selective stent placement.

Neuroprotective role of neurophysiological monitoring during endovascular procedures in the spinal cord

The endovascular treatment of spinal vascular malformations places the spinal cord at risk for ischemia. When these procedures are performed using general anesthesia, the neurophysiological monitoring methods currently available provide the only means by which to assess the functional integrity of sensory and motor pathways. Neurophysiological monitoring allows a warning for the neuroradiologist of impending irreversible neurological damage so that action may be taken for the prompt restoration of adequate spinal cord perfusion. Muscle motor evoked potentials (mMEPs) better reflect spinal cord perfusion in the anterior spinal artery territory than do somatosensory evoked potentials (SEPs), although their use during spinal endovascular procedures remains anecdotal in the literature. In the study reported here we assessed: (1) the feasibility of intraoperative neurophysiological monitoring, (2) the role of provocative tests with Amytal and Xylocaine, and (3) the specific but complementary role played by SEPs and mMEPs, during endovascular embolization of spinal vascular malformations and tumors. The results suggest that: (1) neurophysiological monitoring is feasible during most endovascular procedures in the spine and spinal cord under general anesthesia, (2) provocative tests enhance the safety of the procedure, (3) mMEPs are more feasible than SEPs and more sensitive than SEPs to provocative tests. We strongly suggest the use of multimodal neurophysiological monitoring and provocative tests during the endovascular treatment of spinal and spinal cord vascular lesions.

The role of intraoperative neurophysiology in the protection or documentation of surgically induced injury to the spinal cord

Playing both neuroprotective and educational roles, intraoperative neurophysiology has become an intrinsic part of modern neurosurgery. In this article, we present evidence substantiating the neuroprotective role of intraoperative neurophysiology, specifically its capacity to help prevent injury to the corticospinal tracts and the dorsal columns during spinal cord injury.

Early prognosis in severe sepsis via analyzing the monocyte immunophenotype

OBJECTIVE

To analyze the early discriminative predictive information regarding the immunophenotype components of patients with sepsis, and its potential use as a prognosis tool.

DESIGN

Observational prospective clinical study.

SETTING

Intensive care unit (ICU) in a University Hospital.

PATIENTS

Thirty-five patients admitted with severe sepsis.

MEASUREMENTS

Analysis of peripheral blood on admission and 48 h later of the absolute white cell count and the immunophenotype of lymphocyte (CD3, CD3-HLADR, CD4, CD8, CD4/CD8 ratio, CD19, and CD25) and monocyte (CD13, CD13-HLADR, CD14, CD14-HLADR, CD13-CD14, and CD4) subpopulations.

RESULTS

Due to its high correlation, the immunophenotypic profile studied at admission and 48 h later showed the same prognosis power regardless of the time of performance. The univariate analysis between groups (survival versus death) confirmed the prognostic significance of the total monocyte count and its subpopulations; significant differences were observed from the beginning only in the CD19 lymphocyte subpopulation. Multivariate analysis was performed using logistic regression with survival as the dependent variable. The final model comprised monocytes beta = 0.002 (P = 0.025) and CD13-HLADR beta = 0.016 (P = 0.029). The monocytes receiver operating characteristic (ROC) area obtained was 0.819 (confidence interval 0.663-0.976 at 95 %), the CD13-HLADR ROC area was 0.810 (confidence interval 0.658-0.963), and the monocytes + CD13-HLADR ROC area was 0.918 (confidence interval 0.807-1.000).

CONCLUSIONS

A single blood sample test obtaining the absolute monocyte and CD13-HLADR subpopulation count in the first days of admission could contribute to simplifying the classification of patients with severe sepsis into high- and low-mortality risk.

Provocative Testing for Embolization of Spinal Cord AVMs

SUMMARY

The purpose of this study is to evaluate efficacy and reliability of chemical provocative testing using neurophysiological monitoring prior to embolization of spinal cord AVMs (SCAVMs). We performed retrospective analysis of provocative testing using sodium amytal and lidocaine injected superselectively in 41 angiography and/or embolization procedures in 26 patients with a SCAVM, including 23 amytal and 26 lidocaine injections.All procedures were performed under general anesthesia using neuroleptic drugs, and with monitoring of cortical somatosensory evoked potentials (SEPs) and trans-cranial motor evoked potentials (MEPs). After recording baseline SEPs and MEPs, 50mg of sodium amytal was injected through the microcatheter at the position of the intended embolization, followed by assessment of SEPs and MEPs. If no changes occurred, 40mg of lidocaine was then injected followed by recording of SEPs and MEPs. If again no changes were noted, embolization was performed using NBCA. If there was any change in either SEPs or MEPs, NBCA embolization was not performed from that catheter position. No false negative results of the provocative testing were experienced. One amytal test from the posterior spinal artery (PSA) was positive, causing loss of MEPs. Lidocaine testing was positive in 10 cases including 4 injections in the PSA (with loss of MEPs in two and SEPs in two), 5 injections in the anterior spinal artery (with loss of MEPs in four and SEPs in one), and 1 case involving the posterior inferior cerebellar artery (with loss of MEPs). Neither amytal nor lidocaine injection caused loss of both SEPs and MEPs. In conclusion, sodium amytal and lidocaine are complimentary as pharmacological agents for provocative testing, and SEPs and MEPs are complimentary to each other as physiologic monitoring methods. Provocative testing should be performed using both amytal and lidocaine with monitoring of both SEPs and MEPs.

The Marchetti-Vincenzi universal bundle nail for the treatment of tibial nonunion

The authors report the results obtained in the treatment of 9 cases of uninfected hypertrophic or atrophic nonunion of the tibial diaphysis, using the Marchetti-Vicenzi Universal Bundle Nai. Lesions consisted in the sequelae of different types of diaphyseal fractures treated by means of several surgical procedures. Former fixation material was removed in all of the cases, the tibial medullary canal was reamed, and the Marchetti-Vicenzi Universal Bundle Nail was used for internal fixation. In some cases, additional procedures were used such as Osteomuscular Decortication (DOM) according to Judet, autologous bone grafting. All of the cases healed after a mean time of 22 weeks. The authors suggest that intramedullary nailing using the universal bundle nail is a reliable and safe procedure for the treatment of uninfected tibial nonunion.

Electrophysiologic monitoring in neurointensive care

Cumulative evidence of potential benefits of electroencephalography (EEG) and evoked potentials in the management of patients with acute cerebral damage has been confirmed. Continuous EEG monitoring is the best method for detecting nonconvulsive seizures and is strongly recommended for the treatment of status epilepticus. Continuously displayed, validated quantitative EEG may facilitate early detection of secondary cerebral insults and may play a decision-making role in the management of patients with head injury, stroke, or subarachnoid hemorrhage. Long-latency auditory evoked potentials and cognitive components constitute a new field of interest for the progress of comatose patients. Motor evoked potentials may become clinically important both in acutely injured and elective postoperative patients. In the neurointensive care units adequate techniques can be selected to answer targeted clinical questions. The efficacy can be improved by implementing educational projects based on ad hoc training of nurses and neurointensive care specialists.

Impact of aortic diameter on the outcome of surgical treatment of abdominal aortic aneurysm

Several recent articles have discussed ultrasonographic surveillance of small abdominal aortic aneurysms (AAA). The purpose of this study was to evaluate the impact of lesion size on immediate morbidity and mortality after surgical treatment of AAA. More specifically we investigated whether the mortality rate was lower after treatment of AAA measuring

Effect of sodium chloride concentration on the heat resistance and recovery of Salmonella typhimurium

The survival of Salmonella typhimurium (ATCC 13311) heated and recovered in media with 0, 1, 2, 3, 4 or 5% (w/w) added sodium chloride was investigated. A protective effect in the heating medium and an inhibitory effect in the recovery medium were observed. The results showed an interaction between the effect on, D(58 degrees C) values, of sodium chloride concentration in both media. Lower concentration in the heating media led to a greater effect of the sodium chloride concentration in the recovery media. When the sodium chloride concentration was the same in both media, the protective effect exerted in the heating media dominated over its inhibitory effect in the recovery media.

Cell-based screening approach for antitumor drug leads which exploits sensitivity differences between normal and cancer cells: identification of two novel cell-cycle inhibitors

A cell-based in vitro screening approach for identification of antitumor drug leads that exploits the differential sensitivity between normal and cancer cells was developed. It is a three-step, high-throughput screen for antiproliferative and/or cytotoxic activity measured by a 7 day MTT [3-(4,5-dimethylthiazol-2yl)-2,5-diphenyl tetrazolium bromidel assay using small panels of proliferating primary human cells and established cancer cell lines. Proof-of-concept experiments successfully identified 11 known cancer drugs randomly mixed with 5000 test compounds. Application of this screening approach to a library of 110000 compounds allowed for the identification of several novel chemical classes of compounds active against an expanded panel of cancer cell lines in vitro. Two of the compounds representing novel mitotic inhibitors with in vivo potency against established breast cancer xenografts (MDA-MB-435) are reported here.

Effect on the peripheral nervous system of systemically administered dimethylsulfoxide in the rat: a neurophysiological and pathological study

The issue of dimethylsulfoxide (DMSO) neurotoxicity is an important one, given its wide use in experimental toxicology as a solvent for hydrophobic substances. We examined the effect of the intraperitoneal administration of different DMSO solutions (1.8-7. 2%) on the peripheral nervous system of Wistar rats treated for 10 consecutive days and followed-up for an additional 45 days. DMSO administration induced a dose-dependent reduction in nerve conduction velocity, with complete recovery occurring in the follow-up. No structural changes were found in the sciatic nerve at 1.8% and 3.6% DMSO concentrations, suggesting that the mechanism of action of DMSO involves a functional impairment (i.e. conduction block) similar to that already described for this substance in isolated systems. However, when DMSO was administered at the 7.2% concentration, evident structural changes were observed in the sciatic nerve, with myelin disruption and uncompacted myelin lamelle. The neurophysiological and pathological changes observed in our study are severe enough to merit careful consideration in the course of experimental studies involving DMSO as a solvent for drugs which are under evaluation for their potential neurotoxicity.

Prognostic value of motor evoked potentials elicited by multipulse magnetic stimulation in a surgically induced transitory lesion of the supplementary motor area: a case report

Surgery involving the supplementary motor area (SMA) places the patient at risk of transient motor deficit. To predict outcome in patients with early postoperative hypokinesis would be relevant to both the patient and the surgical team. A 15 year old girl with a large left thalamic tumour removed through a left transcallosal approach is described. Despite intraoperatively preserved muscle motor evoked potentials (mMEPs) from all limbs, elicited by multipulse electrical stimulation, she awoke with a right hemiplegia and mutism. On the first postoperative day, neurophysiological evaluation using a multipulse magnetic stimulation technique, with a train of four magnetic stimuli, confirmed the presence of mMEPs from the hemiplegic right limbs. Slight spontaneous motor activity of the right limbs and initial speech were seen later on the same day with dramatic improvement over subsequent days. It is concluded that multiple rather than single magnetic stimulation techniques may be needed to elicit mMEPs for an early postoperative differential diagnosis of SMA damage versus injury to the primary motor cortex or the corticospinal tract.

Renal artery revascularization in combination with infrarenal aortic reconstruction

Associated stenosis of one or both renal arteries is not uncommon in patients with infrarenal aortic disease (aneurysm or occlusive disease) requiring surgical repair. The purpose of this retrospective study was to analyze the short- and long-term outcome of concomitant renal artery and aortic reconstruction. The present series includes 39 consecutive concomitant procedures. Simultaneous aortic and renal artery reconstruction was performed in a total of 39 (7.2%) of the 540 patients who underwent elective infrarenal abdominal aortic repair between 1987 and 1996. There were 33 men and 6 women with a mean age of 66.7 years. Twenty-eight patients presented hypertension and 7 presented renal insufficiency associated with hypertension. In all cases, the indication for operative treatment was aortic disease, i.e., aortic aneurysm in 20 cases and occlusive aortoiliac disease in 19 cases. A total of 51 renal artery revascularization procedures were performed, including bypass in 40 cases, transposition in 7, and endarterectomy in 4. Combined aortic and renal artery reconstruction gives good short- and long-term results comparable to those of isolated aortic surgery. On the basis of these findings, we think that concomitant repair is the strategy of choice for patients presenting renal artery stenosis associated with infrarenal aortic disease requiring surgical therapy.