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Insufficient hemodynamics during agonal phase-i.e. the period between withdrawal of life-sustaining treatment and circulatory arrest-in Maastricht category III circulatory-death donors (DCD) potentially exacerbate ischemia/reperfusion injury. We included 409 Dutch adult recipients of DCD donor kidneys transplanted between 2006 and 2014. Peripheral oxygen saturation (SpO2-with pulse oximetry at the fingertip) and systolic blood pressure (SBP-with arterial catheter) were measured during agonal phase, and were dichotomized into minutes of SpO2>60% or SpO2 80 mmHg or SBP

While the guidelines for vaccination in renal transplant recipients recommend the use of pneumococcal polysaccharide (PPS) and tetanus toxoid (TT), their efficacy in immunocompromised renal transplant recipients is not known. Here we tested the effect of everolimus on immune responses after vaccination by measuring the capacity of 36 stable renal transplant recipients to mount cellular and humoral responses after vaccination. Twelve patients in each treatment arm received immunosuppressive therapy consisting of prednisolone (P) plus cyclosporine (CsA), mycophenolate sodium (MPA), or everolimus. Patients were vaccinated with the T-cell-dependent antigens immunocyanin and TT, and the T-cell-independent PPS. Treatment with CsA partially inhibited and MPA completely abolished the capacity to mount a primary humoral response, whereas everolimus left this largely intact. Recall responses were inhibited by MPA only. All drug combinations inhibited cellular responses against TT. In patients treated with MPA, B-cell numbers were severely reduced. Thus, combined with P, treatment with MPA completely disturbed primary and secondary humoral responses. Everolimus or CsA allowed the boosting of T-cell-dependent and -independent secondary humoral responses. Treatment with everolimus allowed a primary response. Kidney International (2010) 78, 934-940; doi:10.1038/ki.2010.269; published online 11 August 2010

Objective We systematically reviewed clinical studies on the use of venous and arterial allografts for infrainguinal revascularization. We attempted to find evidence for the best infrainguinal vascular allograft by a systematic review of the available literature. Methods An electronic search of the MEDLINE, EMBASE, and Cochrane databases was used to determine key articles from studies on the different types of vascular allografts used in infrainguinal reconstruction from 1966 to 2004. Articles were independently reviewed by using previously defined inclusion and exclusion criteria. Study results were gathered with cumulative primary patency as the primary end point. Secondary end points were major complications, graft disintegration, and major limb loss. Quantitative analysis was performed on the prospective randomized trials, and linear regression analysis was performed on cumulative primary patency. Fontaine's classification system was applied. Results No systematic review of randomized controlled trials was found. Five randomized controlled trials, 3 prospective cohort or case series, and 15 retrospective case series with 3837 vascular allografts were found. Methods of allograft preservation were cryopreservation (5 studies), cold storage (3 studies), and glutaraldehyde preservation of human umbilical veins (15 studies). One-year cumulative primary patency rates were 13% to 79% for cryopreservation, 63% to 80% for cold storage, and 40% to 91% for glutaraldehyde. The weighted mean 1-year cumulative primary graft patency rate was 41% for cryopreservation, 71% for cold storage, and 70% for glutaraldehyde allografts. Four randomized trials on femoropopliteal bypasses demonstrated higher patency rates of glutaraldehyde-preserved human umbilical veins than polytetrafluoroethylene grafts. Statistical heterogeneity between studies (I 2 = 91.4%) was too high to perform a formal meta-analysis. The rate of major limb loss was 20% to 58% for cryopreservation, 10% to 69% for cold storage, and 0% to 65% for glutaraldehyde, and the percentage of graft disintegration was 2% to 6% for cryopreservation, 4% to 15% for cold storage, and 0% to 11% for glutaraldehyde. Conclusions A firm conclusion could not be made because there were no studies available in which direct comparison was performed between different preservation methods of vascular allografts. In addition, heterogeneity of the individual studies hampered direct comparison of different types of vascular allografts. However, the overall graft performance of glutaraldehyde-preserved human umbilical vein allografts may be superior to that of other vascular allografts.

Objectivesto assess the influence of clinical and graft factors on the development of stenotic lesions. In addition the implications of any significant correlation for duplex surveillance schedules or surgical bypass techniques was examined.Patients and methodsin a prospective three centre study, preoperative and peroperative data on 300 infrainguinal autologous vein grafts was analysed. All grafts were monitored by a strict duplex surveillance program and all received an angiogram in the first postoperative year. A revision was only performed if there was evidence of a stenosis of 70% diameter reduction or greater on the angiogram.Resultsthe minimum graft diameter was the only factor correlated significantly with the development of asignificant graft stenosis(PSV-ratio ≥2.5) during follow-up (p=0.002). Factors that correlated with the development ofevent-causing graft stenosis, associated with revision or occlusion, were minimal graft diameter (p=0.001), the use of a venovenous anastomosis (p=0.005) and length of the graft (p=0.025). Multivariate regression analysis revealed that the minimal graft diameter was the only independent factor that significantly correlated with anevent-causing graft stenosis(p=0.009). The stenosis-free rates for grafts with a minimal diameter

Objectives:To investigate the effectiveness of two alternative vein-graft surveillance strategies. In the first strategy surveillance was restricted to patients with a possible higher risk of significant stenosis development, i.e. those with a moderate stenosis identified early after the operation. In the second strategy the effects of reducing the number of duplex tests per patient was examined.Patients and Methods:In a prospective study in three vascular surgical departments 300 patients (300 femoropopliteal or distal grafts) underwent duplex surveillance during the first year after the operation. The duplex-derived PSV-ratio was considered to represent the degree of stenosis. Arteriographic confirmation of suspected stenoses was routinely obtained, and patients without a suspected graft stenosis underwent a consented arteriogram during the first postoperative year. The decision to perform a graft revision was taken on the basis of an arteriographic stenosis of at least 70% diameter reduction. In the first strategy graft categories were defined on the basis of the first postoperative duplex examination: grafts with a PSV-ratio 3.0. The primary patency rate at 12 months was compared for these categories. In the second alternative strategy the number of examinations and the percentage of event causing de novo stenoses were analysed per surveillance interval.Results:The presence of moderate abnormalities at the initial duplex scan did not identify patients with a high risk of an event, as initial PSV-ratios of 1.5–2.0 and 2.0–2.5 (early mild-moderate lesions) had comparable 12-month primary patencies to patients with a PSV-ratio

Purpose and Methods: The contribution of color-flow duplex surveillance to improving vein graft patency was evaluated in two patient groups after 201 infrainguinal bypass procedures were performed during a 5-year period. Incidence of revision procedures and the primary and assisted primary patency rates were compared for 160 bypass grafts monitored during the first 2 years by use of color-flow duplex scanning of the vein graft and adjacent arterial segments (color-flow surveillance group) versus 41 bypass grafts monitored by use of clinical assessment alone (clinical follow-up group). Only grafts that were patent after the first postoperative month are considered. Results: The two groups were comparable with regard to most of the pertinent clinical factors. Stenotic lesions were identified in 58 bypass grafts, and severity was determined by use of intraarterial digital subtraction angiography. Eighteen bypass grafts with stenoses did not undergo a revision for reasons that were determined by the doctor, the hospital, or the patient. The occlusion rates of revised and nonrevised stenotic grafts were compared for lesions of different severity. None of the grafts for stenoses with 30% to 49% diameter reduction (DR) failed during follow-up. Occlusion occurred in 57% of the nonrevised and 9% of revised grafts ( p = 0.047) for stenoses with 50% to 69% DR. Stenoses with 70% or greater DR were associated with graft failure in 100% of nonrevised bypasses and in 10% of revised grafts ( p = 0.004). The assisted primary patency rate was higher in grafts that underwent color-flow surveillance compared with grafts with that underwent clinical follow-up (3-year patency rates of 91% and 72%, respectively; p = 0.004). The independent correlation of color-flow surveillance with higher patency rates was demonstrated in a proportional hazard analysis. The relative risk (probability of occlusion) in color-flow surveillance grafts is less than one third of the relative risk in bypass grafts that underwent clinical follow-up. Conclusions: We conclude that revision procedures were more optimally used during color-flow surveillance, whereas asymptomatic stenotic graft lesions are missed with clinical follow-up, which results in a higher percentage of graft failures. Overall graft patency rates can be improved with use of color-flow duplex surveillance and repair of significant stenotic lesions. (J VASC SURG 1993;17:42-53.)

Development of stenosis in lower extremity vein grafts or its anastomotic segments is responsible for most graft failures. While these lesions can be treated by minor procedures, timely identification may improve long-term graft patency. In this review, diagnostic methods that are currently applied for vein graft surveillance, criteria for stenosis and recommendations for intervention are discussed.

Coral reef aorta is a distinct calcifying disease causing luminal obstruction of the suprarenal aorta. We report three cases of coral reef aorta. Two of the three patients had symptoms related to significant aortic obstruction and were treated with a thromboendarterectomy. Extensive visceral embolization occurred in the third patient, which required a vascular bypass. Forty-one cases of coral reef aorta were reported in the literature and the overall in-hospital mortality rate of coral reef aorta, including our three cases, is 13.3% (6/44 patients). Multiple organ failure is the main cause of death. Coral reef aorta is a rare disease of the suprarenal aorta which can cause potentially lethal renal and visceral infarctions.