Predictors of Mortality within 24 Months of Initial Arteriovenous Access Creation.

INTRODUCTION: End Stage Renal Disease is increasingly common, with approximately 785,880 patients currently dialysis dependent in the United States. 86% of these patients utilize hemodialysis. Arteriovenous (AV) access with either a fistula or graft is preferred over a catheter due to lowered complication risk. The purpose of this paper is to identify mid- term predictors of mortality to guide the type of AV access in patients with suboptimal cephalic veins. METHODS: This is a retrospective review of patient characteristics at the time of initial AV access placement. All patients receiving first time AV access were reviewed. Mortality data was found via electronic medical records review, social security death index review, and internet search. Patients in whom mortality data could not be found were excluded from the final analysis. Univariate analysis using Chi-Squared testing and Student T-Test was performed. Binary logistic regression analysis was also performed for multivariate investigation. RESULTS: A total of 176 patients underwent first time AV access during the study period. Two year mortality data was available for 149 of these patients. Mortality occurred within 2 years for 27% of patients. Advanced age (70 vs. 61, P < 0.01), arrhythmia (48% vs. 24%, P < 0.01), abnormal EKG (36% vs.14%, P < 0.01), CHF (47% vs. 24%, P < 0.01), white, non-Hispanic race (51% vs. 22%, P < 0.01) and history of smoking (48% vs. 15%, P < 0.01) were statistically significant univariate predictors of 2-year mortality. Advanced age, white race and smoking were multivariate predictors with smoking having the largest impact (multivariate adjusted OR 11.8, P < 0.001). CONCLUSIONS: History of tobacco smoking has a profoundly negative effect on two year survival in patients undergoing initial AV access. Absence of smoking history provides significant 2-year mortality protection and thorough attempt at autologous AVF creation should be made in these patients. Cardiac disease and advanced age continue to be lead predictors of mortality in ESRD patients.

Acellular Dermal Matrix Mimicking a New Retroareolar Mass After Central Pillar Neonipple Reconstruction.

ABSTRACT: Acellular dermal matrix (ADM) is an increasingly popular alloplastic cadaveric dermis used to enhance postmastectomy reconstruction. Acellular dermal matrix can be used as a nipple-shaped cylinder in central pillar nipple reconstruction to help maintain long-term projection. We report a unique presentation of ADM mimicking a retroareolar mass after central pillar neonipple reconstruction. A 49-year-old woman with a history of invasive ductal carcinoma underwent delayed nipple reconstruction after lumpectomy and oncoplastic closure using an inframammary V-Y advancement flap.The nipple reconstruction was performed using pretattoo and articulated tab flaps. A rolled tube of acellular dermal matrix was placed in the central aspect of the neonipple reconstruction for projection. At 4 months postoperative, a screening mammogram and ultrasound noted a new retroareolar mass classified as BIRADS 4 necessitating a breast biopsy. Biopsy revealed portions of fibrous connective tissue consistent with partially incorporated acellular dermal matrix allograft. There was no evidence of malignancy. To mitigate the risk of future radiographic or clinical misinterpretation of ADM in nipple reconstruction, the placement of radiopaque markers such as microclips on the ADM implant could be a useful adjunct. Radiologists and surgeons should include ADM artifact in their differential diagnosis of radiologic imaging when evaluating a new mass in the proximity of prior ADM placement in neonipple reconstruction of the breast.

Massive Gastroepiploic Artery Pseudoaneurysm Presenting as Arterial Enteric Fistula.

A 63-year-old male presented to the Emergency Department with weakness and hematochezia. He was found to have a massive gastroepiploic artery pseudoaneurysm that had eroded into the transverse colon. He underwent open en bloc resection of the aneurysm, a portion of the stomach, and a portion of the transverse colon. The case and a brief review of gastroepiploic aneurysms is presented.

Novel Application of Branched Endograft for Preservation of Pelvic Circulation.

BACKGROUND: Endovascular repair of a proximal anastomotic pseudoaneurysm (APSA) of an end-to-side aortobifemoral bypass (ABF) can lead to pelvic ischemia. We present a novel application of branched aortic endograft to repair such pseudoaneurysm while preserving flow into the ABF and native aortoiliac system. METHODS: A 71-year-old male with history of aortoiliac occlusive disease resulting in lifestyle limiting claudication was treated with an aortobifemoral bypass in 1999. The patient developed an 8.8 cm pseudoaneurysm at the aortic anastomosis. CTA demonstrated patent right common and internal iliac arteries with an occluded right external iliac artery and occluded left common and external iliac arteries. RESULTS: A 24 × 80 mm endograft with an 8 × 15 mm posterior branch based on the Cook Zenith device (Bloomington, IN) was delivered via a right femoral artery exposure. The preloaded wire of the main body was snared via left brachial access. A 10F sheath was advanced into the side branch of the graft to deliver a 10 × 10-mm Bard Fluency (Covington, Georgia) stent graft into the right common iliac artery. The branch was reinforced proximally with an 8 × 17 mm Boston Scientific Express (Marlborough, MA) stent. The patient was discharged after 5 days. At 1 month, CTA demonstrated patent ABF, patent branch graft into the pelvis, and exclusion of the pseudoaneurysm. CONCLUSIONS: Branch grafts can provide minimally invasive revision of a failing ABF, in this case an APSA, while preserving pelvic circulation and lower extremity perfusion.

Educational Value of an Intern-Directed Vascular Access Team at a Community Teaching Hospital.

To gain additional experience in ultrasound-guided procedures, interventional radiology (IR)-bound surgical preliminary interns at an urban community hospital established a difficult intravenous access (DIVA) consult service. This study evaluates the efficacy, safety, and educational value for such a team. The first year of DIVA team results were followed from May 2019 to April 2020. The value of the experience for IR-bound residents vs. categorical general surgery residents (GS) was compared. 239 patients were evaluated by the DIVA team for a total of 4.3 consults per week. General surgery residents performed an additional estimated 2.5 consults per week. For IR residents, 218/230 (94.8%) PIV and 8/9 (88.9%) midline attempts were successful. There were no technical complications that required additional procedural interventions. All residents found educational value in participating in DIVA team. Residents designated to enter IR found participating in the DIVA team to be significantly more beneficial for overall educational value learning identification/access of vessels under ultrasound guidance (P < .01). Interventional radiology residents had a higher mean number of procedures (average 60 vs. 24) before diminishing educational value was noted (P < .05). 100% of GS and IR residents noted that upon entering PGY 2 they felt more adept than their peers at performing ultrasound-guided vascular access and all believed their experience working with DIVA team would benefit them throughout their careers. Establishment of an intern-directed difficult IV access team is beneficial to resident education as well as patient care. Monitoring of case load to avoid service over education is recommended.

Community Hospital Experience With Bovine Tissue in Infected Vascular Fields.

BACKGROUND: Vascular prosthetic graft infections are rare but associated with high morbidity and mortality. Treatment involves removal of the infected graft requiring arteriotomy closure. Previously this was performed with autologous graft, but bovine tissue has increasingly been used. The objective of this paper is to review the community hospital experience with bovine tissue repair in an infected vascular field. MATERIALS AND METHODS: A retrospective review of all cases performed by a single surgeon in a community hospital for infected prosthetic grafts was completed. Sixteen cases were included where bovine tissue was used for repair. Presentation, location of graft, and causative organism were reviewed, and outcomes including reoperation and mortality were recorded. RESULTS: Of the 16 patients, 15 (94%) had positive cultures of the graft. Methicillin-Resistant Staph Aureus was the most commonly isolated organism (50%). There were 3 unplanned reoperations including a revision from below to above knee amputation, drainage of a hematoma, and a wound debridement within the first year. Over the 1 year follow up period, 3 patients died for a mortality of 19%. There were no reinfections during follow-up. DISCUSSION: Prosthetic graft infection is a rare but serious vascular surgery complication. The causative organism has shifted in the last few years to become increasingly drug resistant. Treatment requires excision, and bovine tissue has been demonstrated to provide a safe and durable method of repair.

The safety of bovine tissue arterial repair in removal of infected prosthetic hemodialysis grafts.

BACKGROUND: More than 400,000 Americans require dialysis, and many receive it via a prosthetic arteriovenous graft. Infection of these grafts is rare, but associated with significant morbidity and mortality. The gold standard is total graft excision with arteriotomy closure. This was previously done with autologous vein, but bovine tissue offers a reasonable alternative. The objective of this article is to evaluate a community hospital experience with bovine tissue arterial repair after total graft excision of infected prosthetic arteriovenous graft. METHODS: A retrospective review was performed of all cases of infected prosthetic arteriovenous graft removal with bovine tissue arterial repair was performed. Thirteen cases were identified. Presentation, location of graft, and causative organism were reviewed; outcomes including reoperation and mortality were recorded. RESULTS: Of the 13 patients, 12 (92%) had positive cultures of the graft, bloodstream, or wound. Methicillin-resistant Staphylococcus aureus was the most commonly isolated organism (54%). There were two unplanned reoperations including hematoma drainage and wound debridement within the first year. Over the 1-year follow-up period, 1 patient died for a mortality of 8%. There were no re-infections during follow-up. DISCUSSION: Prosthetic arteriovenous graft infection remains a difficult challenge and is associated with significant morbidity and mortality. It presents in a variety of ways, including within an old thrombosed graft. Over the last several years, the causative organism has increasingly become drug resistant. Treatment with total graft excision requires arteriotomy closure, and for this bovine tissue has been demonstrated to be a viable option.