Sex disparities in popliteal artery aneurysms.

OBJECTIVE: Only 5% of patients with popliteal artery aneurysms (PAAs) are female. Evidence on PAA treatment and outcomes in women is therefore scarce. The POPART Registry provides one of Europe's largest data collections regarding PAA treatment. Data on clinical presentation, aneurysm morphology, and perioperative outcomes after open surgical PAA repair in women will be presented. METHODS: POPART is a multicenter, noninterventional registry for open and endovascular PAA repair, with 42 participating centers in Germany and Luxembourg. All patients aged >18 years who have been treated for PAA since 2010 are eligible for study inclusion. Data collection is based on an online electronic case report form. RESULTS: Of the 1236 PAAs, 58 (4.8%) were in women. There were no significant differences in age or cardiopulmonary comorbidities. However, female patients had a lower prevalence of contralateral PAAs and abdominal aortic aneurysms (P < .05). PAAs in women were more likely to be symptomatic before surgery (65.5% vs 49.4%; P = .017), with 19% of women presenting with acute limb ischemia (vs 11%; P = .067). Women had smaller aneurysm diameters than men (22.5 mm vs 27 mm; P = .004) and became symptomatic at smaller diameters (20 mm vs 26 mm; P = .002). Only 8.6% of women and 11.6% of men underwent endovascular aneurysm repair (P > .05); therefore, the perioperative outcome analysis focused on open surgical repair. In total, 23.5% of women and 16.9% of men developed perioperative complications (P > .05). There were no differences in major cardiovascular events (P > .05), but women showed a higher incidence of impaired wound healing (15.7% vs 7.2%; P = .05) and major amputation (5.9% vs 1.1%; P = .027). Female sex was significantly associated with the need for nonvascular reinterventions within 30 days after surgery (odds ratio: 2.48, 95% confidence interval: 1.26-4.88), whereas no significant differences in the odds for vascular reinterventions were observed (odds ratio: 1.98, 95% confidence interval: 0.68-5.77). In the multiple logistic regression model, female sex, symptomatic PAAs, poor quality of outflow vessels, and graft material other than vein graft were independently associated with perioperative reinterventions. CONCLUSIONS: Women have smaller PAAs, are more likely to be symptomatic before treatment, and are more often affected by nonvascular reinterventions in the perioperative course. As our understanding of aneurysmatic diseases in women continues to expand, sex-specific treatment strategies and screening options for women in well-selected cohorts with modified screening protocols should be continuously re-evaluated.

Long-term outcomes of arteriovenous snuffbox fistulas for hemodialysis.

OBJECTIVE: Autologous arteriovenous fistulas in the arm have been shown to be superior to all other types of arteriovenous access and should be placed as far distally as possible. The aim of the present study was to delineate the advantages of snuffbox fistulas (SBFs). METHODS: From January 2007 through April 2017, first time or new arteriovenous fistula surgery was performed in 375 patients. If feasible, an SBF was chosen. The observation period ended in December 2019. The focus of the present study was on the patency rates, redo surgery, complications, and mortality rates. RESULTS: SBFs were created in 236 patients (92 women and 144 men; mean age, 67 years; 46% with diabetes). Within the first 6 weeks, 11% of the fistulas had failed. The primary patency rates were 75%, 69%, 64%, 61%, 60%, and 58% after 1, 2, 3, 5, 7, and 9 years, respectively. The secondary patency rates were 86%, 83%, 80%, and 77% after 1, 2, 3, and 5 years, respectively. Age, sex, and the presence of diabetes mellitus had no effect on the primary patency rates. Patients with a right-sided SBF had significantly worse primary patency. Of the 236 patients, 154 (65%) had died during the observation period. The incidence of surgical site infection within the first 30 days and access-related ischemia during the observation period was <1%. CONCLUSIONS: The results from the present study have shown that with suitable anatomic conditions, a SBF is a good choice for the creation of dialysis access. The patency rates were encouraging, and it offers the longest puncturable segment of the cephalic vein. Also, the rate of perioperative complications was low.

Visual short-term memory for high resolution associations is impaired in patients with medial temporal lobe damage.

The medial temporal lobe (MTL) plays a critical role in episodic long-term memory, but whether the MTL is necessary for visual short-term memory is controversial. Some studies have indicated that MTL damage disrupts visual short-term memory performance whereas other studies have failed to find such evidence. To account for these mixed results, it has been proposed that the hippocampus is critical in supporting short-term memory for high resolution complex bindings, while the cortex is sufficient to support simple, low resolution bindings. This hypothesis was tested in the current study by assessing visual short-term memory in patients with damage to the MTL and controls for high resolution and low resolution object-location and object-color associations. In the location tests, participants encoded sets of two or four objects in different locations on the screen. After each set, participants performed a two-alternative forced-choice task in which they were required to discriminate the object in the target location from the object in a high or low resolution lure location (i.e., the object locations were very close or far away from the target location, respectively). Similarly, in the color tests, participants were presented with sets of two or four objects in a different color and, after each set, were required to discriminate the object in the target color from the object in a high or low resolution lure color (i.e., the lure color was very similar or very different, respectively, to the studied color). The patients were significantly impaired in visual short-term memory, but importantly, they were more impaired for high resolution object-location and object-color bindings. The results are consistent with the proposal that the hippocampus plays a critical role in forming and maintaining complex, high resolution bindings. © 2016 Wiley Periodicals, Inc.

Flow reduction in high-flow arteriovenous access using intraoperative flow monitoring.

PURPOSE: This study used intraoperative monitoring of the access flow to evaluate the results of flow reduction in the management of high-flow arteriovenous access-related symptoms of distal ischemia and cardiac insufficiency. METHODS: A retrospective study was conducted of 95 patients (78 with ischemia, 17 with cardiac failure) who underwent flow reduction between 1999 and 2005. A preoperatively measured access flow-volume rate > 800 mL/min for autogenous accesses (n = 77) and > 1200 mL/min for prosthetic accesses (n = 18) was the selection criterion for the use of a flow reduction procedure. Flow reduction was achieved using a spindle-like narrowing suture near the anastomosis and final placement of a polytetrafluoroethylene strip while a flow meter was used for intraoperatively measuring the access flow. The desired postoperative flow was 400 mL/min for autogenous and 600 mL/min for prosthetic accesses. RESULTS: The mean preoperative access flow was 1469 +/- 633 mL/min in patients with ischemia and 2084 +/- 463 mL/min in patients with cardiac failure, without significant differences between access types. The flow was reduced to 499 +/- 175 mL/min for autogenous accesses and to 676 +/- 47 mL/min for prosthetic accesses. The mean follow-up was 25 months (range, 1 to 73 months). Complete long-term relief of symptoms was observed in 86% of patients with ischemia and in 96% of patients with cardiac failure. Reconstruction significantly increased the digital-brachial index (0.41 +/- 0.12 vs 0.74 +/- 0.11; P < .05) and mean distal arterial pressure (47 +/- 17 mm Hg vs 79 +/- 21 mm Hg; P < .05) in patients with ischemia. Primary patency rates were significantly better for reconstructed autogenous accesses compared with rates of prosthetic accesses (91% +/- 4% vs 58% +/- 12% at 12 months; 81% +/- 6% vs 41% +/- 14% at 36 months; P < .001). The low patency of reconstructed prosthetic accesses is due to the high thrombosis risk of accesses that have a flow < 700 mL/min. CONCLUSIONS: Flow reduction using intraoperative access flow monitoring is an effective and durable technique allowing for the correction of distal ischemia and cardiac insufficiency in patients with a high-flow autogenous access. The desired postoperative access flow of 400 mL/min is not associated with an increased risk of thrombosis. Flow reduction of prosthetic access is as effective; however, a higher access flow than the desired 600 mL/min seems to be necessary to achieve an acceptable patency in prosthetic accesses.

Arterioarterial prosthetic loop: a new approach for hemodialysis access.

OBJECTIVES: In this report we present a novel procedure that uses an arterioarterial prosthetic loop (AAPL) with the proximal axillary or the femoral artery as a vascular access for hemodialysis in patients who have inadequate vascular conditions for creating an arteriovenous fistula or graft. METHODS: Between April 1996 and September 2004, 34 patients received 36 AAPLs as vascular access, either as an axillary chest loop (n = 31) or as a femoral loop (n = 5). In this procedure the artery is ligated between the anastomoses to direct flow through the AAPL. Data from all patients undergoing the procedure were prospectively collected. RESULTS: The indication for an AAPL was the unsuitability of large deep veins in 64%, steal syndrome in 11%, the combination of only a suitable femoral vein and severe peripheral arterial disease in 22%, and congestive heart failure in 3%. All AAPLs were cannulated 18 +/- 4 days postoperatively. Mean follow-up was 31 months (range, 1 to 83). Primary patency was 73% and secondary patency was 96% at 1 year; these rates at 3 years were 54% and 87%, respectively. The rate of all interventions for the maintenance of AAPL function was 0.47 procedures per patient year. Four grafts were abandoned. More than 11,000 hemodialyses with proven efficiency were performed. CONCLUSIONS: The AAPL is an unusual but useful and easy-to-perform alternative procedure to create vascular access for hemodialysis. It can provide survival for strictly selected patients in whom conventional vascular access is not possible. The axillary chest AAPL is preferred.