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Objective: To present our surgical approach and initial experience of laparoscopic partial nephrectomy (LPN) with sequential precise tumor-specific segmental renal artery clamping in patients with multiple ipsilateral renal tumors.Materials and Methods: Six patients with multiple ipsilateral renal tumors having imperative indications for nephron-sparing surgery underwent LPN with sequential precise tumor-specific segmental renal artery clamping from May 2012 to September 2015. Patient demographics, perioperative variables, renal functions, and postoperative outcomes were reviewed.Results: Overall 15 tumors in 6 patients underwent the sequential precise tumor-specific segmental renal artery clamping LPN without conversion to conventional main renal artery clamping, open surgery, or radical nephrectomy. No severe complication occurred. Mean size of the tumors was 2.5 cm (range 1.8-3.5). Mean tumor-related warm ischemia time was 17 min (range 13-22). The affected kidney functions minimally decreased at recent follow-up and restored 3 months later. No positive tumor margin or extrarenal invasion breakthrough renal capsule was observed after pathologic analysis. Over 12 months' follow-up, no local recurrence and distant metastasis were discovered in these cases postoperatively.Conclusion: LPN with sequential precise tumor-specific segmental renal artery clamping is a feasible approach for multiple ipsilateral renal tumors. It minimizes intraoperative warm ischemic injury and promotes encouraging postoperative function of the affected kidney. [ABSTRACT FROM AUTHOR]

Background: Renal vein anomalies are relatively infrequent and generally asymptomatic. Preoperative knowledge of such variants is, however, of paramount importance in several angiographic and surgical procedures including renal venography, renal vein sampling, spermatic embolization, and renal transplantation. Inadequate knowledge and failure to recognize such anatomic variations may lead to several operative hazards including hemorrhage, nephrectomy, and even death. Case presentation: We report a case of bilateral anomalous drainage of the posterior divisions of renal veins into the azygos venous system in a 20-year-old woman of African descent from Tanzania who presented to us with a 12-year history of recurrent anemia. She had anemia, a positive sickling test, and hemoglobin electrophoresis revealed a sickle cell trait (AS). She underwent computed tomography angiography of her chest and abdomen to rule out the presence of arteriovenous malformations. Aortography findings were normal but venography results revealed features of tortuously dilated azygos and hemiazygos veins each receiving blood from its respective posterior division of renal vein. Conclusions: Although venous anomalies are relatively infrequent and generally lack a clinical significance, a thorough understanding of embryologic development and its associated errors is of immense importance in equipping angiographers and surgeons to select appropriate interventional/operative techniques, anticipate risks, and prevent intervention-related complications. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to introduce a new method for locating the renal artery during retroperitoneal laparoscopic renal surgery. Patients and Methods: The medial arcuate ligament (MAL) is a tendinous arch in the fascia under the diaphragm that arches across the psoas major muscle and is attached medially to the side of the first or the second lumbar vertebra. The renal artery arises at the level of the intervertebral disc between the L1 and L2 vertebrae. We evaluate the role of the MAL that serves as an anatomic landmark for locating the renal artery during retroperitoneal laparoscopic renal surgery. Results: There is a reproducible consistent anatomic relationship between MAL and the renal artery in 210 cases of retroperitoneal laparoscopic renal surgery. Two main types of the MAL, the 'narrow arch' and the 'fascial band' types, can be observed. Conclusion: MAL can serve as an accurate and reproducible anatomic landmark for the identification of the renal artery during retroperitoneal laparoscopic renal surgery. [ABSTRACT FROM AUTHOR]

Objective: To evaluate retroperitoneoscopic renal pedicle lymphatic disconnection (RRPLD) for chyluria in the setting of complex renal vasculature and compare those outcomes with the RRPLD outcomes of patients with normal renal vasculature. Materials and Methods: From December 2002 to December 2011, RRPLD was performed in 14 patients with complex renal vasculature and 64 patients with normal renal vasculature. Preoperative multislice spiral computed tomography angiography for renal vessels was done on 5 patients with complex vasculature. The demographic and perioperative data were collected to assess critical outcomes. Results: The abnormal vasculature was identified using preoperative multislice spiral computed tomography angiography in 5 patients and surgical exploration in 9 patients. RRPLD was successfully completed in all patients without conversion to open surgery or vascular injury. The mean operative time was significantly longer in those with complex renal vasculature than those with normal renal vasculature (105.4 ± 18.7 vs 84.5 ± 15.6 minutes; P = .000). The outcomes were similar in the 2 groups in terms of intraoperative blood loss (P = .060), mean hospital stay (P = .478), and intraoperative complications (P = .660). The occurrence of postoperative gross hematuria was significantly greater in those with complex renal vasculature than in those with normal renal vasculature (4 of 14 vs 2 of 64; P = .008). The event was resolved uneventfully. Conclusion: Although it is technically challenging, RRPLD is feasible and safe for patients in the presence of complex renal vasculature. Preoperative evaluation of the renal vasculature with multislice spiral computed tomography angiography is beneficial for managing abnormal renal vessels. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study is to demonstrate the feasibility of robotically assisted laparoscopy paraaortic lymphadenectomy (PAL), isolated or combined with another procedure using different surgical approaches. Methods: From February 2007 to December 2010, 53 patients underwent paraaortic lymphadenectomy up to the left renal vein. We used three different approaches with three different positions for the robot in relation to the surgical procedure (isolated transperitoneal PAL, isolated extraperitoneal PAL, or transperitoneal PAL combined with another procedure). Thirty-nine patients underwent isolated lomboaortic lymphadenectomy and 14 a combined procedure. Information concerning installation time, operative time, peri- and postoperative complications, blood loss, lymph node count, and conversion rate was recorded. Results: For the whole population, mean installation time was 33 ± 18 min, mean operative time was 197 ± 81 min, and mean hospital stay was 3.9 ± 2.8 days. We observed 15.1% lymph node involvement at definitive pathology. Between isolated trans- and extraperitoneal PAL, only body mass index (BMI, 27.4 versus 22 kg/m) was significantly different. No difference was observed concerning mean number of lymph nodes or hospital stay. We observed statistical difference between combined and isolated PAL concerning mean operative time (256 versus 160 min), mean number of lymph nodes (7.8 versus 14.6), and hospital stay (5.9 versus 2.9 days). Conclusions: Although laparoscopic robotic-assisted PAL is a safe and feasible procedure, lymph node staging seems to be better if the procedure is isolated. In case of combined procedures, the surgical approach should be modified regarding patient BMI and the associated procedure, to increase lymph node count. [ABSTRACT FROM AUTHOR]

Purpose: We describe the feasibility of partial arterial clamping (PAC) during robot-assisted partial nephrectomy (RAPN). Patients and Methods: We undertook a retrospective study of five patients who underwent PAC vs 17 who underwent complete hilar clamping (CHC). Estimated blood loss (EBL), transfusion rate, operative/console time, warm ischemia time (WIT), pathology, and postoperative glomerular filtration rate (GFR) were compared. Results: PAC patients were older ( P=0.002) and more likely to have had previous abdominal surgeries ( P=0.032). PAC vs CHC was associated with higher median EBL (350 mL vs 75 mL, P=0.026), although there were no differences in blood transfusions ( P=0.250). PAC was associated with shorter WIT (14 min vs 21 min, P=0.023). Positive margin rate and GFR change were similar. Conclusions: PAC offers a simple and reproducible technique that limits WIT during RAPN. PAC was not associated with more transfusions or positive margins. Further study is warranted to determine the utility of PAC with larger tumor size as well as the long-term benefits on renal function. [ABSTRACT FROM AUTHOR]

Purpose: We examined the impact of hospital volume on short-term outcomes after nephrectomy for nonmetastatic renal cell carcinoma. Materials and Methods: Using the Nationwide Inpatient Sample we identified 48,172 patients with nonmetastatic renal cell carcinoma treated with nephrectomy (1998 to 2007). Postoperative complications, blood transfusions, prolonged length of stay and in-hospital mortality were examined. Stratification was performed according to teaching status, nephrectomy type (partial vs radical nephrectomy) and surgical approach (open vs laparoscopic). Multivariable logistic regression models were fitted. Results: Patients treated at high volume centers were younger and healthier at nephrectomy. High hospital volume predicted lower blood transfusion rates (8.5% vs 9.7% vs 11.8%), postoperative complications (14.4% vs 16.6% vs 17.2%) and shorter length of stay (43.1% vs 49.8% vs 54.0%, all p <0.001). In multivariable analyses stratified according to teaching status, nephrectomy type and surgical approach, high hospital volume was an independent predictor of lower rates of postoperative complications (OR 0.73–0.88), blood transfusions (OR 0.71–0.78) and prolonged length of stay (OR 0.76–0.89, all p <0.001). Exceptions were postoperative complications at nonteaching centers (OR 0.94, p >0.05) and blood transfusions in nephrectomies performed laparoscopically (OR 0.68, p >0.05). Conclusions: On average, high hospital volume results in more favorable outcomes during hospitalization after nephrectomy. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Resistive index (RI) measured by Doppler sonography in the early period after kidney transplantation is a well-known predictor of kidney transplant outcome. The purpose of this study was to analyze the impact of RI values calculated intraoperatively in renal allograft artery using transit time flowmetry (TTF) on both early and long-term kidney graft function. Material and Methods: TTF was performed on 72 patients who received kidney grafts fed by a single artery. TTF was performed before wound closure. We excluded patients with an early acute rejection (n = 8), an early graft loss (n = 2), or primary graft nonfunction (n = 1). Recipients were divided into RI tertile groups. The initial kidney graft function was defined as immediate (IGF), slow or delayed. Kidney graft estimated glomerular filtration rate (eGFR) was analyzed upon long-term follow-up. Results: Patients with a low RI (< 0.57) showed the highest incidence of immediate graft function (65% versus 5.3%), whereas the high RI group (> 0.70). Show the most frequent rate of delayed graft function (52.6% versus 15%). Recipients with low RI values displayed significantly better eGFR (by at least 12 mL/min/1.73 m2) than those with medium or high RI values at all analyzed times; subjects with medium or high RI showed similar eGFR at 48-months. Conclusion: An high RI value measured intraoperatively was a valuable predictor of inferior early and long-term kidney graft function. [Copyright &y& Elsevier]

Objective: To review the long-term outcome of selective renal arterial embolization (SAE) in treating renal angiomyolipomas (AMLs) in both elective and emergency settings. Materials and Methods: Between October 1988 and September 2008, 27 patients (28 renal units) were treated with SAE, either on an emergency basis for 15 (53.6%) bleeding AMLs or prophylactically for 13 (46.4%) asymptomatic high-risk (size >4.1 cm) AMLs. Six males and 21 females with a mean age of 46.3 years (range, 26–68) were followed for a mean period of 7.1 years (range, 1.3–20.2) for recurrence of symptoms, need for re-embolization, or need for renal surgery. SAE outcome was evaluated using the Kaplan-Meier method. Predictor(s) of outcome were identified with univariate analysis by log-rank test. Results: Mean size of AMLs was 10.9 cm (range, 4–30). Eight (29.6%) patients had bilateral and 19 (70.4%) had unilateral AMLs. Seventeen (60.7%) kidneys had solitary AMLs; 11 (39.2%) kidneys had multicentric AMLs. Of the 15 bleeding AMLs, 12 (80%) patients required a blood transfusion. Twenty-six (93%) AMLs were successfully embolized in the first SAE. During follow-up, four (14.8%) patients required re-embolization. Renal surgery was required in four (14.8%) patients. From the Kaplan-Meier analysis, the overall renal surgery sparing rate at 5 years was 85% (95% CI: 71–99%), whereas the single session SAE success rate at 5 years was 63% (95% CI: 42–84%). Of all the variables, only AML >10 cm was significantly associated with the subsequent need for renal surgery (P = .03). No renal malignancy was noted at final follow-up. Conclusions: SAE is effective and durable in preventing large AMLs from bleeding, treating AMLs presenting with bleeding, and sparing the need for renal surgery. [ABSTRACT FROM AUTHOR]

The aim of this study was to analyse the effect of the right donor kidney and multiple arteries, on donor and recipient outcomes in the era of laparoscopic live donor nephrectomy (LLDN). We retrospectively analysed the 200 donors and recipients who underwent a planned laparoscopic nephrectomy at two hospitals between September 1998 and December 2006. The impact of donor right kidney and multiple donor renal arteries on operative time, hospital stay, graft function, and donor and recipient complications were analysed. Of the total cohort ( n = 200), 140 (70%) were classified as Simple LLDN (left live donor kidney with single renal artery). The Complex LLDN group ( n = 60) contained all right-sided kidney ( n = 28) and left-sided kidneys with multiple renal arteries ( n = 32). Baseline characteristics, extraction time, conversion to open, length of admission, overall graft function and complication rates were similar between the simple and complex groups. The second warm ischaemic time in the Simple LLDN group was slightly shorter than the Complex LLDN group (32 versus 36 min P = 0.016). The 1-month post-operative recipient serum creatinine level was lower in the Simple LLDN group when compared with the Complex LLDN group (117 versus 125 µmol/L P = 0.025). There was no difference in post op dialysis, acute rejection within 3 months or graft survival between the Simple and Complex LLDN groups. Laparoscopic procurements of right kidneys and kidneys with multiple arteries were safe and yielded kidneys with excellent function comparable with those of laparoscopic left donor nephrectomy with single artery. [ABSTRACT FROM AUTHOR]

Introduction: Delayed graft function (DGF), defined as the need for dialysis during the first week after renal transplantation, is an important adverse clinical outcome. A previous model relied on 16 variables to quantify the risk of DGF, thereby undermining its clinical usefulness. We explored the possibility of developing a simpler, equally accurate and more user-friendly paradigm for renal transplant recipients from deceased donors. Methods: Logistic regression analyses addressed the occurrence of DGF in 532 renal transplant recipients from deceased donors. Predictors consisted of recipient age, gender, race, weight, number of HLA-A, HLA-B and HLA-DR mismatches, maximum and last titre of panel reactive antibodies, donor age and cold ischemia time. Accuracy was quantified with the area under the curve. Two hundred bootstrap resamples were used for internal validation. Results: Delayed graft function occurred in 103 patients (19.4%). Recipient weight (p < 0.001), panel of reactive antibodies (p < 0.001), donor age (p < 0.001), cold ischemia time (p = 0.005) and HLADR mismatches (p = 0.05) represented independent predictors. The multivariable nomogram relying on 6 predictors was 74.3% accurate in predicting the probability of DGF. Conclusion: Our simple and user-friendly model requires 6 variables and is at least equally accurate (74%) to the previous nomogram (71%). We demonstrate that DGF can be accurately predicted in different populations with this new model. [ABSTRACT FROM AUTHOR]

Background: Left renal vein division and ligation (LRVDAL) is performed to facilitate complex abdominal aortic surgery. Surgeons restore continuity of the vein due to concern that ligation could cause renal compromise or hematuria. However, we report the short and long-term safety of left renal vein division and ligation. Method: Between 1992 and 2007, we divided the left renal vein in 56 patients (40 males, 16 females) ages 57 to 84 (average 74-years-old) who were treated for aortic occlusive disease (9) or abdominal aortic aneurysm (47). Patients requiring concomitant renal artery reconstruction were excluded from this review. Suprarenal cross-clamp was used in 51 patients with temporary vessel-loop control of the renal arteries. Creatinine (Cr) and glomerular filtration rates (eGFR) were measured pre-, post-, and long-term after surgery. Outpatient records of all patients that had survived more than 12 months were also reviewed in order to evaluate the late effects on renal function or symptoms possibly related to LRVDAL. Results: Median procedure duration was 157 (61-375) minutes. Median cross-clamp time was 16 (10-45) minutes. Median intensive care unit (ICU) and hospital length of stays were 2 (1-11) days and 7 (4-58) days, respectively. There were no deaths. There were no complications directly related to renal vein ligation. Hematuria, seen in 2 patients, was a result of traumatic insertion of a Foley catheter. Median pre-op and discharge Cr levels were 1.1 mg/dL (0.7-2.4 mg/dL) and 1.1 mg/dL (0.6-2.1 mg/dL), respectively (P < .5). Median change in Cr was 0.0 mg/dL and only increased in 14 patients (maximum increase 0.9 mg/dL). Median pre-op and discharge eGFR was 61 mL/minute (28-137 mL/minute/1.73 m2) and 67 mL/minute (32-138 mL/minute/1.73 m2), respectively (P < .5). Cr and eGFR in the 2 patients with a Cr of >2.0 mg/dL remained unchanged post-op. Only 2 patients with a Cr of <2.0 mg/dL had a post-op Cr >2.0 mg/dL and both returned to normal by day 3 post-op. Thirty-six patients have been followed for more than a year (median 34.5 months, maximum 144 months) and Cr has remained stable in all but 2 patients. These 2 patients, both with a pre-op Cr of 1.5 mg/dL, subsequently developed Cr levels of 2.1 mg/dL and 2.4 mg/dL but maintained baseline Cr levels for 25 and 34 months, respectively, before demonstrating these elevated levels which have proven to be unrelated to renal vein ligation. Hematuria and flank pain have never been recorded after discharge. Conclusion: Restoration of left renal vein continuity after LRVDAL may be unnecessary since renal compromise and hematuria was not encountered in this long-term analysis. [Copyright &y& Elsevier]

The article presents a research concerning a 39-year-old male chef who had a history of right aorto-renal artery surgical reimplantation at age eight. It notes that the patient was an active tobacco user for the previous 20 years. With all his medical records as presented, it stresses that the patient was eventually referred for renal artery (RA) angiography. Information regarding the medication is offered.

Abstract: Introduction: Dismembered pyeloplasty has been the traditional technique in the management of pelvi-ureteric junction obstruction (PUJO) secondary to crossing renal vessels in children. Laparoscopic transposition of lower pole vessels for PUJO has been described in children as well as adults. Case report: We report a child with PUJO secondary to lower pole renal vessels who underwent laparoscopic transposition of vessels. The child had persistent PUJO, which was later treated with laparoscopic dismembered pyeloplasty. Conclusion: Laparoscopic transposition of renal vessels is a simple technique, and requires less operating time. It involves no anastomosis or insertion of temporary DJ stent. However, as of now there are no imaging techniques or intraoperative procedures available to confirm that the crossing renal vessels are the sole etiology for PUJO. This option should therefore be used with caution. [Copyright &y& Elsevier]

Background: Significant renal artery stenosis (RAS) in a solitary functioning kidney (SFK) represents one of the most acceptable indications for renal revascularization. Percutaneous transluminal renal artery stenting (PTRAS) is increasingly being used as a first line treatment for renal revascularization, associated with renal function improvement or stabilization in the majority of the patients with solitary kidneys, but also with deterioration in up to 38% of the cases. Atheroembolism during PTRAS has been postulated as a potential cause for this acute renal function worsening. The aim of this study was to report on the feasibility, safety, and early outcomes of PTRAS in a series of patients with SFK using distal embolic protection (DEP). Methods: All PTRAS procedures in SFKs performed under DEP between June 2002 and September 2007 were reviewed. Renal function, blood pressure, and the number of anti-hypertensive medications were assessed pre- and post-intervention. Renal function improvement and deterioration were defined as a 20% increase and decrease in serum creatinine, respectively, compared with preoperative values. Primary and primary assisted patency rates were also calculated. Statistical differences between values before and after intervention were determined by the Student t test and statistical significance was taken at P < .05. Results: Protected PTRAS was performed in 14 patients with a SFK (9 men, 6 women, mean age 65.6 ± 6.8 years). All patients were hypertensive and had varying degrees of azotemia. Mean pre-intervention stenosis degree was 86.8% ± 7.8%. Immediate technical success was obtained in 100% of the patients. Renal function was cured (7.1%), improved (50%), or stabilized (42.9%) in all 14 (100%) patients after the procedure and no deterioration was noticed in any patient at 6-month follow-up. Pre- and postintervention serum creatinine levels were 3.01 ± 1.15 mg/dL and 2.16 ± 0.68 mg/dL, respectively, (P = .02). Hypertension was improved in 6 (42.9%) patients and stabilized in the remaining 8 (57.1%). Primary patency was 100% and 90% at 1 and 3 years, respectively, while primary assisted patency remained 100% for the whole follow-up period (mean, 31.8 ± 19.4 months). Conclusion: These findings suggest that in patients with a SFK, protected PTRAS represents a safe and effective treatment for halting the progression of renal dysfunction to renal loss and warrants further investigation. [Copyright &y& Elsevier]

Persistance of a large spontaneous splenorenal shunt (SRS) may result in graft failure in adult living donor liver transplantation (LDLT) because it reduces the effective portal perfusion to the partial liver graft by diversion of hepatotrophic portal flow into this hepatofugal pathway. We performed a prospective study to evaluate the efficacy of ligation of left renal vein (LRV) to prevent portal flow steal and the safety of this procedure to the renal function in adult LDLT patients with SRS. Between October 2001 and January 2005, 44 cirrhotic patients with large SRS underwent LDLT with ligation of LRV. Each patient received pre- and postoperative computed tomography and Doppler USG to assess the changes of collaterals and portal flow, as well as serial renal and liver function tests. Portal flow after ligation of LRV was statistically and significantly increased when compared with pre-operative value ( P = 0.001). Whereas four patients (9.1%) demonstrated sustained, elevated serum creatinine levels after operation, the renal function tests returned to normal in 40 patients. All patients recovered with satisfactory regeneration of the partial liver graft and there was no procedure-related permanent renal dysfunction. In conclusion, ligation of LRV to prevent a ‘portal steal phenomenon’ seems to be a safe and effective graft salvage procedure for large spontaneous SRS (>10-mm diameter) in adult LDLT. [ABSTRACT FROM AUTHOR]

Background & Aims: Variceal bleeding refractory to medical treatment with β-blockers and endoscopic therapy can be managed by variceal decompression with either surgical shunts or transjugular intrahepatic portal systemic shunts (TIPS). This prospective randomized trial tested the hypothesis that patients receiving distal splenorenal shunts (DSRS) would have significantly lower rebleeding and encephalopathy rates than TIPS in management of refractory variceal bleeding. Methods: A prospective randomized controlled clinical trial at 5 centers was conducted. One hundred forty patients with Child–Pugh class A and B cirrhosis and refractory variceal bleeding were randomized to DSRS or TIPS. Protocol and event follow-up for 2–8 years (mean, 46 ± 26 months) for primary end points of variceal bleeding and encephalopathy and secondary end points of death, ascites, thrombosis and stenosis, liver function, need for transplant, quality of life, and cost were evaluated. Results: There was no significant difference in rebleeding (DSRS, 5.5%; TIPS, 10.5%; P = .29) or first encephalopathy event (DSRS, 50%; TIPS, 50%). Survival at 2 and 5 years (DSRS, 81% and 62%; TIPS, 88% and 61%, respectively) were not significantly different (P = .87). Thrombosis, stenosis, and reintervention rates (DSRS, 11%; TIPS, 82%) were significantly (P < .001) higher in the TIPS group. Ascites, need for transplant, quality of life, and costs were not significantly different. Conclusions: DSRS and TIPS are similarly efficacious in the control of refractory variceal bleeding in Child–Pugh class A and B patients. Reintervention is significantly greater for TIPS compared with DSRS. Because both procedures have equivalent outcomes, the choice is dependent on available expertise and ability to monitor the shunt and reintervene when needed. [Copyright &y& Elsevier]

Percutaneous renal artery angioplasty and stent placement have demonstrated safety and effectiveness in the treatment of selected patients with renovascular hypertension and ischemic nephropathy. Major complications have been predominantly confined to the affected renal artery and kidneys, including renal artery dissection and/or thrombosis, distal embolization, and contrast-related nephropathy. We report a case in which treatment of an ostial renal artery lesion with placement of a balloon-expandable stent was complicated by the development of an acute Type B aortic dissection. [ABSTRACT FROM AUTHOR]

The technical success of an endovascular abdominal aortic aneurysm repair depends on the endograft exclusion of the aneurysm along with preservation of flow to major aortic branches, such as the renal or hypogastric artery. A proximally malpositioned aortic endograft may result in inadvertent renal artery occlusion, which may lead to renal infarction with irreversible loss of the renal function. In this report, the authors describe an endovascular rescue technique to salvage a proximally maldeployed aortic endograft that inadvertently covered the renal artery orifice. Physicians performing endovascular aneurysm procedures should be aware of such a salvage maneuver in the event an aortic endograft is proximally maldeployed and occludes the renal artery orifice. [ABSTRACT FROM AUTHOR]

Complications of vascular access are the most common cause of hospitalization for patients with end stage renal disease. Physicians involved in the placement and maintenance of hemodialysis access must have a long-term strategy for sequential placement of autogenous fistulas and synthetic grafts to preserve limited access sites. Although many principles involving hemodialysis access surgery are widely accepted, significant controversies exist regarding optimal access strategies. Autogenous access is generally preferred over prosthetic grafts. The nondominant upper extremity is the preferred site of initial access. Cuffed catheters are discouraged for long-term vascular access unless no other options are present. Recent advances in forearm, upper arm, and femoral venous transpositions have facilitated the performance of increased numbers of autogenous access procedures. Nevertheless, substantial numbers of patients on chronic hemodialysis require prosthetic arteriovenous grafts. Although the Kidney Disease Outcomes Quality Initiative of the National Kidney Foundation has provided general guidelines for access creation, considerable controversy remains regarding the optimal choice of prosthetic graft material and configuration. We present a strategy for the sequential placement of arteriovenous fistulas, venous transpositions, and arteriovenous grafts to guide the surgeon in the management of these often challenging patients. [ABSTRACT FROM AUTHOR]

Over the past two decades, percutaneous transluminal renal angioplasty has been performed with increasing frequency and for more liberal indications, even though only a handful of prospective clinical trials have been reported and indications for intervention and long-term effectiveness have not been well established. This procedure continues to rapidly evolve, driven by a high physician, public, and industry demand for a less morbid minimally invasive approach to renovascular occlusive disease. Although percutaneous transluminal renal angioplasty procedures are traditionally considered "low risk", complications and failures are not innocuous in terms of clinical consequences. We review the fundamental aspects of renal angioplasty and stenting, with emphasis on the technical details, caveats to avoid complications, and a brief review of our experience with percutaneous transluminal renal angioplasty at Southern Illinois University School of Medicine. [ABSTRACT FROM AUTHOR]

Discusses renal percutaneous transluminal angioplasty and stenting. Technical demands of the procedure; Preprocedural angiography; Angiographic control; Pressure gradient measurement; Stenting the lesion; Angioplasty of distal lesions.

Presents a case study describing the use of the celiac artery as an inflow source in bilateral extraanatomic renal revascularization in Iowa City, Iowa. Information on the preferred procedures for renal revascularization; Details on the medical and health history of the patient; Disadvantage of using celiac artery in excessively long bypass.

Reviews risks and benefits attributed to simultaneous aortic and renal revascularization. Differences in research data on mortality, morbidity and benefits of simultaneous treatment; Variations in indications for operation and selection of patients; Aortic reconstruction; Renal artery revascularization; Outcome of combined procedures.

The role of percutaneous transluminal angioplasty (PTA) in the management of renovascular hypertension is controversial when the cause is known to be atherosclerotic disease. The authors report a life-threatening complication of PTA, wherein renal artery rupture was successfully managed by emergency splenorenal bypass with preservation of the kidney function. Close cooperation between radiologists and the surgical team is a prerequisite for such interventional technique. [ABSTRACT FROM AUTHOR]

Splenorenal artery bypass is not an uncommon procedure for correctable renal hypertension. Although it is well known that the removal of the spleen greatly impairs humoral immunity, no data exist regarding the humoral response after a splenorenal artery bypass. The purpose of this study was to assess the humoral response to an intravenous bolus of sheep erythrocytes in Sprague-Dawley rats after they underwent a splenorenal artery bypass. Sixteen male, retired breeder, Sprague-Dawley rats (weight 400 to 450 g) were divided into three groups and successfully studied. The first six rats were the control group and underwent sham operations consisting of a midline laparotomy followed by primary closure. The second group (n=6) underwent splenectomies with suture ligation of the splenic artery at the hilum. A splenic artery to left renal artery bypass was performed on the rats in the last group (n=4). After recovery, the rats were given an intravenous bolus of sheep erythrocytes via direct cannulation of the femoral vein. One week later, their antibody titers were assessed by hemagglutination assays. The antibody titers of the sham-operated rats (939 ±244.4) were significantly different than those of the splenectomized group (16 ±3.6) and the bypassed group (80 ±16.0). Furthermore, there was no significant difference between the bypassed and splenectomized rats. The results suggest that the use of pneumococcal vaccine and early antibiotic treatment may be warranted in splenorenal artery bypass patients in order to avoid infectious sequelae. [ABSTRACT FROM AUTHOR]

We report a case of severe hemolysis after distal splenorenal shunt. Hemolysis was suddenly recognized at the time splenorenal venous anastomosis was completed, and it continued on the operative day and the first postoperative day. After the shunt., the intraoperative splenic venous blood flow was approximately double its previous level, as measured by electromagnetic flowmeter. Angiographic partial splenic emholization was performed on the second postoperative day, and then hemolysis stopped suddenly. This suggested that hemolysis after distal splenorenal shunt was related to increased splenic blood flow and acceleration of erythrocyte destruction. [ABSTRACT FROM AUTHOR]

Studies the arterial, capillary, and venous phases of renal vascular flow in dogs. Occurrence of changes in the vasculature after three to four weeks after surgery; Constriction of the main renal artery in three animals with silk ligature; Angiographical images of the kidneys after surgery.

Abstract: Introduction: Renal artery dissection is a rare cause of abdominal pain. The renal arteries are the commonest site of primary dissection involving visceral vessels but spontaneous bilateral dissection is extremely rare. Presentation of case: We present a case of spontaneous bilateral renal artery dissection in a previously fit 43-year-old man who presented with right iliac fossa pain. He was treated conservatively with anticoagulation for 6 months, with resolution of the dissections on imaging at 6-month follow-up. Discussion: The presentation of spontaneous renal artery dissection is non-specific, making it a diagnostic challenge. Computed Tomography angiography is now the gold standard for diagnosis and follow-up of these patients. Conclusion: This case highlights the importance of considering other causes of abdominal pain in a young man with normal initial investigations and the role of conservative management. [Copyright &y& Elsevier]

Abstract: Background: We sought to determine the risk factors influencing the occurrence of early graft loss among kidney transplant recipients. Study design: One hundred forty-six potential donors and 230 kidney recipients were included in the study. Prior to organ procurement we collected demographic data as well as hemodynamic data of mean arterial pressure, central venous pressure, pulmonary capillary wedge pressure, systemic vascular resistance index acquired by means of a thermodilution method. The recipient data included age, gender, prior hemodialysis period, panel-reactive antibodies, cold ischemia time, renal insufficiency cause, and donor-recipient gender mismatch. We assessed the influence of the data on graft loss at 30 days after renal transplantation. To confirm the relationships, we performed statistical analyses using chi-square, Fisher exact, and V. Cramer tests. Results: There were no significant relationships between the analyzed parameters and early graft loss in the study group except for gender mismatch. The 71 female recipients of male kidneys showed the lowest graft survival: donor/recipient male/female 89%; donor/recipient female/male 97%; no mismatch 97% (P = .01). Conclusions: Female recipients of male kidneys may experience a greater risk of early graft loss compared with all other gender combinations. [Copyright &y& Elsevier]

Leiomyosarcoma of inferior vena cava (IVC) involving bilateral renal veins presents a surgical challenge. Herein, we report the successful management of two such cases using restoration of left renal venous outflow by saphenous vein interposition graft as fi rst step of surgery. Then radical resection of tumor and right kidney was done. IVC was lastly reconstructed using Gore-Tex graft. This report highlights the surgical challenges to ensure radical resection. Furthermore, the importance of restoring left renal outflow in presence of concomitant right nephrectomy is discussed. Both the patients were disease free at six months with no loss of left renal glomerular filtration rate. [ABSTRACT FROM AUTHOR]

Abstract: The problems deriving from the anatomic differences between the two harvested kidneys make the bench surgery necessary to solve some technical difficulties in transplantation. This condition is particularly real in the case of right kidney transplantation, especially in presence of arterial anomalies. In this study, we focused our attention on venous reconstruction in cases of short renal right veins. In 3 years, we performed 55 consecutive cadaveric renal transplants in patients with an end-stage chronic renal insufficiency. The right kidney was used in 30 patients, eight of whom had two or more arteries attached to a single aortic patch, and 22 had a single artery. In these right transplanted kidneys, the elongation of renal vein was performed end-to-side to the external iliac vein, reconstructing a “T-patch” (angular reconstruction) in 28 patients and a “linear” one in two cases. The vascular anastomoses had no thrombotic problems. We have followed the progress of the patients for more than 2 years; no one has lost the graft due to chronic rejection or other complications. In conclusion, elongation of the right renal vein with a T-patch constitutes a feasible, physiological procedure without vascular complications or apparent reverberations for graft blood flow. [Copyright &y& Elsevier]

End-stage renal disease is a significant health problem. The primary use of the autogenous arteriovenous access is recommended by NKF-DOQI (National Kidney Foundation-Dialysis Outcomes Quality Initiative) guidelines. Though basilic vein transposition is well established in multiple failed fistulae's and obese patients, it requires large incision and morbidities like edema and infection. To avoid such compilations we, at our institution, adopted a small incision technique using two small 3-4 cm incisions. This method is inspired by videoendoscopic minimally invasive method used to dissect the basilic vein, thus avoiding extensive dissection and related morbidities. [ABSTRACT FROM AUTHOR]

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A 47-year-old man with a past history of splenectomy was referred for biopsy of a liver lesion. A subsequent 99mtechnetium heat-damaged red cell scan helped make the diagnosis of splenosis and averted a biopsy procedure. [ABSTRACT FROM AUTHOR]

Percutaneous transluminal angioplasty is increasingly used in children. We present a case of successful balloon angioplasty of an occluded surgical splenorenal shunt in a 4-year-old child who underwent liver transplantation because of biliary atresia. Percutaneous reopening of the shunt is a relatively safe procedure that may spare patients of surgical intervention. [ABSTRACT FROM AUTHOR]

The article comments on a study on the contribution of renovascular disease to excretory renal insufficiency. Early renal function response after surgical repair is the strongest predictor of all cause of mortality. Recovery of renal function after successful surgical repair is uncertain. Failed surgical intervention is associated with eventual dialysis dependence.

We report on a patient who presented with perforation of the left main renal artery as a complication of a percutaneous retroperitoneal drainage procedure. Only a small number of cases of iatrogenic main renal artery perforations have been reported, none of them due to a percutaneous drainage attempt. Endovascular treatment by means of a coronary stent-graft was successful. [ABSTRACT FROM AUTHOR]

The article comments on a study associating failed surgical renal revascularization with dialysis dependence. The burgeoning of the dialysis population in the U.S. is foreseen, which may represent the history of untreated renovascular atherosclerotic disease. Although primary operative renal revascularization has declined, the volume of renal angioplasty procedures has increased.

Presents a case report of a successful laser-assisted ablation of renal hemangioma. Patient history; Symptoms of renal hemangioma.

In this article the authors discuss the risk found in the angioplasty and stenting for renal artery lesions (ASTRAL). They muse on the controversial role of percutaneous transluminal renal angioplasty (PTRA)/stenting in renal artery stenosis (RAS) despite the findings. The authors conclude that there is no treatment that fits all but the complex pathophysiologic processes involving RAS require treatment modalities that must be individualized.

The article presents two cases of spontaneous splenorenal shunts in portal hypertension. One patient was diagnosed with autoimmune hepatitis at the age of 4 years. Selective catheterization of the superior mesenteric artery reveals the mesenteric vein back flow to the splenic vein and a big shunt between the splenic and left renal vein. The other patient had portal hypertension because of portal vein thrombosis associated with factor V Leiden mutation.

The article comments on a study on vascular access surgery for hemodialysis. Dialysis access has become challenging given the almost universal access to hemodialysis in an aging population. Prospective randomized trials could potentially answer many difficult questions regarding optimal strategies for hemodialysis access.

The article discusses various reports published within the issue, including one by Hazim Safi on the prevention of renal ischemia during the surgical treatment of thoracoabdominal aneurysms, and another by Kim Hodgson on the results of renal artery balloon angioplasty and stenting for renovascular hypertension and renal salvage.

Comments on a study which examined splenorenal shunts as an ideal procedure for patients with psychosocial issues or limited access to tertiary medical centers. Options for managing variceal bleeding; Remoteness of some of the patients from medical care as a justification for a surgical shunt.