Impact of pre-operative venography on the planning and outcome of vascular access for hemodialysis patients

Objective

Pre-operative venous mapping has increased dramatically in most dialysis units since the Dialysis Outcome Quality Initiative (DOQI) guidelines recommended a native arteriovenous venous fistula (AVF) rather than a graft for hemodialysis (HD) access procedures. However, there are conflicting consequences as a result of this policy. Some studies have showed that routine mapping has resulted in a marked increase in maturation rate while others have observed the reverse. This study aimed to evaluate the impact of pre-operative venography on the planning and outcome of AVF for our HD patients.

Patients and methods

A prospective study was performed on all patients with end-stage renal disease (ESRD) who had HD access procedures and pre-operative venography between October 2003 and November 2005. Upper limb venography was done for all patients except those that required primary access and had visible veins. All patients had HD immediately after the venography. Access procedure selection was based on the result of the venography. The complications of venography, the surgical procedure and the outcome were recorded.

Results

One hundred and twenty-nine patients with ESRD who had pre-operative venography were included in this study. They were mostly middle age (mean age ± SD = 41 ± 15.5 yrs) with a high rate of diabetes mellitus (53%). No single complication was reported. A graft was placed in six patients (5%) only. Unsuccessful surgical exploration was 0%. Early failure was in 10 patients (8%).

Conclusion

Pre-operative venography resulted in an increase in the number of AVFs. It can improve the results of HD access procedures by selecting the most suitable veins.

Prospective Evaluation of Factors Associated with Early Failure of Arteriovenous Fistulae in Hemodialysis Patients

Recent guidelines have recommended performing native arteriovenous fistulae (AVF) in hemodialysis patients rather than synthetic grafts whenever possible. However, early failure of AVF may reach up to 50%. The purpose of this study was to assess the factors associated with early failure of such procedures in hemodialysis patients.

A prospective study was performed on all patients with end-stage renal disease who had an AVF between June 2003 and March 2005. Data including patient characteristics and the type of AVF were recorded. The internal diameter of the vein and artery and intraoperative blood flow were measured. Patients were followed up for 3 months.

One hundred twenty-six AVF were included in this study. Early failure was in 14 (9%) patients. The internal diameter of the vein and artery and intraoperative blood flow were significantly lower in the failure group than in the patent group. The failure rate was not significantly related to other parameters.

Our data showed that intraoperative blood flow is a reliable parameter that determines the early failure of an AVF. Careful selection of the vein and the artery may reduce the rate of failure.

Surgical and Endovascular Management of Arteriovenous Malformation: Case Series from a Single Center

Management of arteriovenous malformation (AVM) remains a major challenge to vascular surgeons. A multidisciplinary approach was introduced in our hospital to manage these cases from October 2003 to date. This is a report of our experience in their management. A prospective study was done on all patients with symptomatic AVM admitted to our unit between October 2003 and May 2006. All patients had preoperative duplex scanning and magnetic resonance imaging with or without conventional angiography. A multidisciplinary team assessed and treated these cases according to the type of malformation. Thirty-two cases were included in this study, with a mean follow-up of 18.3 months. Of these, 20 cases were predominantly venous and treated with surgical excision ( n = 14) or ethanol sclerotherapy ( n = 6). Twelve cases were predominantly arterial or arteriovenous shunting; 10 were treated with preoperative embolization followed by surgical excision and the remaining 2 with superselective embolization alone. The overall complication rate was high (31%). However, all were minor and settled down conservatively. No recurrence was observed in the early follow-up period. Management of AVM by a surgical and endovascular approach can deliver excellent results, with acceptable morbidity and no recurrence in the early follow-up period.

Durability of aneurysm treatments in patients with active Behcet's disease

OBJECTIVE

Aneurysms in Behcet's disease are rare, serious, and recurrent. To achieve durable treatment, patients should receive immunosuppressive therapy before intervention to induce remission. We present early and long-term results of emergency cases of active Behcet's disease, which did not permit waiting for suppressive treatment.

PATIENTS AND METHODS

The study was undertaken on all cases admitted to the vascular unit, King Fahd Hospital of University for aneurysm treatment in patients with active Behcet's disease over about 10 years. All patients had exclusion of the aneurysm either by open surgery or endovascular intervention. Morbidities and mortality were recorded within the hospital admission and on the follow-up.

RESULTS

During the study period, three cases were included. All interventions were successful and lifesaving. However, two cases, treated with surgical interposition grafts, were blocked in the intermediate term follow-up (2-12 months) and one case, treated with endovascular treatment, complicated with pseudoaneurysm at femoral puncture site after six months.

CONCLUSION

Although early results were good, intermediate ones were not satisfactory because of progressive graft thrombosis and formation of new aneurysms. Awareness of these rare cases help for early identification and proper immunosuppressive before emergency vascular intervention is warranted.

A comparative finite elemental analysis of glass abutment supported and unsupported cantilever fixed partial denture

OBJECTIVE

The purpose of this study was to investigate and compare the load distribution and displacement of cantilever prostheses with and without glass abutment by three dimensional finite element analysis. Micro-computed tomography was used to study the relationship between the glass abutment and the ridge.

METHODS

The external surface of the maxilla was scanned, and a simplified finite element model was constructed. The ZX-27 glass abutment and the maxillary first and second premolars were created and modified. The solid model of the three-unit cantilever fixed partial denture was scanned, and the fitting surface was modified with reference to the created abutments using the 3D CAD system. The finite element analysis was completed in ANSYS. The fit and total gap volume between the glass abutment and dental model were determined by Skyscan 1173 high-energy spiral micro-CT scan.

RESULTS

The results of the finite element analysis in this study showed that the cantilever prosthesis supported by the glass abutment demonstrated significantly less stress on the terminal abutment and overall deformation of the prosthesis under vertical and oblique load. Micro-computed tomography determined a gap volume of 6.74162 mm(3).

SIGNIFICANCE

By contacting the mucosa, glass abutments transfer some amount of masticatory load to the residual alveolar ridge, thereby preventing damage to the periodontal microstructures of the terminal abutment. The passive contact of the glass abutment with the mucosa not only preserves the health of the mucosa covering the ridge but also permits easy cleaning. It is possible to increase the success rate of cantilever FPDs by supporting the cantilevered pontic with glass abutments.

Management of sizeable carotid body tumor: Case report and review of literature

Carotid body tumor is a paraganglioma derived from the neural crest. It arises from the carotid body which acts as a vascular chemoreceptors and is usually located at the carotid bifurcation. Sizeable (Shamblin III, >5 cm size) tumors are large and typically encase the carotid artery requiring vessel resection and replacement. Management of such tumors carries a high risk of postoperative mortality and morbidity rates specially with regards to neurovascular complications. We report a case of sizeable tumor which was surgically removed with minimal complications.

Screening of diabetic foot in surgical inpatients: a hospital-based study in saudi arabia

Previous reports found that identification of diabetic patients at high risk of foot ulcers, and managing the risk factors early, lower extremity amputations could be prevented. The aim of this study is to determine the value of screening diabetics in estimating the risk of foot ulceration among surgical inpatients. This is a prospective study on all diabetic patients admitted to the surgical department, King Fahd Hospital of the University, Saudi Arabia, during the year 2011. Patients were screened for the presence of diabetic foot. They were classified according to the international working group on the diabetic foot into four grades [0 (lowest risk patients), 1, 2, 3 (highest risk patients)]. During the study period, 391 patients had diabetes mellitus (DM), of these 73 (19%) had active ulcer and were excluded from the study and the rest were screened. Grade 0 was in 174 (54.5%) patients, the rest were grades 1, 2, and 3. There was significant difference between low-risk groups (grades 0, 1) and high-risk groups (grades 2, 3) as regards age, smoking and duration of DM. This study indicates that prevalence of diabetic patients with risk of foot ulceration in surgical inpatients was high. Routine screening of diabetic foot is recommended specially in old patients.

Limb salvage in a child with severely injured mangled lower extremity and muscle rigor

Most surgeons make their decision to amputate or perform limb salvage of a mangled extremity based on scoring systems and grading of acute ischemic limb. We report on a child in whom limb salvage was achieved in spite of a clinical picture of irreversible ischemia with high mangled severity scores. Attempts to revascularize the mangled extremity of children are recommended, regardless of their severity scores and condition of the foot.

Atherosclerosis in sickle cell disease - a review

Acute, vaso-occlusive crises are the most common and earliest clinical manifestations of sickle cell disease. Recent thoughts about development of atherosclerosis as a result of this disease are presented. Current insights into the pathogenesis of atherosclerosis in sickle cell disease are reviewed, in particular the role of endothelial dysfunction, homocysteine and platelets. Common and uncommon sites of atherosclerosis are described. Radiological assessment and potential therapeutic agents to slow the progression of atherosclerosis are discussed. Finally, treatment of atherosclerosis in certain sites is evaluated and reviewed.

Impact of atherosclerosis risk factors on the clinical presentation of arterial occlusive disease in Arabic patients

BACKGROUND

Although the risk factors for atherosclerosis have been identified, their impact on the presentation of arterial occlusive disease has not been studied among Arabs.

OBJECTIVE

To determine the correlation between atherosclerotic risk factors and the extent and presentation of atherosclerotic disease in different arterial systems.

METHODS

The present case-control study was performed on a consecutive series of Arabic patients over one year. There were two groups - an atherosclerotic group, which included patients with peripheral arterial disease, extracranial cerebrovascular disease or coronary artery disease (CAD), and the control group, which included patients admitted to one of the general surgical units who were free from atherosclerotic disease. All patients underwent evaluation of risk factors (diabetes mellitus [DM], smoking, dyslipidemia and hypertension) for atherosclerosis and systemic assessment of the vascular tree.

RESULTS

Two hundred fifteen patients in the atherosclerotic group and 191 patients in the control group were included in the study. There were positive correlations between the prevalence of DM, smoking, dyslipidemia and the severity of presentation of peripheral arterial disease, and the extent of CAD. The correlation between the incidence of DM and the severity of presentation of CAD was also significant. The correlation was also positive between the incidence of ex-smoking and hypertension, and the severity of presentation of extracranial cerebrovascular disease.

CONCLUSION

Different risk factors may interact in different ways in the clinical presentation of atherosclerotic disease in different arterial systems.

Human CD34+ stem cells promote healing of diabetic foot ulcers in rats

OBJECTIVE

Diabetic patients with foot ulcers usually manifest with high amputation and mortality rates. Preliminary evidence supports the effectiveness of stem cell (St) therapy on diabetic foot ulcers. The objective of this study was to evaluate the efficacy of stem cells in the healing of wounds among streptozotocin-induced diabetic albino rats.

METHODS

Thirty male albino rats were divided into three groups each of 10 rats: control group, diabetic control (DC) group and St group. Diabetes was induced by intra-peritoneal injection of streptozotocin. A full thickness circular wound of ∼10 mm in diameter was performed on the front of right legs of all rats. In the diabetic St group, the wounds were treated by injection of umbilical cord blood-derived CD34+ stem cells into the wound bed. Half of each group rats were sacrificed after 1 week and the rest after 2 weeks. The wound areas were used for histopathology, immunohistochemistry and transmission electron microscope studies. Assessment of wound surface area, epidermal thickness, blood vessel proliferation and collagen deposition were performed.

RESULTS

There was a significant decrease in mean wound surface area, increase in mean epidermal thickness, blood vessel proliferation and collagen deposition in the St group compared with the DC group.

CONCLUSION

Treatment with CD34+-enriched cells decreased wound size, accelerated epidermal healing and dramatically accelerated revascularization of the wounds compared with the DC group.

Screening for asymptomatic cardiovascular disease in Arab patients with diabetes

AIM

Diabetes mellitus is a major risk factor for atherosclerosis and accordingly increased morbidity and mortality. This study aimed at screening high risk diabetic patients for atherosclerosis in different arterial territories.

METHODS

All high risk asymptomatic patients attending the diabetic clinic, King Fahd Hospital of the University, Saudi Arabia were invited to be screened for peripheral arterial disease (PAD), extra-cranial cerebrovascular disease (CVD) and coronary artery disease (CAD) over one year. All participants underwent measurement of ankle brachial pressure index, carotid Duplex scan and exercise electrocardiography (ECG). All patients underwent evaluation of conventional risk factors for atherosclerosis

RESULTS

One hundred and sixty nine patients were invited to be screened. Of these 138 (82%) completed all the screening tests. The mean age was 53.5±7.18 years. Seventy-five (55%) had evidence of subclinical atherosclerosis. In the atherosclerotic group, 24 patients had PAD, 47 had CVD and 30 had CAD. There were significant differences between the atherosclerotic and non-atherosclerotic groups with regard to most risk factors. In age, sex adjusted, the risk of developing atherosclerosis was significantly increased with all risk factors. Dyslipidemia had the highest association (OR 9.7, 95% CI 8.1-10.2)

CONCLUSION

Participation and diagnostic yield of screening for atherosclerosis had satisfactory validity and reliability. Routine screening in high-risk diabetic patients can serve as an effective tool for diagnosis of sub clinical cardiovascular disease and provide strategies to optimize risk reduction.

Does regional anesthesia influence early outcome of upper arm arteriovenous fistula?

To assess the effect of regional anesthesia on the outcome of elbow arteriovenous fistula (AVF), prospectively studied consecutive patients with end-stage renal disease referred for permanent vascular access to the Vascular Unit of King Fahd University Hospital between September 2004 and September 2007. The patients were divided into 2 groups: Group 1: patients who underwent the construction of the AVF under regional anesthesia and Group 2: patients who were operated under general anesthesia, indicated by their preferences or failure of regional anesthesia. Data including patient characteristics and type of AVF were recorded. The internal diameter of the vein and the artery and intra-operative blood flow were measured. The complications of both types of anesthesia were recorded. The patients were followed up for three months. Eighty four cases were recruited in this study. Complete brachial plexus block was achieved in 57 (68%) patients. Seven patients were converted to general anesthesia and 20 patients had AVF under general anesthesia from the start. There were no significant differences between the 2 groups with regard to basic characteristics or operative data. There were no instances of systemic toxicity, hematomas, or nerve injury from the regional block. No major complications were reported from the general anesthesia. There was no significant difference between both groups regarding early failure of AVF (Group 1, 14% vs. Group2; 11%. P= 0.80). No significant advantage of regional over general anesthesia in terms of early outcome of AVF was seen in this study.

Effect of Anastomotic Length on the Development of Intimal Hyperplasia in the Distal Anastomosis of Bypass Graft

Many hemodynamic factors have been shown to be associated with increased intimal hyperplasia at the distal anastomosis of arterial bypass graft. However, the relationship between the length of anastomosis and the development of such a complication has not been studied before. The aim of this study was to assess this relationship at the distal anastomosis with a Dacron graft. Iliofemoral bypass using 6 mm Dacron grafts was performed in 10 German shepherd dogs. In accordance with preoperative randomization to individual animal legs, distal anastomoses were reconstructed using four different groups (A, B, C, and D), depending on the length of the arteriotomy: 3.0, 3.5, 4.0, and 4.5 times the internal diameter of the artery, respectively. The vessels were harvested 6 months after the operation, and specimens were processed for histologic and transmission electron microscopic (TEM) studies. Quantitative analysis was performed to assess the extent of intimal hyperplasia at three zones (heel, toe, and midzone of the arterial bed) of the distal anastomosis. Sixteen arterial bypasses were included in this study. Both light and TEM studies revealed evidence of intimal hyperplasia in the four groups. Quantitative analysis showed a significant decrease in intimal hyperplasia with increasing the length of the anastomosis at the heel, toe, or midzone of the arterial bed. Mean (μm ± SD) intimal hyperplasia of the three zones together was significantly higher in group A than group B (585 ± 106 vs 423 ± 8.6, p < .001) and in group B than group C (423 ± 8.6 vs 202 ± 15, p < .001). However, the difference between group C and group D (202 ± 15 vs 162 ± 8.6; p = .13) was statistically insignificant. The present study showed that the length of the anastomosis is one of the hemodynamic factors involved in the development of intimal hyperplasia. Anastomotic techniques that resulted in the least intimal hyperplasia were end to side, with length 4 or 4.5 times the internal diameter of the artery.

Impact of atherosclerotic risk factors on the extent of arterial occlusive disease among Arabian patients: a hospital based study

AIM

Although the risk factors for atherosclerosis have been identified, their impacts on the extent of arterial occlusive disease among Arabian population have never been studied before.

METHODS

A case control study was undertaken on consecutive series of Arabian patients over one year. The study comprised 2 patients groups: atherosclerotic group which included patients aged 40 years and older admitted with peripheral, carotid or coronary artery disease and the control group, including patients admitted to one of the general surgical units who were free from atherosclerotic disease. All patients underwent evaluation of risk factors for atherosclerotic and systemic study of the vascular tree. Correlation and association were checked between prevalence of these factors and the extent of atherosclerotic disease into different territories.

RESULTS

Two hundred and fifteen patients in the atherosclerotic group and 191 patients in the control group were included. The incidence of diabetes mellitus (DM) was very high in the atherosclerotic group (67.8%). There was significant correlation between incidence of risk factors and risk and extent of atherosclerosis. In age, sex and nationality-adjusted logistic regression analysis, combination of some risk factors augmented the risk and extent of atherosclerosis e.g. diabetes alone increased the risk of atherosclerosis slightly in one affected system (OR 2.28, 95% CI 1.9-2.7) while combination of diabetes, smoking and dyslipidemia enhanced this risk (OR 7.4, 95% CI 2.5-22.4).

CONCLUSIONS

The risk factors of atherosclerosis increase its incidence and extent into different territories.

Fate of left kidney after left renal vein division during management of aortic occlusive disease

AIM

Left renal vein division (LRVD) has been used as a technical aid to gain exposure to the peri-renal aorta and to control bleeding in abdominal aortic operations. A few retrospective series studied the effects of such division on the overall renal function with contradicting results. The aim of this study was to assess the effect of such division on the left kidney during the management of aortic occlusive disease.

METHODS

A prospective study was undertaken on all patients that had abdominal aortic bypass surgery for juxta-renal aortic occlusive disease scheduled between October 2003 and September 2007. Renal function was assessed by measuring serum creatinine (mg/L+/-SD) and creatinine clearance (mL/min+/-SD) preoperatively and postoperatively up to 14 days in patients who had LRVD and patients who had left renal vein intact (LRVI) which served as control. Left kidney was assessed preoperatively by performing abdominal computed tomography angiography (CTA) and postoperatively with either ultrasonography (US) or CTA depending on the serum creatinine level.

RESULTS

Thirty-two patients were included in this study. Six patients had LRVD. There was no statistically significant difference between the LRVD and LRVI groups as regard mean serum creatinine, preoperatively (LRVD 1.05+/-0.31 vs LRVI 1.08+/-0.21,P=0.38) and XIV day postoperatively (LRVD 1.15+/-0.31 vs LRVI 1.09+/-0.24, P=0.34), and mean creatinine clearance, preoperatively (LRVD 94+/-17.4 vs LRVI 97.9+/-11.1, P=0.31) and XIV day postoperatively (LRVD 88.8+/-13.1 vs LRVI 94.3+/-6.7 p=0.11). CTA and US showed postoperative early diffuse swelling and congestion of the left kidney in 4 cases that had LRVD, which reverted to normal at XIV day postoperatively.

CONCLUSIONS

Selective LRVD during aortic occlusive surgery does not compromise the left kidney.

Unusual case of left iliac vein compression secondary to May-Thurner syndrome and crossed fused renal ectopia

External compression of the left iliac vein against the fifth lumbar vertebra by the right iliac artery May and Thurner syndrome is a well-known anatomic variant. We identified a rare case of May-Thurner syndrome associated with crossed fused renal ectopia on the left side. The patient presented with complete thrombosis of the left common iliac vein down to the popliteal vein. He was treated with catheter directed thrombolysis followed by anticoagulant therapy.

Handlebar hernia: a rare type of abdominal wall hernia

Handlebar hernias are abdominal wall hernias resulting from direct trauma to the anterior abdominal wall. They usually result at weak anatomic locations of the abdominal wall. Such traumatic hernias are rare, requiring a high index of suspicion for a clinical diagnosis. We report the case of a handlebar hernia resulting from an injury sustained during a vehicular injury, and discuss the management of such injuries.

Role of saphenous vein wall in the pathogenesis of primary varicose veins

Varicose veins may be due to weakness of the vein wall as a result of structural problems. There are conflicting findings in the literature about these problems especially concerning collagen, elastin and smooth muscle cells content. The aim of this study was to look at the structural abnormalities of varicose veins (with and without valvular incompetence).

MATERIALS AND METHODS

We studied 70 specimens of long saphenous veins from 35 patients (24 with varicose and 11 with normal veins). Two specimens were taken from each vein approximately 3-4 cm from the saphenofemoral junction. Vein specimens were processed for histological and electron microscopic studies. Both qualitative and quantitative analyses were performed to assess the degree of wall changes. Using the image analyzer, contents of collagen, elastin and smooth muscle cells, in addition to intimal and medial thickness, were measured.

RESULTS

Light microscopy revealed significant increase in intimal and medial thickness and collagen content of media and significant decrease in elastin content in varicose veins compared with normal veins. There was no statistical significant difference between varicose veins with and without saphenofemoral valve incompetence. Electron microscopy showed marked degenerative changes in intima and media of varicose veins.

CONCLUSION

The findings in our study supported the theory of primary weakness of the vein wall as a cause of varicosity. This weakness is due to intimal changes, disturbance in the connective tissue components and smooth muscle cells.

Can multi-detector computed tomographic angiography replace conventional angiography prior to lower extremity arterial reconstruction?

Computed tomographic (CT) angiography has become a valuable diagnostic technique prior to lower extremity arterial reconstruction. The purpose of this study is to evaluate its accuracy, compared to conventional angiography for planning lower limb revascularization procedures.

PATIENTS AND METHODS

A prospective study was performed on all patients who underwent lower extremity arterial reconstruction procedures and had both CT angiography and conventional angiography between October 2003 and November 2005. We compared both modalities of angiography to intra-operative findings and whether a change in operative procedure would have resulted. The time for performance of both techniques and their complications were also reported.

RESULTS

Sixty nine patients were included in this study. Discrepancies between intra-operative findings and CT angiography were noted in four (6%) cases while there was none with conventional angiography (p = 0.127). Disagreements between intra-operative findings and CT angiography have lead to a different procedure in three (4.5%) cases and all were infra-inguinal. The time for performance of CT angiography was significantly shorter than that for conventional angiography (2.5 +/- 0.3 minutes vs 37.5 +/- 5.2, p = 0.006).

CONCLUSION

For arterial reconstructive procedures CT angiography provides a less invasive and accurate imaging with short examination time. It can be used as a primary imaging modality in evaluation of lower limb ischemia.

Saphenoperitoneal shunt for intractable ascites

OBJECTIVE

Ascites usually complicates chronic liver disease, and some patients with ascites are refractory to medical treatment. Recently, saphenoperitoneal shunt (SPS) was described to treat this condition. This procedure avoids the insertion of a foreign expensive shunt into the circulation. We present our experience with this procedure with some modification in the technique.

METHODS

We performed a prospective study on 11 patients with intractable ascites admitted to the Vascular Unit, Suez Canal University Hospital, Egypt from June 2001 to October 2003. We divided the long saphenous vein approximately at 15 cm distally. We turned the proximal cut end upwards and tunneled under the skin towards the midline in the suprapubic region where we anastomosed it to the peritoneum.

RESULTS

One patient died from liver failure 8 days after the operation. Two patients died during follow-up, one at 3 months from liver failure, and the other at 4 months from variceal hemorrhage. We lost one patient to follow up. Seven patients remained alive with patent shunt up to 6 months follow up.

CONCLUSION

The SPS is a safe and effective procedure in the management of intractable ascites.

Pre-operative evaluation of hemodialysis access fistula. A multidisciplinary approach

Recent guidelines published by the National Kidney Foundation Dialysis Outcome Quality Initiative (DOQI) on vascular access has suggested that for patients requiring chronic hemodialysis, the preferred site for access is a native arteriovenous fistula (AVF). The recommendation of DOQI may cause an aggressive approach for creation of fistula rather than a graft. Although fistulae have longer patency as compared to grafts, a substantial number of fistulae do not function adequately either due to failing maturation or to thrombosis directly after the operation. We analyse the perioperative factors that are associated with early failure of hemodialysis access fistulae,in order to improve their functional patency. We also highlight the importance of multi-disciplinary approach including nephrologists, vascular surgeons and radiologists in ensuring optimal vascular access for hemodialysis patients.

Dramatic vascular course of Behcet's disease

Vascular involvement in Behcet's disease is rare approximately 14% venous and 1.6% arterial, serious and recurrent. We report a case of Behcet's disease with deep venous thrombosis and right iliac pseudoaneurysm which was repaired with polytetrafluoroethylene PTFE graft. The patient received warfarin, aspirin, clopidogrel, immunosuppressive and corticosteroids. Two months later the patient developed manifestations of superior vena cava thrombosis and the graft was blocked. Three months later, ischemia of the right foot deteriorated and left femoral artery to right femoral artery crossover PTFE graft was performed.

Effect of left renal vein division during aortic surgery on renal function

A total of 398 consecutive patients underwent surgery for an aneurysm or occlusive disease of the aorta at Norfolk and Norwich Hospital between December 1994 and October 1998. It was necessary to divide the left renal vein in 58 (14.6%) cases. We examined the effect of this division on the mortality rate and renal function. Renal function was assessed by measuring serum creatinine pre-operatively, peri-operatively and long-term postoperatively. There was no significant difference in the mortality rate between patients who had the left renal vein divided (LRVD) and in whom the left renal vein remained intact (LRVI)--31% versus 32%, P = 0.83. There was no significant difference in the pre-operative serum creatinine level between both groups (107 +/- 21 mumol/l in LRVD versus 103 +/- 29 mumol/l in LRVI, P = 0.14). There was an insignificant rise in the mean serum creatinine 7 days postoperatively (111 +/- 21 mumol/l in LRVD versus 107 +/- 31 mumol/l in LRVI, P = 0.05). The mean serum creatinine returned back to the pre-operative level at 30 days postoperatively (106 +/- 16 mumol/l in LRVD and 105 +/- 29 mumol/l, P = 0.20). After 1 month, there was no significant difference in the number of patients who had a sustained elevation of serum creatinine level (7.5% in LRVD versus 2.7% in LRVI, P = 0.11). We feel that division of the left renal vein is a safe and helpful procedure during juxtarenal aortic surgery.