Optimising islet engraftment is critical for successful clinical islet transplantation

Clinical islet transplantation is currently being explored as a treatment for persons with type 1 diabetes and hypoglycaemia unawareness. Although 'proof-of-principle' has been established in recent clinical studies, the procedure suffers from low efficacy. At the time of transplantation, the isolated islets are allowed to embolise the liver after injection in the portal vein, a procedure that is unique in the area of transplantation. A novel view on the engraftment of intraportally transplanted islets is presented that could explain the low efficacy of the procedure.

Selected activities in Scandiatransplant

Scandiatransplant is the Nordic organ exchange organization. It has existed for 35 years and it is owned by all organ transplantation hospital departments in the five Nordic countries--Denmark, Finland, Iceland, Norway, and Sweden. The use of living organ donors for kidney transplantation has become a more common procedure not only in Norway but also in Sweden and Denmark. For the first time, in 2003, one transplant center performed relatively more living donor kidney transplantations than with deceased donors. The overall organ transplant activity reveals a remarkably stable situation in the area covered by Scandiatransplant. Scandiatransplant as an organ exchange organization has changed from a solely kidney exchange organization to an organization in which the more immediate vital organs as liver and heart are exchanged more commonly than kidneys.

Two Doses of Daclizumab in Conjunction with Low-Dose Cyclosporine, Mycophenolate Mofetil and Steroids Resulted in a Low Incidence of Acute Rejection after Renal Transplantation

Five doses of daclizumab, given initially after kidney transplantation, reduce the rate of acute rejection (AR). Without cyclosporin A (CsA), a protocol, including daclizumab, mycophenolate mofetil (MMF) and corticosteroids (CSs), has recently shown efficacy in terms of graft function and survival. The rate of AR was relatively high, however. In this single-centre study, a CsA low-dose regimen was combined with two doses of daclizumab (1 mg/kg day 0 and 14), plus MMF (2 g) and CS. Forty-three cadaver donor renal recipients were included. Following the onset of graft function, target trough levels of CsA were 150-200 ng/ml for 90 days, then 100-150 ng/ml. One year AR rate was 23% (n = 10) and events occurred at a median of 2.9 months (range from 9 days to 9.6 months). Delayed graft function (DGF) (absent spontaneous reduction of serum creatinine day 1) was 51%. Graft survival was 95% and patient survival 98% after 1 year. With respect to our previous experience, we used CsA, azathioprine and CSs (n = 223) from 1988 to 1995, and the rate of AR was 57%. From 1996 to 1998, standard CsA doses, MMF and CS (n = 67) resulted in 31% AR. Median time to AR was 0.8 and 1.0 month, and the rate of DGF was 20 and 22%, respectively. This CsA low-dose protocol, including two doses of daclizumab, MMF and CS, resulted in a reduction and delay of AR episodes and excellent graft function, graft survival and patient survival, despite an increase in DGF.

Attitudes toward xenotransplantation--patients waiting for transplantation versus the general public

The aim of this study was to survey attitudes toward xenotransplantation and to investigate whether there is a difference in attitudes between patients awaiting a kidney transplantation and the general public. A questionnaire was sent to randomly selected members of the public aged 18-75 (n = 1000) and to all patients of the same age group waiting for kidney transplants in Sweden in 1998 (n = 460). Among the public, 60 % expressed a positive attitude toward receiving an animal kidney graft with the same degree of risk as a human kidney graft, compared with 66 % for the patients. The proportion in favour of receiving a heart remained 60 % for the public, but rose to 70 % for the patients. If a human heart was not available, 61 % of the public were for the use of an animal heart, compared with 73 % in the patient group. A majority of the respondents would accept a transplant from an animal, provided the result and risk of infection were the same as with a human transplant. A greater proportion of patients had a positive attitude to receiving a xenotransplant than did the general public. A life threatening situation marginally increased the positive proportions.

Attitudes towards organ donation and transplantation--a study involving Baltic physicians

The aim of this study was to identify and describe attitudes towards organ donation and transplantation among a group of Baltic physicians who are involved in this aspect of medical care. A total of 151 neurosurgeons, anesthesiologists, and neurologists anonymously answered a questionnaire between February and March 1995. The majority of physicians said they would be willing to donate their own organs after their death but disagreed with the idea of using organs from a dead person who had had a negative opinion towards organ donation. Given a patient who fulfilled the criteria for brain death, this group of physicians found it widely acceptable to keep the patient on a ventilator until organ donation could take place. We conclude that the participating physicians generally have similar attitudes towards organ donation and transplantation. This study is valuable in that it shows the interest in, and the need for, clinical and research collaboration, including a discussion of ethics, within the area of organ donation and transplantation. This is essential for future collaboration with Western countries.

Color Doppler energy: detection of hypoperfused areas in renal transplants

The aim of this study was to determine if an area of decreased color on color Doppler energy scans in a transplanted kidney could be related to significant pathologic conditions. Three hundred and ninety-eight scans in 150 patients were thus evaluated prospectively, and 12 such areas were found and correlated to B-mode, spectral, and color Doppler sonography as well as clinical and laboratory findings. A cause for the hypoperfused area was found in all cases; causes included two cases of focal infection, four arteriovenous fistulas, one kinking of an artery, and five perioperatively severed accessory arteries. We conclude that a color Doppler energy evaluation of perfusion differences can be used to detect pathologic lesions in a transplanted kidney.

Organ exchange in the Nordic countries

Scandiatransplant is an organ exchange organisation founded in 1969. It serves a population of 23 million inhabitants in the five Nordic countries; Iceland, Norway, Sweden, Finland and Denmark. Scandiatransplant maintains a common central waiting list for all Nordic patients waiting for necro-organ transplantation. The waiting lists are maintained on a central computer by each of the eleven transplant centres in the organisation. The number of necro-organ donors in Scandiatransplant is about 340-375 yearly, corresponding to 15-16 donors per million population (PMP) per year. Since the foundation, a total of 14,500 necro-kidney transplants have been performed, and the number of transplants with extrarenal organs is steadily increasing. Presently, about 7-8 liver transplants PMP are being performed, and the heart transplant activity amounts to about 5 PMP. The supreme authority of Scandiatransplant is the Council of Representatives, in which each transplant centre is represented by one or more professionals who are clinically active in organ transplantation. The responsibility for day-to-day operations lies with the Board which has one member appointed by each of the five Nordic countries and a chairman elected by the Council. The activities of Scandiatransplant are financed exclusively by the participating centres.

Scandiatransplant: organ transplantation in the Nordic countries 1996

The Nordic collaboration in organ transplantation was initiated nearly 30 years ago in the frame of Scandiatransplant. With a recent formalization of its structure, Scandiatransplant has become a modern organ exchange organization. The increasing activities of Scandiatransplant clearly reflect the continuously growing need for a close and firm Nordic collaboration in the transplantation field, for the benefit of the numerous patients waiting for an organ transplant.

Impaired renal artery blood flow at transplantation is correlated to delayed onset of graft function

The aim of this prospective study was to evaluate a transit time flowmeter (Transonic, USA) in renal transplantation with respect to feasibility and estimation of graft circulation. Subsequently, the measurements were evaluated for their ability to predict delayed onset of function, occurrence of acute rejection or graft loss within 3 months after transplantation. Renal artery blood flow was measured and resistance calculated in 100 transplants-62 cadaveric donor (CD) and 38 living donor (LD)-immediately after restoration of graft circulation and before wound closure. Low blood flow (< 250 ml/min) and high resistance (> 392 mPRU) correlated positively with a long cold ischemia time and delayed onset of graft function, including the need for post-transplant dialysis. No correlation with rejection or graft loss was found. Blood flow measurements with the transit time flowmeter were easy to perform and immediate estimation of transplant circulation was achieved. Transplants at risk for delayed onset of function were identified.

Rescue therapy with tacrolimus (FK 506) in renal transplant recipients--a Scandinavian multicenter analysis

All renal allograft recipients (n = 32) in Sweden and Norway who were converted from cyclosporin (CyA)-based immunosuppression to FK 506 (tacrolimus) between October 1992 and June 1995 were analyzed retrospectively. The reasons for conversion were acute refractory rejection (n = 21), chronic rejection (n = 4), and suspected CyA toxicity (n = 6); one patient was converted for psychological reasons. The mean time from transplantation to conversion was 29 (range 1-243) weeks and there was a mean follow-up of 46 (2-143) weeks. Overall graft survival was 59%, with graft survival 52% in patients converted because of acute rejection, 50% in patients converted because of chronic rejection, and 83% in patients converted because of CyA toxicity. There was no significant correlation between preconversion serum creatinine and outcome. Seventy-two percent of the patients had significant side effects during FK 506 treatment, the most frequent ones being neurological and gastrointestinal symptoms. These improved after dose reduction. Two patients became overimmunosuppressed and developed lymphoma. One patient died of the primary kidney disease, hemolytic uraemic syndrome. We conclude that FK 506 therapy is able to salvage kidneys with acute refractory rejection and that it is an alternative in patients with CyA toxicity. However, the risk of overimmunosuppression must be considered.

Hepatitis C superinfection in hepatitis C virus (HCV)-infected patients transplanted with an HCV-infected kidney

Hepatitis C virus (HCV) genotypes, determined by polymerase chain reaction with type-specific primers, were studied in 5 already HCV-infected patients receiving kidneys from HCV-infected cadaver donors. Three patients were investigated retrospectively using stored pre- and posttransplantation sera and followed 18-28 months after transplantation. Two recipients with HCV genotype 2b infection had received kidneys from 1 genotype 3a-infected donor. In 1 recipient, HCV 2b was replaced by the donor's type; in the other recipient, a prolonged mixed infection of 3a and 2b occurred. Persistent alanine aminotransferase (ALT) elevation (3- to 5-fold) appeared in both patients. The third patient, also HCV 2b infected when transplanted with an HCV 3a-infected kidney, remained infected with HCV 2b only. Two patients, one with HCV genotype 1b and the other with genotype 3a, were followed prospectively with frequent bleeds (initially biweekly) and genotyping over 14 months after they had received kidneys from 1 HCV genotype 1a-infected donor. The HCV 1b-infected recipient remained infected with 1b only and had minimal biochemical signs of liver injury. In the other recipient, mixed infection of 3a and 1a appeared at week 3 and persisted for several weeks, until only genotype 1a could be detected. This patient had elevated ALT levels before transplantation. After onset of mixed infection, ALT levels increased further for several weeks, and returned to pretransplantation levels when only HCV 1a was found. HCV-infected kidneys transplanted into HCV-infected recipients gave 3 different virus patterns. Most patients benefitted in the short term, but some super-infected patients experienced increased liver damage.

Ischemic heart disease--major cause of death and graft loss after renal transplantation in Scandinavia

Causes of graft loss and death were studied in 1347 recipients of primary renal transplants followed for 5 years after transplantation irrespective of graft function. Immunosuppression consisted of high or medium dose CsA and prednisolone or low dose CsA and prednisolone and azathioprine. In recipients of cadaver grafts, death with a functioning transplant was more common than graft rejection after the first posttransplant year, accounting for 49% and 41% of the graft losses, respectively. Of deaths with a functioning graft, 53% were due to ischemic heart disease (IHD) and 10% were due to other vascular disease. In the 55- to 64-year-old age group, the risk of death from IHD was 6.4 times higher in the transplanted nondiabetic patients, 8.6 times higher in the dialysis patients (European Dialysis and Transplant Association figures), and 20.8 times higher in the transplanted diabetic patients than in the general population (national figures). A multivariate Cox regression analysis showed that old age, diabetes mellitus, occurrence of acute rejection, pretransplant transfusions, delayed onset of graft function, and male gender were significant for death in IHD. We conclude that, in comparison to reports from other regions, Scandinavian renal transplant recipients are at high risk of dying of IHD. Future advances in long-term renal graft survival will depend largely on the success of preventing myocardial infarction and death in this patient population.

A randomized multicenter trial of cyclosporin and prednisolone versus cyclosporin, azathioprine, and prednisolone following primary living donor renal transplantation

A total of 195 consecutive recipients of primary living donor renal transplants were randomized to receive either cyclosporin (CyA) and prednisolone (double therapy) or CyA, prednisolone, and azathioprine (triple therapy). There was no significant difference in patient or graft survival, incidence of acute rejection episodes, or major complications between the groups. The graft survival at 5 years was 71.5% in patients receiving double therapy and 71.6% in patients receiving triple therapy. In a Cox regression analysis, recipient age and occurrence of acute rejection were the only independently significant variables affecting graft survival, whereas treatment schedule did not. Renal function was stable throughout the observation period and did not differ between the double and triple therapy groups. A linear regression analysis showed that recipient age, donor age, gender, and occurrence of acute rejection significantly influenced the serum creatinine level. This and previous similar prospective studies in cadaveric renal transplantation indicate that there is no advantage of routinely adding azathioprine to a double drug regimen.

Does low-dose acetylsalicylic acid prevent stroke after carotid surgery? A double-blind, placebo-controlled randomized trial

BACKGROUND AND PURPOSE

The aim of this randomized double-blind, placebo-controlled trial was to evaluate whether neurological deficits could be prevented with low-dose acetylsalicylic acid (ASA) as an adjunct to carotid endarterectomy.

METHODS

A total of 232 patients were randomized to two groups, 75 mg/d ASA starting preoperatively and continued for 6 months (n = 117) or placebo (identical tablets) (n = 115). The patients were followed up regularly for 1 year.

RESULTS

The groups were well matched regarding laboratory data and indication for operation. The number of patients with intraoperative or postoperative stroke without complete recovery within 1 week were 0 and 2 at 30 days and 6 months, respectively, in the ASA group, compared with 7 and 11 in the placebo group (P = .01). Including all neurological events within 6 months, this was found in 15 patients in the ASA group compared with 24 in the placebo group (P = .12). Mortality was 0.8% and 3.4% at 30 days and 6 months, respectively, in the ASA group. In the placebo group, the corresponding figures were 4.3% and 6.0%, respectively (P = .12). The intraoperative bleeding did not differ between the groups nor did the number of reoperations due to bleeding or other complications related to pharmacology.

CONCLUSIONS

This study indicates that low-dose ASA (75 mg/d) reduces the number of postoperative strokes without complete recovery within 1 week. Overall neurological events are insignificantly reduced, as also mortality. The use of low-dose ASA (75 mg) seems safe and effective in reducing cerebrovascular events after carotid endarterectomy.

The impact of acute rejection episodes on long-term graft function and outcome in 1347 primary renal transplants treated by 3 cyclosporine regimens

To characterize factors of importance for the occurrence of acute rejection as well as study the impact of these episodes on long-term renal survival and function, a total of 819 acute rejection episodes were studied in 951 primary cadaveric donor kidney recipients (CD) and in 396 primary living donor kidney recipients (LD). The patients were treated by three immunosuppressive schedules, namely, CsA given in a high dose, a medium dose, or a low dose. Additionally, all patients received PRED and patients in the low-dose group received AZA. The incidence of acute rejection was higher and occurred earlier after transplantation in the CsA medium dose and low dose groups than in the CsA high dose group (P < 0.05 and P < 0.01, respectively). Although the incidence of first acute rejection was similar in CD and LD patients, 59.1% vs. 60.6%, it was successfully reversed by antirejection treatment in a higher percentage in LD patients. The estimated graft half-life was shorter in patients who had acute rejection episodes than those who did not, 6.6 years vs. 12.5 years in CD patients (P < 0.0001). Renal function at 1-5 years after transplantation was stable, but significantly poorer in CD patients who had experienced acute rejection than in patients who had not, with the mean creatinine clearance rates in the ranges 45-47 vs. 54-60 ml/min in the other groups (P < 0.0001). In a stepwise Cox regression analysis in CD recipients, risk factors for acute rejection were CsA (low dose) treatment schedule, immunization as displayed by presence of panel-reactive antibodies and positive B cell cross-match, young recipient age, disease of diabetes mellitus, and HLA-DR mismatching. In LD recipients, the corresponding risk factors were treatment schedule, young recipient, HLA mismatching, and transplantation from parent to child. Thus, the study has demonstrated some factors of importance for acute rejection episodes in CsA-treated patients as well as showing the detrimental effect of these episodes on long-term graft survival and renal function. These results suggest that a primary aim of future treatment strategies should be to reduce the incidence of these episodes.

Can recurrent stenosis after carotid endarterectomy be prevented by low-dose acetylsalicylic acid? A double-blind, randomised and placebo-controlled study

Recurrent stenosis (> 50%) after carotid endarterectomy is reported with a frequency ranging from 7-20%. 232 patients undergoing carotid endarterectomy were randomised to low-dose acetylsalicylic acid (ASA, 75 mg daily) or placebo (identical tablets). The treatment was started the day before surgery and continued for 6 months. All patients were followed clinically for 1 year. Doppler examination was performed preoperatively (n = 230) and postoperatively (n = 228) and at follow-up at 2 (n = 220) and at 6 months (n = 174) after surgery. The degree of stenosis was estimated from the maximum Doppler frequency shift in the internal carotid artery. Recurrent stenosis of 30% or more was detected in 85 of the 220 patients (38.6%) at 2 months, and at 6 months in 73 of the 174 examined patients (42.0%). Stenosis > 50% was seen in 16 patients (9.2%) and occlusion was found in four patients (1.8%) at 6 months. No difference between the low-dose ASA-treated group (n = 112) compared to the placebo group (n = 108) was seen regarding recurrent stenosis. Women had an increased risk of recurrent stenosis (p < 0.001), whereas other factors such as age, hyperlipidaemia, diabetes and smoking were not associated with increased risk. Importantly, the number of neurological events did not differ between those with or without restenosis. Therefore, the indications for surgery of asymptomatic recurrent stenosis are questionable. The progress of arteriosclerosis in the contralateral carotid artery did not differ between the treatment groups.

A randomized trial of cyclosporine and prednisolone versus cyclosporine, azathioprine, and prednisolone in primary cadaveric renal transplantation

A randomized trial was performed with the aim to compare two immunosuppressive treatment schedules in adult recipients of first cadaveric renal transplants. A total of 229 patients were randomized to double therapy with cyclosporine and prednisolone and 234 patients were randomized to triple therapy with cyclosporine, azathioprine, and prednisolone. Minimum follow-up was 4 years. The actuarial 5-year patient survival was 79.8% in the double therapy group and 82.3% in the triple therapy group (n.s.). The corresponding graft survival figures were 54.4% and 59.6% in the two groups, respectively (n.s.). There were no differences between the groups regarding cause of death or cause of graft loss. Renal function as determined by serum creatinine did not differ between the groups and was stable throughout the observation period. Azathioprine was instituted in a total of 51 patients randomized to double therapy. This subgroup of patients had a patient and graft survival not different from the remaining patients randomized to double therapy or from the patients randomized to triple therapy. There were no differences between the double and triple therapy groups regarding incidence and timing of acute rejection or infections. The incidence of other medical diseases and adverse events such as nephrotoxicity or malignancy did not differ between the groups. Azathioprine-induced leukopenia was uncommon (19 episodes in the triple therapy group). In a multivariate analysis of the whole series the only covariates that significantly influenced graft survival were age of recipient and occurrence of acute rejection, while among other factors treatment schedule did not. Thus this prospective study, in accordance with previous such studies, failed to find support for the use of triple therapy as first choice immunosuppression in first cadaveric renal transplantation. However, the study could not rule out the possibility that some patients at risk for the development of irreversible rejection or nephrotoxicity of CsA might benefit from the addition of azathioprine to the treatment schedule.

Accessory nerve injury after carotid endarterectomy. Case report

Although cranial nerve injuries associated with carotid endarterectomy are well known, involvement of the accessory nerve is extremely rare. A case of partly reversible accessory nerve injury is described. Hitherto published cases are analyzed and possible pathogenetic mechanisms discussed.

Modification of postischemic increase of leukocyte adhesion and vascular permeability in the hamster by Iloprost

This study of the postischemic events in the hamster cheek pouch showed that there is an increase in number of leukocytes adhering to the venular endothelium after reperfusion. It also showed that the stable prostacyclin analogue Iloprost could counteract both the postischemic increase in leukocyte adhesion and the postischemic increase in vascular permeability to macromolecules. The hamsters were anesthetized and the cheek pouch was everted and prepared for intravital microscopy. Temporary ischemia (30 min) was obtained using an expandable cuff placed around the proximal part of the cheek pouch. Fluorescein labelled dextran (FITC-dextran, Mw 150,000) was used as a tracer of macromolecular leakage from the postcapillary venules. Iloprost, given either topically (0.1 nM) or as an intravenous infusion (40 ng/kg/min), reduced the postischemic permeability increase (P less than 0.05) but did not affect the hemodynamics or the permeability response induced by histamine. It is proposed that these effects could be due to inhibition of leukocyte activation by Iloprost, indicating that these cells could play a role in the permeability increase during reperfusion after ischemia.

Lower-limb oedema after thromboembolectomy for acute arterial occlusion

To establish the degree of oedema after thromboembolectomy ad modum Fogarty, leg volume changes were recorded daily in 56 patients. Significant increase was found in the volume of the ipsilateral leg, maximally 12.9 +/- 12% after c. 1 week. The swelling was significantly greater if the popliteal artery had been explored than if it had not. The volume increase was weakly correlated to the duration of ischaemia, but this could be explained by higher incidence of below-knee incisions in patients with longer preoperative ischaemia. Compartment syndrome occurred in one case. The outcome of the operation correlated to leg volume changes on postoperative day 1, but not significantly to the maximal volume increase. It is suggested that the early volume changes represent increased microvascular permeability, and that to this relatively modest oedema is in some cases later added more severe swelling due to impairment of the lymphatic outflow.

Compartment syndrome after prolonged surgery with leg supports

Compartment syndrome has been reported in a few cases after prolonged surgery with patients in leg supports. A recent case in our hospital (57-year-old man undergoing cystourethrectomy because of cancer) made us interested in the problem. This case together with six from the literature are analysed. Moreover, the first 11 cases operated on with a pelvic pouch and ileoanal anastomosis at our department were reviewed. They had been in the leg support position for a median duration of 6.4 (5.8-8) h. In four of them leg pain and swelling developed within 12 h. Three showed regression within a few days, one after a week. In one patient with swelling compartment pressure was measured with a transducer tipped catheter. Intermittently the pressure was up to 50 mm Hg. There was an obvious decrease in pressure on knee bending. Also, in a patient without swelling large pressure variations were seen but not to critical levels.

Superoxide dismutase as an inhibitor of postischemic microvascular permeability increase in the hamster

The purpose was to elucidate the involvement of superoxide radical (O2-.) in the postischemic increase in the vascular permeability in the hamster cheek pouch. Cheek pouches of anesthetized hamsters were everted, prepared for intravital microscopy, and superfused with a bicarbonate buffered saline solution. Local ischemia for 30 min was obtained using a cuff placed around the proximal part of the cheek pouch. The vascular permeability in the postcapillary venules was quantified as leakage of intravenously injected fluorescein labeled dextran (FITC-dextran, Mw 150,000), using intravital microscopy and fluorimetry. There was a significant and reversible permeability increase after the reperfusion started. In the first series of experiments, combined intravenous infusion and topical application of human recombinant extracellular superoxide dismutase C (EC-SOD C) reduced the postischemic permeability response by 80%. Bovine CuZn-SOD given in exactly the same way reduced the response by 60%. In the second series of experiments, inactivated EC-SOD C was given to the control animals and active EC-SOD C was given to the treated animals. The topical treatment was excluded. Only active EC-SOD C reduced significantly the postischemic permeability increase when present during the ischemic period. Treatment with mannitol (i.v.) did not alter the postischemic response. Since active EC-SOD C and CuZn-SOD but not inactivated EC-SOD C effectively inhibited the response, we suggest that the superoxide anion is involved in the mediation of the postischemic permeability increase in the hamster.

Local versus general anaesthesia in carotid surgery. A prospective, randomised study

A randomised, prospective study was performed to compare local (LA) and general anaesthesia (GA) in carotid surgery with special emphasis on complications and the need for intra-operative shunting. Fifty-six patients were randomised to LA and 55 to GA. Eight patients in the LA group required a GA for various reasons. During the same period 14 patients were not randomised. Seven perioperative neurological deficits occurred (5.6%), four in the LA group, two in the GA group, and one in the non-randomised group (NS). Selective shunting was used, in the Ga group according to stump pressure or in cases with a previous stroke and in the LA group according to the appearance of neurological symptoms. In the GA group 25 patients were shunted and in the LA group five patients (P less than 0.001) needed a shunt. If strict pressure criteria for shunting had been used in the LA patients, ten would have been shunted and three of the patients who developed symptoms during clamping would not have been shunted. During surgery the highest recorded systolic pressure was significantly higher in the LA group (210 mmHg versus 173 mmHg, P less than 0.001). LA for carotid endarterectomy is comparable with general anaesthesia regarding peroperative complications but produces significantly higher blood pressures than general anaesthesia. On the other hand it allows the possibility of neurologic monitoring of the patient and leads to significantly less use of an intra-operative shunt.

Lipid peroxidation and activity of antioxidant enzymes in muscle of the lower leg before and after arterial reconstruction

Reperfusion syndrome and lipid peroxidation due to toxic effects of free oxygen radicals might be one pathophysiological cause of the oedema that develops during the first week after a femoro-popliteal reconstruction. This paper reports the activity of the protecting antioxidant enzymes superoxide dismutase (SOD), glutathione peroxidase and catalase in gastrocnemic muscle before and after reperfusion of chronically ischaemic legs with comparison to activities in non-ischaemic muscle. Furthermore the susceptibility to lipid peroxidation in the muscle was measured as thiobarbituric acid reactive material (TBAR). The activities of CuZn SOD, Mn SOD and glutathione peroxidase were equal in normally perfused and chronically ischaemic muscle and there was no difference after reperfusion. Muscle catalase activity was low compared to activity of red blood cells and could not be reliably estimated. There was no difference in iron-stimulated lipid peroxidation of ischaemic and non-ischaemic muscle but in reliably estimated. There was no difference in iron-stimulated lipid peroxidation of ischaemic and non-ischaemic muscle but in muscle biopsied 10 min after reperfusion there was a significant increase in production of TBAR indicating an increased susceptibility for lipid peroxidation at this time. The finding is compatible with the occurrence of an oxidant insult on the muscle at reperfusion. Ischaemia--or reperfusion--induced reductions in activity of antioxidant enzymes are however not related to this reaction.

Lower limb oedema after arterial reconstructive surgery. Influence of preoperative ischaemia, type of reconstruction and postoperative outcome

To investigate the early limb oedema after various types of arterial reconstructions 180 patients operated on due to occlusive or aneurysmatic arterial disease were followed by daily circumference measurements of the lower leg. For volume calculations circumference measurements were shown to be well correlated to water displacement volumetry. Femoro-popliteal bypass resulted regularly in a pronounced oedema, significantly more than in any of the other groups. Aortofemoral reconstruction did not lead to significant leg oedema, but all other reconstructions resulted in a volume increase in the symptomatic leg. Following distal reconstruction, patients with popliteal aneurysm and no ischaemia developed the same maximal volume increase as patients with severe ischaemia. Regarding all patients as one group the volume increase was not significantly correlated to the preoperative ankle blood pressure or ankle brachial pressure index. Only after various proximal reconstructions, with a limited postoperative oedema, there was a correlation between the degree of preoperative ischaemia and postoperative volume increase. A successful reconstruction was not necessary for the development of postoperative oedema. A failed distal reconstruction was followed by a significant oedema, although less pronounced than after a successful. Exploration of the vessels without reconstruction also led to a postoperative oedema. The findings indicate that the pathogenesis of postreconstructive oedema is multifactorial. The type of reconstruction is the most important predictive factor and degree of preoperative ischaemia and success of operation are contributing factors.

Longstanding groin pain in athletes. A multidisciplinary approach

In 21 male athletes (age 20 to 40 years) with longstanding unexplained groin pain, a multidisciplinary investigation was performed in order to reveal the underlying cause. These examinations included general surgery for detection of inguinal hernia and neuralgia, orthopaedic surgery for detection of adductor tenoperiostitis and symphysitis, urology for detection of prostatitis, radiology for performing herniography and plain film of the pelvic bones, nuclear medicine for isotope studies of the pubic bone and symphysis. In 19 patients there was a positive diagnosis for 2 or more of the diseases (10 patients had 2 diseases, 6 patients had 3 diseases, 3 patients had 4 diseases). Two patients had only signs of symphysitis. Our results show the complexity of longstanding groin pain in athletes. It also explains why therapy for one specific disease entity may fail. We conclude that this clinical setting demands the recruitment of a team with experience of different aspects of groin pain.

Heparinization of polytetrafluoroethylene (ePTFE) grafts. The effect on pseudointimal hyperplasia

A study was undertaken to evaluate the effect of a covalent heparinization on thrombogenicity of ePTFE grafts in sheep. With scanning electron microscopy heparinization occurred as a thin smooth layer covering the network of ePTFE. Most of it had disappeared already after 2 hours. In long-term experiments a high and low flow part of the ePTFE graft was created in the carotid artery system. The heparinization had no effect on patency and there was no difference between the high and low flow parts of the graft. The graft surface was covered with fibrous tissue, which was significantly thicker than the pannus in the host vessel. In the graft interstices (internodal distance of 30 micron) capillaries were seen without difference between occluded and patent grafts. The capillary density was significantly higher proximally than distally.

Macromolecular permeability increase following incomplete ischemia in the hamster cheek pouch and its inhibition by terbutaline

The microvascular permeability increase during the reperfusion after incomplete ischemia in the everted hamster cheek pouch preparation was measured by intravital microscopy. FITC-dextran 1500,000 was given i.v. as tracer of macromolecular leakage. Incomplete ischemia of the left cheek pouch was obtained by occlusion of the ipsilateral carotid artery, its external branch and the contralateral external carotid artery. Reperfusion after thirty minutes of incomplete ischemia resulted in a fully reversible increase in the number of FITC-dextran leakage sites (leaks) from 0 to 68 +/- 18 in 7 hamsters. The response to a second period of ischemia, starting one hour after the first ischemia period, was significantly smaller (9 +/- 5 leaks). Local treatment with terbutaline (10(-6) M), a beta 2-receptor agonist, abolished the permeability response to ischemia almost completely (0.5 +/- 0.3 leaks, n = 6). Local application of histamine (2 X 10(-6) M) at the end of the experiments gave a response that was in accordance with that seen in hamsters not subjected to ischemia. These results were compared with those obtained from previous studies in our laboratory with a complete ischemia model and it appears as these two methods, incomplete and complete ischemia, give similar results.

Terbutaline and budesonide as inhibitors of postischaemic permeability increase

A temporary ischaemia with total circulatory arrest of the hamster cheek pouch was obtained by clamping the neck of the everted cheek pouch. The macromolecular permeability increase in postcapillary venules was quantified as the leakage of fluorescein-labelled dextran using intravital microscopy and a fluorometer simultaneously. At reperfusion after 30 min ischaemia, there was a significant and reversible permeability increase. This response could be totally prevented by topical administration of either terbutaline, a selective beta 2-receptor agonist, or budesonide, a glucocorticoid, but it was not significantly impeded by the antihistamine mepyramine. The study shows that, in conformity with the situation in inflammation, the postischaemic permeability increase at reperfusion after ischaemia can be blocked by either beta 2-stimulation or glucocorticoids. Furthermore, it indicates that histamine, a common inflammatory mediator, is not responsible for the postischaemic permeability increase.

Management of early neurologic deficits after carotid thrombendarterectomy

A neurologic deficit appearing during the early postoperative period after an interval following an otherwise successful carotid endarterectomy may be caused by thrombotic material formed in the carotid bifurcation. Our experience of immediate reoperation on eight such cases during a period of 2 years is reported in this paper. Thrombotic occlusion was found at reoperation in seven cases and a non-occluding thrombus in one case. Four of the patients were fully restored immediately after reoperation. In two cases good recovery but with some persisting symptoms was seen. One patient became hemiparetic with moderate restitution and one suffered a dense hemiplegia. We recommend an aggressive approach with immediate reoperation in these cases.