Arteriovenous fistula aneurysmorrhaphy is associated with improved patency and decreased vascular access abandonment.

BACKGROUND: Upper extremity hemodialysis arteriovenous fistulas (AVFs) can become aneurysmal over time due to repeated cannulation and/or outflow steno-occlusive disease. The optimal surgical management of aneurysmal AVFs (aneurysmorrhaphy vs interposition graft) has remained unclear. METHODS: We performed a retrospective review in which current procedural terminology codes were used to screen for patients who had undergone surgical treatment of aneurysmal AVFs between 2016 and 2021 at a single hospital system. The patients were included after a review of the operative reports. The cases were divided by surgical procedure (aneurysmorrhaphy vs interposition graft placement). The patients who had undergone primary AVF ligation or other types of repair were excluded. The primary outcomes were primary assisted and secondary patency, and the secondary outcome was dialysis access abandonment. Multivariable Cox proportional hazards regression was used to test the association between the type of AVF aneurysm repair and the primary and secondary outcomes. RESULTS: From 2016 to 2021, 6951 patients had undergone 16,190 dialysis access procedures. Of these procedures, 381 (2.4%) were related to surgical treatment of an aneurysmal AVF. We excluded 58 primary AVF ligation cases and 20 cases involving other types of repair, leaving 303 cases for analysis. These were divided into two groups: aneurysmorrhaphy (n = 123; 41%) and interposition graft (n = 180; 59%). No differences were found between the groups in male gender (68% vs 63%), hypertension (98% vs 98%), or central stenosis (14% vs 22%). The patients who had undergone aneurysmorrhaphy were younger (median age, 54 years vs 59 years); had had a lower rate of diabetes (41% vs 59%), coronary artery disease (41% vs 58%), and congestive heart failure (41% vs 55%); and were less likely to have undergone upper arm access (72% vs 92%). The median follow-up was 11.1 months (interquartile range, 3.6-25.2 months). No differences were found in the incidence of 30-day wound complications (1% vs 3%) or surgical site infections (4% vs 6%). On multivariable Cox regression, interposition graft placement was associated with the loss of primary assisted patency (adjusted hazard ratio [aHR], 2.42; 95% confidence interval [CI], 1.18-4.95), loss of secondary patency (aHR, 3.10; 95% CI, 1.21-7.94), and abandonment of dialysis access (aHR, 3.07; 95% CI, 1.61-5.87; P < .05 for all) at 2 years. CONCLUSIONS: AVF aneurysmorrhaphy was associated with improved primary assisted and secondary patency and decreased abandonment of dialysis access. We suggest using aneurysmorrhaphy when AVF aneurysms are indicated for repair. However, individual factors such as patient comorbidities, AVF anatomy, remaining dialysis access options, and patient preference should be considered when planning the surgical approach.

Efficacy of premixed versus succedent administration of fentanyl and bupivacaine in subarachnoid block for lower limb surgeries: A randomised control trial.

BACKGROUND AND AIMS: Subarachnoid block is the most commonly used anaesthesia technique for lower limb surgeries. Opioids are the most commonly used adjuvants with local anesthetics (LA). Adjuvants are given premixed with LA loaded in a single syringe. This study was conducted to evaluate differences in level of sensory and motor block and incidence of hypotension whilst administering hyperbaric bupivacaine and fentanyl either in a single syringe or different syringes. The effect of administering opioid prior to LA and vice versa on these parameters was also assessed. METHODS: One hundred and twenty patients were randomly allocated into three groups of 40 each: Group A received premixed 0.5% heavy bupivacaine 2.5 ml (12.5 mg) and 0.5 ml (25 microgram) of fentanyl in a single 3.0 ml syringe, Group B received 0.5 ml (25 microgram) of fentanyl in a 3.0 ml syringe followed by 0.5% heavy bupivacaine 2.5 ml (12.5 mg) in a 3.0 ml syringe, Group C received 0.5% heavy bupivacaine 2.5 ml (12.5 mg) in a 3.0 ml syringe followed by 0.5 ml (25 microgram) fentanyl in a 3.0 ml syringe. All statistical calculations were done using SPSS 21 version statistical program for Microsoft Windows. RESULTS: The mean time for onset of sensory and motor block was least in group C followed by group B. The duration of sensory and motor block was prolonged in groups B and C. Patients in group A experienced more hypotension as compared to groups B and C. CONCLUSION: Administering hyperbaric bupivacaine first followed by fentanyl leads to an early onset and prolonged duration of sensory and motor block.

Clear cell variant, urothelial carcinoma of ureter: A rare entity.

Clear cell variants of transitional cell carcinoma of upper urinary tract is extremely rare. Although clear cell of urinary bladder has been reported, its occurrence in the upper tract has not been reported readily in literature. We present a case of 77 year old female who was suspected with TCC of the ureter, but was found to have clear cell variant on histology post radical nephroureterectomy. This was the first such case in our institution.

Early cannulation of bovine carotid artery grafts (Artegraft) after primary vascular access and fistula revision procedures.

OBJECTIVE: Tunneled dialysis catheter (TDC) use has been associated with increased infectious complications and mortality in hemodialysis-dependent patients. Unfortunately, patients who undergo fistula revisions or creation of a new arteriovenous fistula frequently require a TDC during the postoperative period. Bovine carotid artery grafts (BCAGs) can be used as an early-access dialysis conduit to reduce TDC dependence. This study describes the performance of BCAGs that were cannulated early (<3 days) after implantation and associated clinical outcomes. METHODS: BCAGs were implanted in 63 consecutive dialysis-dependent patients. Patients and dialysis centers were directly provided early cannulation instructions; 31 (49%) patients were cannulated early, and of the 31 patients cannulated early, 21 (68%) were cannulated during the first postoperative day. Early complications, primary patency, secondary patency, and TDC incidence were monitored through clinic visits, hospital records, and phone calls to dialysis centers. RESULTS: The primary patency of BCAGs at 1 year in the early and late cannulation cohorts was 28% and 39%, respectively. The secondary patency of BCAGs at 1 year in the early and late cannulation cohorts was 74% and 77%, respectively. Early complications occurred in 11 (19%) patients who received a BCAG. There were no significant differences in complication rates between early and late cannulation patients. Of the 24 patients who underwent the operation without a pre-existing TDC, only three (13%) required TDC placement during the 30-day postoperative period. CONCLUSIONS: BCAGs can be cannulated early without increased complication rates or a negative impact on midterm patency. Early cannulation of BCAGs obviates the need for a TDC postoperatively in dialysis-dependent patients undergoing primary vascular access or fistula revision procedures.

Radial Nerve Palsy following Endovascular Embolization of an Arteriovenous Malformation.

Background Arteriovenous malformations (AVMs) are commonly treated using endovascular techniques. Previous nerve palsies after embolization have been reported as isolated case reports, none of which affected the forearm. Case Description A case of acute, transient neuropathy of the radial nerve following embolization of a forearm AVM is described. The patient, an otherwise healthy 27-year-old man, began having symptoms of superficial radial nerve (SRN) and posterior interosseous nerve (PIN) palsies immediately following endovascular embolization. He underwent decompression of the radial nerve within 5 days and was found to have direct compression of the PIN and SRN. The patient recovered completely at the time of his 7-month follow-up. Literature Review Few cases of nerve palsy after endovascular embolization have been reported in the literature. Many are intracranial, but rare instances of peripheral nerve palsy have been reported, including two sciatic nerve and four digital nerve palsies after endovascular embolization. No cases of peripheral nerve palsy in the forearm have been reported. Clinical Relevance We recommend careful consideration of surrounding neural elements at risk for palsy prior to endovascular embolization and detailed discussion with the patient during the informed consent process.

Comparison of intravascular ultrasound- and centerline computed tomography-determined aortic diameters during thoracic endovascular aortic repair.

BACKGROUND: Accurate sizing of stent grafts during thoracic endovascular aortic repair (TEVAR) is critical for a successful outcome. Centerline measurements using three-dimensional reconstruction of preoperative computed tomography angiography (CTA) is the current standard for stent graft sizing. However, this technique is predicated on an idealized straightened aorta and does not account for the variability in the aortic diameter during the cardiac cycle or the overall status of the patient's volume. Intravascular ultrasound (IVUS) offers real-time cross-sectional imaging of the aorta orthogonal to the support wire, thereby providing an adjunctive method for aortic diameter determination at the time of TEVAR. METHODS: A retrospective review was performed on all patients who underwent TEVAR for nontraumatic aortic pathology from July 2015 to December 2015. Preoperative CTA images were reconstructed on a dedicated three-dimensional workstation. CTA centerline aortic diameter measurements were performed in major and minor axes at 1-cm intervals from the left subclavian origin to 20 cm distally. The IVUS images were acquired intraoperatively through 1-cm stepwise pullback along the aorta from the left subclavian origin to 20 cm. IVUS aortic diameters were measured at the maximum phase during the cardiac cycle. The average values of major and minor axes diameters from both modalities were calculated at each location for comparison. Linear regression analysis was performed to evaluate correlation, and Bland-Altman plots assessed agreement between different imaging modalities. RESULTS: During the study period, 26 patients underwent TEVAR. Of these, 20 patients had adequate CTA and IVUS images, providing 355 paired measurements. There was a high correlation between CTA- and IVUS-determined aortic diameters (R = 0.62; P < .001). However, Bland-Altman analysis showed that, compared with CT, IVUS resulted in larger aortic diameters, with the mean difference of 3.09 mm. There was a significant variability between IVUS and CTA with the standard deviation of difference (SD diff) of 4.56 mm. When stratified by the aortic position, a high degree of agreement was observed at the base of the left subclavian (position 0), with a mean difference of -2.69 mm and an SD diff of 4 mm. The agreement was the lowest at the angulated aortic segments (2 cm to 7 cm distal to the subclavian origin) with a mean difference up to 7.96 mm and an SD diff up to 8.27 mm. CONCLUSIONS: IVUS imaging and centerline CTA may provide significantly different aortic diameter measurements, particularly in angulated aortic segments. Caution must be taken when sizing a stent graft using CTA alone, particularly in an angulated proximal landing zone.

Management and Outcome of Patients with Pancreatic Trauma.

INTRODUCTION: Pancreatic trauma is a rare entity occurring in 0.2% of patients with blunt trauma abdomen. Once the diagnosis is made, the management of patients is dependent on multiple variables. Conservative management, suture repair, drainage, and resection have been utilized with varying degree of success. This study is aimed to evaluate the management of patients with pancreatic trauma. MATERIALS AND METHODS: This was a prospective study done in the Department of Surgery in Dayanand Medical College and Hospital where forty hemodynamically stable patients diagnosed to have pancreatic trauma on contrast-enhanced computed tomography abdomen were included in the study. RESULTS: Out of forty patients taken in this study, 38 were male and two were female with age ranging from 3 to 50 years. Road traffic accident was the most common cause of pancreatic injury. Pancreatic injuries were graded according to the American Association for Surgery in Trauma scale. Twelve patients had Grade I and II injuries. Grade III was the most common injury occurring in 14 patients. Twenty-four patients underwent surgical management. Mortality rate was 45% and it was in direct correlation with the severity of injury. CONCLUSION: Grade I and II pancreatic injury can be managed conservatively depending upon the hemodynamic status of the patient. Grade III and IV injuries have a better prognosis if managed surgically.

The Impact of Aneurysm Morphology and Anatomic Characteristics on Long-Term Survival after Endovascular Abdominal Aortic Aneurysm Repair.

BACKGROUND: Hostile anatomic characteristics in patients undergoing endovascular abdominal aortic aneurysm repair (EVAR) and the placement of endografts not in concordance with the specific device anatomic guidelines (or instructions for use [IFU]) have shown decreased technical success of the procedure. But these factors have never been evaluated in regard to patient postoperative survival. We sought to assess the association between survival and (1) aneurysm anatomy and characteristics and (2) implantation in compliance with manufacturer's anatomic IFU guidelines in patients undergoing endovascular aortic aneurysm repair. METHODS: The cohort included 273 consecutive patients who underwent EVAR at Baylor Heart and Vascular Hospital between January 1, 2002 and December 31, 2009 and had their preoperative computed tomography (CT) scan digitally retrievable. The CT scans and operative notes were then reviewed, and the anatomic severity grading (ASG) score, maximum aneurysm diameter, thrombus width, patency of aortic side branch vessels, and implantation in compliance with IFU guidelines were assessed. The unadjusted association between survival (assessed until November 1, 2011) and these variables was assessed with the Kaplan-Meier method. Moreover, propensity-adjusted (for a comprehensive array of clinical and nonclinical risk factors) proportional hazard models were developed to assess the adjusted associations. RESULTS: Seven (2.56%) patients died within 30 days from EVAR, and 88 (30.04%) patients died during the study follow-up. Patient mean survival was 6.3 years. The unadjusted analysis showed a statistically significant association between survival and thrombus width (P = 0.007), ASG score (P = 0.004), and implantation in compliance with IFU guidelines (P = 0.007). However, the adjusted analysis revealed that none of the anatomic and compliance factors were significantly associated with long-term survival (ASG, P = 0.149; diameter, P = 0.836; thrombus, P = 0.639; patency, P = 0.219; and implantation compliance, P = 0.219). CONCLUSIONS: Unfavorable aneurysm morphologic characteristics and endograft implantation not in compliance with IFU guidelines did not adversely affect patient survival after EVAR in this group of patients. This implies that unfavorable anatomy, even that which would necessitate implantation of the EVAR device outside of the IFU guidelines, should not necessarily contraindicate EVAR.

Role of Amylase and Lipase Levels in Diagnosis of Blunt Trauma Abdomen.

INTRODUCTION: Blunt Trauma Abdomen (BTA) is the leading cause of morbidity and mortality amongst all age groups. Spectrum of injury may vary from simple to life threatening multi organ involvement and therefore proper assessment and diagnosis becomes very important. AIM: To evaluate the role of serum amylase and lipase in diagnosis of blunt trauma abdomen. MATERIALS AND METHODS: This study was done on 50 patients with diagnosis of BTA admitted in Dayanand Medical College and Hospital, Ludhiana. Serum amylase and lipase levels were estimated on days 1, 3 and 5 of admission. RESULTS: Road side accident was the most common aetiology accounting for 40 patients. Thirty one patients were less than 35 years of age and 42 patients were males. Abdominal tenderness was the most common per abdomen finding, found in 31 patients, followed by distension, found in 21 patients. The most common organ injured was liver, seen in 27 patients. Fifteen patients underwent laparotomy while 35 patients were managed conservatively. There was statistically significant rise in serum amylase levels on days 1, 3 and 5 in patients with small and large intestinal injury. There was statistically significant rise in serum lipase levels on days 1, 3 and 5 in patients with stomach injury. Raised levels of serum amylase and lipase had a statistically significant prediction for the need of surgery in these patients. CONCLUSION: Serum amylase and lipase levels, when coupled with other laboratory tests and imaging modalities, may have significant role in predicting the site of injury as well as the surgical outcome in patients of BTA.

Acute subdural hematoma secondary to cerebral venous sinus thrombosis: Case report and review of literature.

Cerebral venous sinus thrombosis is a rare type of stroke primarily affecting young women. Diagnosis is generally delayed or overlooked due to a wide spectrum of clinical symptoms. Subdural hematoma secondary to cerebral venous sinus thrombosis is very rare. We report a case of 40-year-old female with cerebral venous sinus thrombosis who presented to us with an acute subdural hematoma and subarachnoid hemorrhage besides venous infarct. Management of such patients is complicated due to the rarity of the condition and contraindication for the use of anticoagulation. We conducted a thorough literature search through PubMed and could find only nine cases of spontaneous subdural hematoma secondary to cerebral venous sinus thrombosis.

Transbrachial branch cannulation during Zenith fenestrated endovascular aortic aneurysm repair using a robotically guided body-floss technique.

Caudal angulation and stenosis of the renal arteries pose significant challenges in branch cannulation during the standard fenestrated endovascular aortic aneurysm repair (FEVAR). We describe an alternative technique of branch cannulation during FEVAR in a patient with a 6.5-cm juxtarenal abdominal aortic aneurysm, renal artery stenosis, and bilateral caudally oriented renal arteries. A brachiofemoral or "body-floss" access was established by traversing the top scallop. The brachial sheath was deflected toward the target fenestration using a steerable robotic femoral sheath, enabling transbrachial cannulation of the downgoing target renal artery. Postoperatively, the patient was discharged without complications. Steerable sheath-guided body-floss technique may facilitate cannulation of severely downgoing branch vessels during FEVAR.

A Rare Case of Intra- Abdominal Bronchogenic Cyst- A Case Report.

Bronchogenic cysts are developmental foregut anomalies usually located in the mediastinum. A 90% of the bronchogenic cysts occur in the posterior aspect of superior mediastinum. Retroperitoneal location of a bronchogenic cyst is rare. We report a rare case of intra abdominal bronchogenic cyst. A CT scan was done for a 34-year-old female who presented with complains of heaviness in the right flank. CT scan revealed a large cyst of 10 x 6 cm in the right hypochondrium. Cyst was removed laparoscopically and the histopathology revealed a bronchogenic cyst.

Large Cervical Paraspinal Haemangioma in Association with Intraosseous Haemangioma: A Rare Case Report.

Haemangiomas are most commonly found in skin and subcutaneous tissue and are very rare in intramuscular region. Paraspinal musculature has been barely reported as location of intramuscular haemangioma while we could not find any literature reporting haemangioma in cervical paraspinal previously. We report a case of middle aged woman with a large intamuscular haemangioma involving left cervical paraspinal musculature extending from suboccipital region to C5 vertebra and reaching upto left parotid gland along with C6 vertebral body haemangioma.

Spontaneous Disappearance of a Large Chronic Subdural Hematoma: A Pleasant Surprise.

We report an extremely rare case of spontaneous complete disappearance of a large chronic subdural hematoma in a 78-year aged man with a significant mass effect and a large midline shift which was diagnosed around 6 weeks before admission. Repeat NCCT of the head in our department to everyone's surprise revealed almost complete spontaneous resolution. Spontaneous resolution of a large chronic subdural hematoma is extremely rare, and the scarce literature whatsoever is available is especially in cases of immune thrombocytopenic purpura where steroids may play a role in the stabilization of neomembranes. Our interest is in this case because of the benign clinical course despite a large size causing severe mass effect and large midline shift. Chronic subdural hematoma is a common entity in the elderly generally seen weeks following minor trauma. Surgical evacuation of a chronic subdural hematoma remains the gold standard treatment, but controversy exists regarding the best surgical option. Spontaneous resolution of a chronic subdural hematoma has also been reported rarely, but mainly in patients with immune thrombocytopenic purpura.

Ultrasonically targeted delivery into endothelial and smooth muscle cells in ex vivo arteries.

This study tested the hypothesis that ultrasound can target intracellular uptake of drugs into vascular endothelial cells (ECs) at low to intermediate energy and into smooth muscle cells (SMCs) at high energy. Ultrasound-enhanced delivery has been shown to enhance and target intracellular drug and gene delivery in the vasculature to treat cardiovascular disease, but quantitative studies of the delivery process are lacking. Viable ex vivo porcine carotid arteries were placed in a solution containing a model drug, TO-PRO(R)-1, and Optison microbubbles. Arteries were exposed to ultrasound at 1.1 MHz and acoustic energies of 5.0, 66, or 630 J/cm(2). Using confocal microscopy and fluorescent labeling of cells, the artery endothelium and media were imaged to determine the localization and to quantify intracellular uptake and cell death. At low to intermediate ultrasound energy, ultrasound was shown to target intracellular delivery into viable cells that represented 9-24% of exposed ECs. These conditions also typically caused 7-25% EC death. At high energy, intracellular delivery was targeted to SMCs, which was associated with denuding or death of proximal ECs. This work represents the first known in-depth study to evaluate intracellular uptake into cells in tissue. We conclude that significant intracellular uptake of molecules can be targeted into ECs and SMCs by ultrasound-enhanced delivery suggesting possible applications for treatment of cardiovascular diseases and dysfunctions.

Measurement and correlation of acoustic cavitation with cellular bioeffects.

Using broadband noise as a measure of cavitation activity, this study determined the kinetics of cavitation during sonication of Optison contrast agent and tested whether cellular bioeffects can be predicted by cavitation dose. Cell suspensions were exposed to ultrasound at varying acoustic frequency, pressure, exposure time, Optison concentration and cell type to obtain a broad range of bioeffects, i.e., intracellular uptake and loss of viability, as quantified by flow cytometry. We found that cavitation activity measured by broadband noise increased and peaked within 20 ms and then decayed with a half-life of tens to hundreds of milliseconds. Intracellular uptake and loss of viability correlated well with the cavitation dose determined by the time integral of broadband noise magnitude. These results demonstrate that broadband noise correlates with bioeffects over a broad range of experimental conditions, which suggests a noninvasive feedback method to control ultrasound's bioeffects in real time.