Faculty Bibliography

In the past 9 years, 1,196 patients whose lower extremity was threatened because of infrainguinal arteriosclerosis have been treated at Montefiore Hospital. In the last 6 years, limb salvage was attempted in 679, or 90% of 755 patients. Femoropopliteal (318), small vessel (204) and axillopopliteal (29) bypasses were used along with transluminal angioplasty (128) and aggressive local operations to obtain a healed foot. Immediate (one month) limb salvage was achieved in 583, or 85%, of the 679 patients in whom revascularization was possible. The 30-day mortality rate was 3%. The cumulative life table (LT) survival rate of all the patients undergoing reconstructive arterial operations was 48% at 5 years. The cumulative LT limb salvage rate after all reconstructive arterial operations was 66% at 5 years. The cumulative LT patency rate of femoropopliteal bypasses was not influenced by angiographic outflow characteristics of the popliteal artery but was increased 15% by appropriate reoperations to 67% at 5 years. Cumulative LT patency and limb salvage rates of small vessel and axillopopliteal bypasses were more than 50% at 2 years. Of patients undergoing arterial reconstruction, 88% of those who died within 5 years did so without losing their limbs. Of all the patients in whom limb salvage was attempted, 68% lived more than one year with a viable, usable extremity, and 54% lived over 2 years with an intact limb. We believe this aggressive approach to limb salvage is justified, and can be undertaken with a low cost in mortality, knee loss and morbidity

The medical, emotional, and legal environments in which consent for organ donation is pursued greatly influence the outcome of this request. Knowledge of the circumstances and facts regarding brain death are important first steps in resolving misconceptions a potential donor's family may have that might preclude a favorable decision. The attitudes of hospital staff members toward these issues, and the grief and shock experienced at these times by next-of-kin, further complicate the circumstances in which consent for organ donation is requested. Clarification of traditional religious beliefs and reconciliation of these with the concept of organ donation may also have to be addressed at this time. Significant benefit to the bereaved family as well as to the transplantation process can accrue only in an atmosphere in which all involved understand the facts of brain death, and in which organ donation is viewed positively. $$:

Previous studies of the value of percutaneous renal transplant biopsy have been retrospective. We prospectively studied whether biopsy affected patient management. Thirty-five patients with elevated serum creatinine level underwent 44 biopsies in situations in which the diagnosis was in doubt. At the time of biopsy, all clinical and laboratory data were reviewed, and a proposed treatment plan was outlined. Biopsy results were available within 24 hours. We evaluated whether biopsy influenced treatment. Other than hematuria (less than 24 hours), there were no complications. Nine biopsy specimens (20.5%) were inadequate for evaluation. Forty-six percent of adequate biopsy specimens (36% of total biopsy specimens) influenced patient management. Adequate biopsy specimens resulted in a change in treatment in 10 of 19 patients receiving prednisone and azathioprine and 6 of 16 receiving prednisone and cyclosporine. The remaining biopsy specimens, although not changing management confirmed the treatment plan in ambiguous clinical situations. We conclude that percutaneous biopsy is an important aid in patient management

Bronchial anastomotic healing was evaluated in 22 long-term-surviving canine lung allotransplant recipients treated with cyclosporine as the major immunosuppressive agent. Mean survival in these dogs was over 155 days, and 4 animals survived 1-3 years. Bronchial anastomotic complications were limited to 5 cases of minimal (less than 15%) bronchostenosis. The bronchial anastomoses became somewhat edematous and friable during rejection episodes, but no clinically serious sequelae--such as hemorrhage, peribronchial abscess, or bronchial dehiscence--were observed. Gross and microscopic evaluation of the recipient and donor segments of the anastomoses revealed excellent healing, with only scattered areas of inflammatory cells. The decreased frequency and severity of rejection episodes in animals treated with cyclosporine permits early revascularization of the bronchus to take place and reduces the need for other immunosuppressive agents that may interfere with bronchial healing. Cyclosporine is an effective immunosuppressive agent for canine lung allotransplantation and allows normal bronchial anastomotic healing to occur

Ischemia of the donor bronchus, perfused solely by retrograde collaterals from the pulmonary circulation, is an important factor in the impaired healing of the bronchial anastomosis of transplanted lungs. The healing of two experimental models of bronchial anastomotic ischemia, the bronchial segmental autograft and the postpneumonectomy bronchial autograft, was assessed in dogs. The application of a polytetrafluoroethylene wrap to the bronchial segmental autograft and the application of an intercostal pedicle flap to the postpneumonectomy bronchial autograft, with and without concomitant administration of corticosteroids, were also studied to elucidate factors that affect bronchial anastomotic healing. The bronchial segmental autograft healed normally without stricture, but isolation of this autograft from the mediastinum and lung by the polytetrafluoroethylene wrap resulted in necrosis of the autograft. All dogs that had a postpneumonectomy bronchial autograft died of bronchopleural fistulas due to autograft necrosis. Application of an intercostal pedicle flap to the autograft resulted in healing in all animals. Arteriography and Microfil injection demonstrated revascularization of the postpneumonectomy bronchial autograft by the pedicled intercostal artery. Several conclusions can be drawn: With the lung in situ the bronchial segmental autograft survives, probably as a free composite graft. In contrast, the postpneumonectomy bronchial autograft is an excellent model of bronchial anastomotic ischemia. The intercostal pedicle flap is a reliable method for providing neovascularity and mechanical reinforcement to an ischemic bronchial anastomosis. Its effect on bronchial anastomotic healing was not diminished by administration of corticosteroids. The intercostal pedicle flap may be useful in preventing bronchial anastomotic complications in clinical lung transplantation