A retrospective case control study of 271 patients with peripheral arterial occlusion (PAO) who were treated with urokinase (UK) or streptokinase (SK) at two clinical centers, Alexandria Hospital and the Cleveland Clinic, was performed. The primary objective was to evaluate the relative cost-effectiveness of thrombolytic therapy with SK or UK in the treatment of PAO. A secondary objective was to identify factors to which any major differences in cost-effectiveness between these two agents could be attributed. All available patients hospitalized at the two centers for PAO who underwent treatment with UK or SK from 1979 to 1987 were included. Therapeutic success was defined as complete clot lysis or partial clot lysis judged to be of clinical benefit by the attending physician, with no major bleeding or other serious complication such as renal insufficiency or death. Success rates with UK were higher than those with SK at both centers. The advantage with UK could not be explained by baseline patient characteristics. A cost-effectiveness ratio--dollars expended on medical care for up to 2 days after infusion per therapeutic success--was calculated for each of the treatments. Overall, at Alexandria Hospital, $10,700 was expended per therapeutic success with UK therapy compared with $14,500 for successful SK therapy. At the Cleveland Clinic, differences were more pronounced, with $15,000 expended per therapeutic success for UK treatment and $46,400 per success for SK treatment. Support for preference of UK therapy is provided by the consistency of results in favor of UK cost-effectiveness for subgroups of patients that were determined according to site of occlusion and type of therapy following lysis. The cost-effectiveness of UK was not dependent on the definition of patient costs associated with PAO.

The usefulness of lymphangiography and CT in the diagnosis and localization of laceration of the thoracic duct was evaluated in 12 patients with chylothorax or chylous ascites after surgery. Bipedal lymphangiography was performed in all 12 patients. The last four patients studied also had CT after lymphangiography. Seven patients had abnormal findings on lymphangiograms; five with leaks from the thoracic duct, one with a lymphocele in a nephrectomy bed, and one with obstructed intestinal lymphatic vessels after thoracotomy. Five patients had no evidence of lymphatic leakage. CT in one patient with evidence of a leak on lymphangiography showed extravasation of contrast medium into the mediastinum and pleural space. CT in three patients with no abnormalities on lymphangiography also showed no abnormalities. Four of the five thoracic duct lacerations and the lymphocele were confirmed surgically. The diagnosis of obstructed intestinal lymphatic vessels was supported clinically. Four of the five patients with normal findings on lymphangiograms had resolution of their pleural effusions and no evidence of recurrence during a follow-up period of 1-27 months. One patient with normal findings on lymphangiography had an alternative diagnosis established at surgery. Laceration of the thoracic duct was accurately diagnosed and localized with lymphangiography, which allowed definitive surgical repair. CT was of little additional value in diagnosing these injuries.

Percutaneous nephrostomy has become a well-established procedure for a wide variety of urologic disorders. However, its role in the management of patients with upper urinary tract transitional cell carcinoma has not been defined. We utilized percutaneous nephrostomy in 23 renal units for the evaluation or treatment of 21 patients in whom standard techniques were inconclusive or inadequate. The percutaneous nephrostomy provided adequate relief of obstruction in the face of significant azotemia or infection. Diagnostic abilities were improved through the use of antegrade pyelography, selective cytologic examination, and, at times, by providing direct access for endoscopic visualization and biopsy. In select cases, the percutaneous access provided a route for definitive or adjunctive treatment of the lesion. Complications were few and seeding of the tract or local tumor spread has not occurred at follow-up ranging from one to one hundred twenty-one (mean 27.8) months.

PURPOSE:To determine the prevalence of atherosclerotic renal artery stenosis in patients who have atherosclerosis elsewhere but lack the usual clinical clues to suggest renal artery stenosis.PATIENTS AND METHODS:The arteriograms and charts of 395 consecutive patients were prospectively reviewed by a member of the Vascular Medicine Department and a member of the Radiology Department. These patients underwent arteriography as part of the routine evaluation for abdominal aortic aneurysm (109 patients), aorto-occlusive disease (21 patients), lower-extremity occlusive disease (189 patients), and suspected renal artery stenosis (76 patients). Patients in the first three groups did not have the usual clues that suggest renal artery stenosis.RESULTS:There was greater than 50% renal artery stenosis in 41 patients (38%) with abdominal aortic aneurysm, seven patients (33%) with aorto-occlusive disease, 74 patients (39%) with lower-extremity occlusive disease, and 53 patients (70%) with suspected renal artery stenosis. The prevalence of renal artery stenosis was similar in diabetic and nondiabetic patients with abdominal aortic aneurysm, aorto-occlusive disease, or suspected renal artery stenosis, but higher in diabetics with lower-extremity occlusive disease (50%) compared to nondiabetics with lower-extremity occlusive disease (33%) (p = 0.022). High-grade bilateral disease was present in approximately 13% of patients with abdominal aortic aneurysm or lower-extremity occlusive disease, and totally occluded renal arteries occurred in 5% of the patients in these groups. There was an association between increasing degree of renal artery stenosis and the presence of hypertension and worsening of renal function.CONCLUSION:Patients with atherosclerosis elsewhere, especially abdominal aortic aneurysm, aorto-occlusive disease, or lower-extremity occlusive disease, have a high prevalence of significant renal artery stenosis even in the absence of the usual clues to suspect renal artery stenosis. Diabetic patients have a similar prevalence as nondiabetic patients. This information may have important therapeutic implications in patients being considered for vascular surgery.

A prospective study was done to compare the relative efficacy of an abdominal radiograph and renal ultrasound to excretory urography for the evaluation of asymptomatic patients 1 month after extracorporeal shock wave lithotripsy.

Transluminal ureteral dilation was performed in 11 renal allograft recipients with transplant ureteral obstruction. Success was achieved in 5 patients (45 per cent) with a followup of 12 to 29 months (mean 19.6 months). All failures have been evident within 12 months of dilation. We conclude that ureteral dilation can provide long-term success in renal allograft recipients. However, continued close long-term monitoring of the anatomical and functional result is mandatory for patients treated in this manner.

The generation of D-dimer was studied in the course of local thrombolytic therapy of peripheral arterial occlusions with low doses of recombinant human tissue-type plasminogen activator (rt-PA) in 7 patients. Intermittent local application of rt-PA resulted in a marked increase in D-dimer exceeding values usually seen after intravenous application of manifold higher doses used in myocardial infarction. The increase in D-dimer was related to the estimated thrombus size (length of the occlusion) and the total dose of rt-PA applied. During local rt-PA infusion of 6 of 7 patients maintained plasminogen activator inhibitor capacity (PAI-cap) between 34% and 79% of their corresponding pre-treatment levels; detectable levels of PAI-cap in circulating blood during the procedure did not interfere with the success of therapy.

Twenty-two patients were selected from a group of 33 patients who underwent recombinant human tissue—type plasminogen activator (rt-PA) thrombolysis for thrombosed infrainguinal bypass grafts of the lower extremity and were compared with 38 matched patients who had undergone surgical thrombectomy during the same period. The proportion of persons with diabetes mellitus, smokers, and types of bypass grafts was similar in both groups. More patients in the rt-PA—treated group had hypertension (p = 0.01). To evaluate the different lengths of follow-up, Kaplan-Meier survival analysis was used with a log-rank test to compare the proportion of persons with patent grafts in the two treatment groups. At 30 days, 86% of the rt-PA—treated grafts were still patent compared with 42% of the surgically treated grafts (p = 0.001). When risk factors on the Kaplan-Meier curves were compared, there was no statistical difference with regard to graft patency among the groups. According to simultaneous Cox regression analysis, no risk factor was significantly associated with graft patency. When amputation was evaluated between treatment groups simultaneously with other risk factors in a logistic regression analysis, smoking and age of the graft were marginally significant (p = 0.07), whereas all other factors were clearly not significant. In 91% of the rt-PA—treated patients, a secondary surgical procedure was required to maintain patency of the graft segment. Eighty-nine percent of the surgically treated patients required similar graft revisions. Two patients in the surgical group and one patient in the rt-PA—treated group had major complications. This short clinical experience suggests that better 30-day patency rates and a lower risk of amputation can be achieved when thrombolysis is associated with surgical revision compared with surgical revision alone. (J VASC SURG 1988;7:347-55.)

Urologic complications continue to occur in renal transplant recipients. Furthermore, standard, secondary operative intervention for these problems has been associated with high morbidity and even mortality. Currently, percutaneous techniques are being used with increasing frequency for these patients to temporize or even avoid the need for subsequent operative procedures. The indications, techniques, and results of such intervention are reviewed.

From April 1979 to June 1985 percutaneous transluminal angioplasty was attempted in 68 patients at our clinic to treat renovascular hypertension and/or to preserve renal function. The etiology of renal artery disease was atherosclerosis in 55 patients, fibrous dysplasia in 6, renal transplant arterial stenosis in 5 and postoperative saphenous vein graft stenosis in 2. A successful clinical outcome, defined as a decrease in blood pressure and/or improvement in renal function, was achieved in 12 patients (26.1 per cent) with atherosclerotic renal artery disease, 3 (75 per cent) with fibrous dysplasia, 2 (100 per cent) with saphenous vein graft stenosis and all 5 with transplant renal arterial stenosis (100 per cent). Improved results were observed in patients with nonostial atherosclerotic lesions compared to ostial lesions. There were 23 complications (33.8 per cent) after percutaneous transluminal angioplasty and all but 1 occurred with atherosclerosis. Of these complications 13 (19 per cent) were considered major. Since the beginning of 1983, however, only 3 complications occurred among 32 procedures (9.4 per cent) and only 1 of these was of major significance. When technically feasible, percutaneous transluminal angioplasty can provide effective treatment for selected patients with renal artery stenosis.

A total of 71 potential living kidney donors was evaluated on an outpatient basis with either a modification of standard catheter angiography (30 patients) or intra-arterial digital subtraction angiography (41 patients). Both procedures provided accurate assessment of the main renal vasculature as proved at the time of donor nephrectomy. Neither technique was associated with any significant morbidity. We conclude that complete angiographic evaluation of potential kidney donors can be performed accurately and safely on an outpatient basis.

Fifty patients requiring intervention for upper or mid ureteral calculi were managed initially with a percutaneous antegrade approach (25 patients) or a transurethral ureteroscopic approach (25 patients). In both groups, a crossover to the other modality was at times utilized to accomplish stone removal. Success for either group was defined as complete stone removal without the need for open intervention.

This study was done to determine whether intravenous digital subtraction angiography could reliably image the main renal arterial supply in patients with extensive renal calculus disease and compromised renal function. Thirteen patients undergoing complex intrarenal surgery for calculus disease, who otherwise would have been evaluated preoperatively with standard catheter arteriography, instead underwent intravenous digital subtraction angiography. The images obtained were found to have been accurately interpreted in all cases, as determined definitively at the time of renal exploration. T h e authors conclude that intravenous digital subtraction angiography is a reliable alternative arterial imaging procedure in patients with complex renal calculus disease and compromised renal function.

From 1979 until 1984, 70 elderly (greater than or equal to 65 years of age) patients with atherosclerotic renal arterial disease underwent surgical revascularization (SR, N = 46) or percutaneous transluminal renal angioplasty (PTRA, N = 24). After SR, there were no operative deaths and seven major complications. After PTRA, there were six major complications, including two deaths. The clinical success rate with SR was better than with PTRA both in terms of amelioration of hypertension (100.0 versus 27.3 per cent) and preservation of renal function (85.0 versus 68.4 per cent). SR can be done safely and is the most effective treatment for elderly patients with renal artery disease.

Resultats tres satisfaisants de l'evaluation angiographique precise chez 18 donneurs potentiels de rein, ne demandant pas d'hospitalisation

This study examines the comparative efficacy, safety, and cost associated with treatment of deep vein thrombosis with streptokinase or urokinase. Sixty patients were analyzed retrospectively, 30 treated with streptokinase and 30 treated with urokinase. Statistically significant greater fibrinogenolysis was noted when streptokinase was used to treat patients with deep venous thrombosis (p = 0.01). The mean decrease in fibrinogen from preinfusion value was 83 % in the streptokinase treated group and 61 % in the urokinase treated group. Five of 30 (17 %) of the streptokinase treated patients experienced major complications. No major complications were seen in the urokinase treated group (p = 0.019). Cost analysis demonstrates that therapy with urokinase was $ 11.40 per patient more than streptokinase. If complications are not included in the cost analysis, then urokinase becomes only $ 650 per patient more expensive than streptokinase therapy. These data support that deep vein thrombosis treatment with urokinase is effective, safer and more cost efficient when compared to streptokinase.

No AccessJournal of Urology1 Jun 1987Outpatient Renal Donor Angiography Stevan B. Streem, William F. Spencer, Michael A. Geisinger, Barbara Risius, and Margaret G. Zelch Stevan B. StreemStevan B. Streem More articles by this author , William F. SpencerWilliam F. Spencer More articles by this author , Michael A. GeisingerMichael A. Geisinger More articles by this author , Barbara RisiusBarbara Risius More articles by this author , and Margaret G. ZelchMargaret G. Zelch More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)76031-4AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Outpatient Renal Donor Angiography." The Journal of Urology, 137(6), p. 324A © 1987 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 137Issue 6June 1987Page: 324A Advertisement Copyright & Permissions© 1987 by The American Urological Association Education and Research, Inc.MetricsAuthor Information Stevan B. Streem More articles by this author William F. Spencer More articles by this author Michael A. Geisinger More articles by this author Barbara Risius More articles by this author Margaret G. Zelch More articles by this author Expand All Advertisement PDF downloadLoading ...