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Notes: Abstract The presence of horseshoe kidney in conjunction with abdominal aortic disease significantly increases the technical difficulty of aortic reconstruction. Preservation of the renal blood supply and collecting system during the surgical procedure is the goal of operative management. The pertinent issues that remain unresolved include the need for specific preoperative studies, the optimal operative approach and the safety of isthmus division. From 1979 to 1994 eight patients with horseshoe kidney underwent operative intervention for aortic disease. Five men and three women who had a mean age of 66 years underwent seven reconstructions for aneurysmal disease and one for aortoiliac occlusive disease. All operations were elective and the transperitoneal approach was used in all cases. In the patients with aneurysmal disease the mean maximal aortic diameter was 7.3 cm. The mean preoperative serum creatinine value was 1.1 mg/dl. Preoperative identification of horseshoe kidney was accomplished in all seven patients with aneurysmal disease but not in the patient with occlusive disease. The anomaly was correctly identified by CT scan in seven of seven (100%) patients, arteriography in two of eight (25%) patients, ultrasonography in two of seven (29%) patients, and renal scan in one patient. In the three patients who underwent intravenous pyelography (IVP) the caliceal system was demonstrated to be completely separate from the isthmus. Renal artery anomalies were present in six (75%) patients; in three (50%) these anomalies could be not visualized on the preoperative arteriogram. Renal revascularization was accomplished by a variety of techniques, including reimplantation of multiple (one patient) and single (four patients) renal arteries and branch grafting to an individual renal artery (one patient). Isthmus division was required in three patients. Seven patients had no postoperative elevation in the serum creatinine level including the three patients in whom the isthmus was divided. One patient had postoperative renal failure requiring permanent hemodialysis; this patient had massive intraoperative blood loss due to technical difficulties unrelated to the horseshoe kidney. There were no perioperative deaths. Preoperative identification of horseshoe kidney is best accomplished by CT scanning. Arteriography and IVP should be performed routinely to evaluate the arterial and caliceal anatomy. Arteriography frequently fails to identify anomalous circulation; the transperitoneal approach affords the best opportunity to identify these anomalies intraoperatively. Preoperative IVP allows identification of the renal collecting system, facilitating safe division of the isthmus if necessary.

Notes: Abstract Sixty-two bypass grafts to the peroneal artery were performed at the University of Rochester Medical Center between 1984 and 1990. An autogenous conduit was used in 45 patients and a prosthetic conduit in 17 patients. Primary cumulative patiency rates were 49% at two years and 30% at four years following operation. Limb salvage was achieved in 68% of patients. The two year cumulative patency rate was significantly better when the peroneal artery was of good quality arteriographically compared with those in which stenoses were present (75% versus 25%, p〈0.05); in patients without inflow disease compared with patients with inflow disease (56% versus 11%, p〈0.05); and in saphenous vein grafts compared with prosthetic grafts (55% versus 17%, p〈0.05). The factors that did not influence patency were the presence of a direct peroneal collateral vessel filling a pedal vessel, age, sex, diabetes, and the size of the peroneal artery. The results of peroneal artery bypass in end-stage patients are dependent on the presence of adequate autogenous vein and a recipient peroneal vessel free of disease. Under these circumstances, the results of the procedure approach that of standard femorotibial reconstruction.

Notes: Abstract A total of 1572 carotid endarterectomies were performed at one institution between 1975 and 1987. One hundred five patients had early (〈3 weeks) neurologic events following carotid endarterectomy. Sixty-five patients had cerebral vascular accidents (CVAs) (4.1%), 14 patients had reversible ischemic neurologic deficits (0.9%), and 26 patients had transient ischemic attacks (1.7%). Eight patients died from CVAs (0.5%). The mean follow-up was 31 months (range 1 to 137 months) with a 5-year cumulative survival of 77%. The median time of occurrence of neurologic events was 4 hours. Ages, cerebral protection, patches, carotid occlusion time (mean 29 minutes), gender, and status of the contralateral carotid arteries were not predictors of outcome. Death from neurologic events increased significantly in patients who had preoperative CVAs compared with patients with preoperative transient neurologic deficits (p〈0.05). The time of occurrence of CVA after carotid endarterectomy affected outcome, and an early CVA (〈4 hours) was associated with a higher mortality at 30 days and at 4 months as a consequence of the initial CVA (p=0.11). Patients who had a neurologic event more than 4 hours after surgery had a significantly better resolution of their symptoms (66%) compared with patients who had an early neurologic event (35%,p〈0.05). The long-term follow-up of the surviving patients demonstrated an improvement in neurologic function in 75% of the CVA group (36/48) and 92% (76/83) of all patients who had neurologic events in long-term follow-up.