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Background. Apheresis of low-density lipoprotein (LDL) is an effective lipid-lowering treatment in hypercholesterolemic patients who have coronary artery disease and are refractory to drugs. More aggressive lipid-lowering therapy may further slow the progression of atherosclerosis. Objective: To compare the effect of LDL apheresis and simvastatin therapy with the effect of simvastatin therapy alone on the progression of peripheral vascular disease. Design: Open, randomized, single-center study. Setting: University hospital. Patients: 42 men with primary hypercholesterolemia (total cholesterol level > 8.0 mmol/L) and extensive coronary atherosclerosis. Intervention: Biweekly apheresis of LDL plus simvastatin, 40 mg/d (n = 21), or simvastatin, 40 mg/d (n = 21), for 2 years. Measurements: Lipid and lipoprotein levels, changes in hemodynamically significant stenoses in the aortotibial tract (measured by ankle:arm systolic blood pressure ratio combined with Doppler spectrum analysis of the femoral artery), and changes in the mean intima-media thickness of three carotid artery segments. Results: Mean baseline LDL cholesterol levels decreased from 7.8 to 3.0 mmol/L in the apheresis and simvastatin group and from 7.9 to 4.1 mmol/L in the simvastatin-only group; mean lipoprotein(a) levels decreased from 57.0 to 44.5 mg/dL (change, 19%) in the former group and increased from 38.4 to 44.5 mg/dL (change, 15%) in the latter group. in the apheresis group, the number of patients with hemodynamically significant stenoses in the aortotibial tract decreased from 9 to 7; in the simvastatinonly group, the number increased from 6 to 13 (P = 0.002). Mean intima-media thickness decreased by a mean [+ or -] SD of 0.05 [+ or -] 0.34 mm in the apheresis group and increased by 0.06 [+ or -] 0.38 mm in the simvastatin-only group (P < 0.001). According to multiple regression analysis, changes in apolipoprotein B, total cholesterol, and lipoprotein(a) levels accounted for changes in the aortotibial tract ([R.sup.2] = 0.36); changes in lipoprotein(a) and apolipoprotein A1 levels accounted for changes in the intima-media thickness of the carotid artery ([R.sup.2] = 0.49). Conclusions: Aggressive lipid lowering with simvastatin and LDL apheresis decreased the intima-media thickness of the carotid artery and prevented an increase in the number of hemodynamically significant stenoses in the lower limbs. Therapy with simvastatin alone did not prevent progression of carotid or aortotibial vascular disease., A selective cholesterol-removing blood treatment called apheresis in combination with simvastin drug treatment appears to be effective in slowing the progression of existing heart disease. For two years 42 men with existing heart disease and high cholesterol were treated with either apheresis and simvastin (combination group) or simvastin alone. Lipoprotein (a) levels and the number of blocked or narrowed arteries decreased in the combination group while these measurements increased in the simvastin treatment group. Low density lipoprotein levels decreased in both groups but more so in the combination therapy group.

In recent years, use of the internal mammary artery (IMA) as first graft of choice has been expanded with bilateral and sequential grafts in primary myocardial revascularization. The use of bilateral IMA grafts in reoperation has seldom been reported. The experience and early results with bilateral IMA grafting in 47 patients undergoing coronary reoperation are described. Hospital mortality was 6.3%. Four patients had postoperative signs of low cardiac output, and 4 had a perioperative myocardial infarction. At follow-up (18 [+ or -] 18 months), 2 cardiac-related, late deaths were noted. Thirteen patients (29%) improved 1 New York Heart Association class, and 28 (63%) improved >1 class. In 1 of 44 surviving patients, operation did not result in a decrease in angina. On the basis of the early results, the bilateral use of the IMA in coronary reoperation appears justified. (Am J Cardiol 1992;70:1113-1116)

During posttransplant acute renal failure (ARF), the diagnosis of allograft rejection constitutes a major problem. We evaluated the value of Doppler ultrasonography in identifying grafts at risk of rejection during ARF. In 184 recipients of a renal allograft, Doppler examinations were performed on the first and fifth postoperative day. Doppler spectra were quantitatively analyzed with a user-written computer program. Doppler findings were not used in clinical decision making. ARF was defined as a diuresis < 400 ml/24 hr and/or the necessity for dialysis. Doppler spectra obtained on the first day after transplantation showed a resistance index (RI) of 0.59±0.09 in recipients with immediately functioning cadaveric grafts (n123), while living related donor grafts (n20) showed a lower RI (0.55±0.07; P<0.05). Grafts with ARF (n41) showed a considerably higher RI (0.67±0.13; P<0.05). When grafts with a duration of ARF ≤ 4 days (n17) were compared with ARF > 4 days (n24), RI was not significantly different (0.63±0.07 vs. 0.68±0.15; NS). However, the acceleration time of the systolic deflection of the spectrum waveform (Tmax) was shorter in grafts with ARF > 4 days (86±47 msec vs. 128±39 msec; P<0.05). On the fifth day after transplantation, Doppler spectra in grafts with ARF > 4 days (n24) snowed a Tmax < 90 msec in 9 patients, 8 of whom experienced rejection during ARF (positive predictive value, 8/989). In the 15 patients with Tmax ≥ 90 msec, only 2 rejections occurred (negative predictive value, 13/ 1587). For the RI (< 0.85), positive predictive value was 4/580 and negative predictive value (RI≤0.85) was 13/1968.