Unique report of iliocaval endovascular reconstruction successfully enabling a kidney transplant.

Patients with end-stage renal disease and iliocaval venous obstruction are normally nonviable recipients of kidney transplantation. We report a case of a 34-year-old male patient who has been receiving hemodialysis as renal replacement therapy for 6 years due to immunoglobulin A nephropathy. Past medical history included multiple central venous catheter infections and catheter-associated thrombosis. Iliac confluence and inferior vena cava occlusion previously excluded the patient from the renal transplantation list. The exhaustion of venous access sites was already documented. After multidisciplinary discussion, the patient was proposed for endovascular iliocaval reconstruction aiming for a future kidney transplant. Iliocaval recanalization was achieved through bilateral femoral access. Inferior vena cava and iliac angioplasty were performed. A dedicated venous stent was deployed in the inferior vena cava, followed by a double-barrel reconstruction of the iliac confluence. Successful iliocaval recanalization was accomplished. Five months after kidney transplantation was performed with a deceased donor graft in the right iliac fossa. The postoperative period was uneventful. After 12 months, the patient remained free from kidney replacement therapies with a serum creatinine level of 1.3 mg/dL. To the best of our knowledge, this is the first clinical description of a successful kidney transplant in a patient with a previous iliocaval reconstruction.

Use of a Paclitaxel Drug-Eluting Stent for the Treatment of Hemodialysis Access Outflow Stenosis.

PURPOSE: To evaluate the outcomes and durability of drug-eluting stents (DESs) for the treatment of hemodialysis access outflow stenosis. MATERIAL AND METHODS: A single-center retrospective analysis was conducted of all patients with hemodialysis vascular access outflow stenosis treated with a paclitaxel-coated DES (Eluvia; Boston Scientific, Marlborough, Massachusetts) between January 2020 and July 2022. A total of 34 DESs were implanted to treat outflow stenosis in 32 patients. Primary target lesion patency after stent deployment was the main outcome. Comparison between the time interval free from target lesion reintervention (TLR) after previous plain balloon angioplasty (PBA) and that after stent deployment for the same target lesion was considered a secondary outcome. RESULTS: The primary patency at 6, 12, and 18 months was 63.1%, 47.6%, and 41.7%, respectively. The secondary patency rate was 100% at 18 months. The median time interval free from TLR increased from 4.1 to 11.9 months (P < .001). No adverse events were observed during the median follow-up period of 387 days. CONCLUSIONS: The patency rates after use of DES for hemodialysis access outflow stenosis were comparable with results for drug-coated balloons and stent grafts, addressing recoil and minimizing the risk of jailing by a covered stent.

Proximalization of Arterial Inflow for the Treatment of Limb Ischemia in a Transposed Femoral Arteriovenous Fistula-A Case Report.

INTRODUCTION: Femoral vein transposition is one of the final resorts for vascular access in patients with exhaustion of upper limb venous patrimony and central venous occlusive disease. Its major pitfalls include hemodialysis access-induced distal ischemia and infection. Surgical procedures may be warranted to preserve vascular access if ischemia develops. Several techniques are reported in the literature for femoral vein transposition. CASE REPORT: We expose an endoscopic femoral vein harvesting as an alternative to the single thigh incision in order to avoid its associated complications. In the setting of ischemia, proximalization of arterial inflow was used to manage femoral vein transposition associated limb ischemia. CONCLUSION: This case report aims to expose the aforementioned unreported surgical techniques for lower limb arteriovenous fistula, its advantages, and pitfalls, as well as considerations on its future use.

Correlation Between Pedal Acceleration Time and Transcutaneous Oxygen Pressures - A Prognostic Tool for Wound Healing in the Diabetic Foot Population.

BACKGROUND: Pedal arch interrogation by ultrasound through systolic acceleration time measurement (Pedal Acceleration Time [PAT]) is a recently described technique that offers valuable insights into foot hemodynamics. Previous studies have demonstrated a correlation between PAT and the ankle-brachial index and PAT has been proposed as a prognostic tool for wound healing in patients with peripheral artery disease. This study aims to assess the correlation between PAT and Transcutaneous Pressure of Oxygen (TcPO2) in the diabetic foot population. METHODS: In this single-center cross-sectional study PAT and TcPO2 were measured in diabetic patients with ischemic foot ulcers. The assessment of wound status was performed between the 12th and 16th week after the first evaluation. The primary outcome was to assess the correlation between the values obtained for PAT and TcPO2. The secondary outcome was to establish a cut-off value for wound healing. RESULTS: Sixty limbs with ischemic foot ulcers were evaluated. The results showed a correlation between PAT and TcPO2 [F (1.52) = 16.928; R2 = 0.246; P < 0.001]. The receiver operating characteristics curve analysis showed an optimal cut-off value at PAT >186 ms for predicting a nonhealing ulcer with a 96% specificity (area under the curve = 0.774; confidence interval 0.648-0.872; P < 0.001). CONCLUSIONS: PAT showed a significant correlation with TcPO2 with high specificity to identify nonhealing foot ulcers due to insufficient foot perfusion with a potential prognostic value in the diabetic foot population.

Navigating complexity: The Supera's triumph in femoropopliteal lesions.

INTRODUCTION: The femoropopliteal sector endovascular treatment is particularly challenging due to its high tortuosity and torsional forces. Better results are still needed to ensure the long-term patency of stenting in this area. The Supera stent appears to change this paradigm. METHODS: This single-center retrospective cohort study aims to evaluate the efficacy and safety of femoropopliteal stenting with Supera in a real-world population. Seventy-nine patients were treated between January 2015 and December 2020, and the results are reported with a median follow-up of 28 months. RESULTS: Indications for revascularization were chronic limb-threatening ischemia with tissue loss (73.6%) or ischemic rest pain (17.7%) and claudication (7.6%). Thirty-six patients (45.6%) were classified as GLASS stage III according to the Global Limb Anatomic Staging System, with 65.8% and 30.4% in grades 3 and 4 of femoropopliteal and infrapopliteal sectors, respectively. The 36-month primary, primary-assisted, and secondary patency rates were 68.6%, 72.0%, and 79.0%, respectively, with an amputation-free survival rate of 86.6%. There was no significant difference between primary patency rates in GLASS stages I-II compared with GLASS stage III (36-month primary patency rates of 72% vs 63% respectively, p = 0.342) nor in amputation-free survival (88% vs 84%, p = 0.877). After adjusting for potential confounders, only the stent conformation significantly affected the primary patency rates, with a higher hazard of reintervention for the elongated (HR = 3.179; p = 0.36; CI 1.081-9.347) and the compressed (HR = 3.014; p = 0.42; CI 1.039-8.746) forms. CONCLUSIONS: The 36-month patency of the Supera stents in our real-world cohort was similar to other reported series. The GLASS stage did not interfere with the stent patency, proving it is a good choice even in the most adverse anatomy patients. Only the non-nominal stent conformation affected the primary patency rates in our patients.

Outflow Rescue of Elbow-Blockade Forearm Arteriovenous Fistulas: Outcomes of Open Surgical Techniques.

BACKGROUND: Venous scarring at the elbow is a common problem that can cause early and late forearm arteriovenous fistula (AVF) dysfunction in hemodialysis patients. However, any effort to prolong the long-term patency of distal vascular accesses could benefit the patient's survival, maximizing the use of restricted venous patrimony. This study aims to report a single-center experience in the recovery of distal autologous AVF with venous outflow obstruction at the elbow using different surgical techniques. METHODS: Retrospective observational study of all patients treated at a single vascular access center from January 2011 to March 2022, with dysfunctional forearm AVFs presenting with outflow stenosis or occlusions at the elbow treated by open surgery, using 3 different surgical techniques. Demographics and clinically relevant data were collected. Evaluated endpoints included primary, assisted primary, and secondary patency rates at 1 and 2 years. RESULTS: Twenty-three patients with elbow-blocked outflow forearm AVFs have been treated with a mean age of 64 ± 15 years. The majority (96%) had a radiocephalic fistula. The median time from vascular access creation to intervention was 34.5 months (12-216 months). A total of 24 procedures have been performed using 3 different surgical techniques for bypassing the obstructed venous outflow at the elbow. Technical success was achieved in 96% of the surgically treated patients. Primary and secondary patency rates at 1 year were 67.4% and 89.4%, respectively, and 52.9% and 82.0% at 2 years, with a median follow-up of 19 months (6-92 months). CONCLUSIONS: AVFs outflow stenosis or occlusions at the elbow not amenable to endovascular therapy could lead to vascular access abandonment. Our study demonstrates multiple surgical solutions to avoid this adverse outcome. Elbow venous outflow surgical reconstruction seems effective for distal vascular access preservation. Close surveillance is essential for timely endovascular treatment of newly developed stenosis at the venous drainage.

Ruptured arteriovenous fistula pseudoaneurysm treatment by balloon-assisted direct percutaneous thrombin injection.

We present the case of a male patient on hemodialysis with a ruptured pseudoaneurysm in a brachiocephalic arteriovenous fistula (AVF) and with edema and pain in the right arm attended to in the emergency department. An ultrasonographic scan identified a ruptured pseudoaneurysm with hemorrhagic infiltration of the arm muscular tissues. We performed a percutaneous ultrasound-guided thrombin injection with an angioplasty balloon inflated in the lumen of the AVF achieving the pseudoaneurysm thrombosis. After 6 months of follow-up, the patient's arteriovenous access remains functional. Percutaneous ultrasound-guided thrombin injection assisted by an angioplasty balloon may be a good alternative to surgical intervention in the treatment of symptomatic growing pseudoaneurysms of the arteriovenous fistula with the benefit of preserving the vascular access.

Radio-cephalic fistula recovered with drainage to median basilic vein by straightening of the forearm cephalic vein: A case report.

The distal arteriovenous fistula (AVF) has less complications and better patency than the proximal fistula, when it works properly. The complications of outflow of the fistula are complex, and it is necessary to analyze all solutions to solve the problem. We introduce a novel approach to solve outflow problems of a radio-cephalic AVF by straightening of the forearm cephalic vein with drainage into the median basilic vein.

Acceptability and Feasibility of the ProLiSMental Psychoeducational Intervention to Promote Adolescents' Mental Health Literacy on Anxiety in a School Context.

The ProLiSMental psychoeducational intervention intends to promote adolescents' mental health literacy on anxiety, facilitating their access, understanding, evaluation, and use of effective mental health information. This study aimed to assess the acceptability and feasibility of that intervention in a school context and improve its content, structure, and procedure. A convenience sample of seventeen participants has been recruited: eleven students (mean age = 14.09 years, SD = 0,30) and six education and health professionals (mean age = 53.00 years, SD = 4,05). High levels of acceptability and feasibility of the ProLiSMental psychoeducational intervention were observed and important improvements were made.

Renal Artery Aneurysm A Neverland Entity.

Renal artery aneurysms are rare. The indication for treatment at 20mm diameter comes from studies conducted before the advent of cross-sectional imaging. We present a case of a 61years-old woman with a 23mm saccular right renal artery aneurysm under surveillance for 6 years without growing.

Surgical Treatment of Cephalic Arch Stenosis through Rotation of the External Jugular Vein.

The percutaneous transluminal balloon angioplasty or cephalic vein transposition is the treatment for cephalic arch stenosis. In some cases, rotation of the external jugular vein may be a good option for the cephalic arch problems. We describe a new technique to treat cephalic arch stenosis. The technique enables the cephalic arch and subclavian vein to be bypassed altogether through the rotation of the external jugular vein. It consists of 3 small incisions, thus causing minimal surgical damage.

The Role of Doppler Ultrassonography in Significant and Borderline Stenosis Definition.

BACKGROUND: The definition of significant stenosis (SS) remains controversial. METHODS: We retrospectively reviewed 1,040 consultations. SS was defined in the presence of clinical and echo-Doppler (DDU) criteria: Qa <500 mL/min or Qa decrease >25%; RI >0.7 in the feeding artery or absolute minimal luminal stenosis diameter <2.0 mm. Stenosis without any additional criteria were considered borderline stenosis (BS). RESULTS: Two hundred twenty-one arteriovenous fistulas (AVFs) were included: 58.8% had SS, 18.6% had BS, and 22.6% had no dysfunctional access (ND). SS had a significantly higher thrombotic events than BS and ND (13.1 vs. 4.4%, p = 0.018). The annual thrombosis rate was 0.007, 0.037, and 0.004 in the ND, SS, and BS, respectively. AVF cumulative survival at 5 years was significantly lower in SS (89.5%) compared to BS (100%) and ND (97.4%; p = 0.03). BS had an HR for AVF failure of 1.1, p = 0.955, while the SS presented an HR of 5.9, p = 0.09. CONCLUSION: AVF clinical monitoring with additional DDU criteria appear to be appropriate for therapeutic referral.

Brachio-Brachial Arteriovenous Fistula Superficialization with Short Skip Incisions.

The exhaustion of superficial venous patrimony or reduced diameter of superficial veins usually prevents patients from having an arteriovenous fistula created. In such cases, using deep vessels can be a more viable option as opposed to an arteriovenous graft. We describe a new approach for the brachio-brachial arteriovenous fistula creation technique. It consists of 3 small incisions, thus causing minimal surgical damage. We have found it to be better tolerated by the patients and well received by dialysis nurses. This procedure also allows improved access for cannulation and more available puncture sites.

Impact of Endovascular Aortic Aneurysm Repair in a Renal Transplantation Program.

BACKGROUND: An increasing number of abdominal aortic aneurysms (AAAs) may occur in renal failure patients waiting for kidney transplantation because of sharing atherosclerotic risk factors. There is increasing possibility to diagnose an AAA in this group, where treatment has some particularities. After aneurysm treatment these patients remain candidates to kidney transplantation. Similarly, there is an increasing possibility to diagnose AAA in kidney transplantation recipients. Our aim is to present our experience and review the published literature. METHODS: We studied the patients who underwent endovascular aneurysm repair (EVAR) and were later submitted to kidney transplantation, and the patients who underwent kidney transplantation and were later diagnosed with AAA and treated by EVAR. RESULTS: Our experience with renal transplantation began in 1987 and with EVAR in 2001. We performed EVAR in 3 kidney transplantation recipients, without complications as endoleaks or loss of the transplanted kidney. We performed kidney transplantation in 2 patients who underwent EVAR. CONCLUSIONS: As patients waiting for kidney transplantation wait for several months to years, necessity to treat the aortic aneurysm is sometimes imperative. EVAR is the preferred method in this high-risk group with the particularity of necessity to preserve the internal/external iliac arteries to allow anastomosis between renal artery of the transplanted kidney and recipient's iliac artery. Ensuring this, kidney transplantation remains possible and we did not detect differences in comparison with a regular procedure. Kidney transplantation recipients have some particularities as immunosuppressive therapy; in this group, EVAR was recognized as less aggressive and with less impact in renal function.

[Deep vein thrombosis in the pediatric population - a rare entity of uncertain prognosis]. / Trombose Venosa Profunda na População Pediátrica ­ Entidade Rara de Prognóstico Incerto.

Deep vein thrombosis, whose prevalence remains unknown in the pediatric population, is an increasingly common diag- nosis in this age group. This increased incidence makes the post-thrombotic syndrome a likely long-term complication, so there is a critical need to establish high quality evidence over its suitable approach in this population. We present two cases of deep vein thrombosis in children and their management in a hospital of the northern region of Portugal, reviewing the literature on this under researched subject. In conclusion, further investigation is needed to assess the incidence, the prevalence, the predictors and the safety and efficacy of therapies for the prevention and appropriate treatment of deep vein thrombosis in children and eventual post- -thrombotic syndrome.

A trombose venosa profunda, cuja prevalência permanece desconhecida na população pediátrica, é um diagnóstico cada vez mais frequente neste grupo etário. Este aumento de incidência faz da síndrome pós-trombótica uma complicação provável a longo prazo, existindo uma necessidade crítica em estabelecer evidência de alta qualidade sobre a sua adequada abordagem nesta população. São apresentados dois casos clínicos pediátricos de trombose venosa profunda, e respetiva abordagem, num hospital da região Norte de Portugal. Em seguida, procede-se à discussão e revisão da literatura sobre o assunto. Em conclusão, são necessários estudos que avaliem a incidência, a prevalência, os fatores preditivos e a segurança e a eficácia de terapias para a prevenção e o tratamento adequados da trombose venosa profunda e da possível futura síndrome pós-trombótica associada em crianças.

[Buerger's Disease - A National Institutional Experience and Literature Review]. / Doença de Buerger - Experiência de um Serviço Nacional de Revisão da Literatura.

Buerger's disease, or thromboangiitis obliterans, is a primary systemic vasculitis of unknown etiology, that affects the arteries and veins of medium and small caliber, causing inflammatory thrombotic phenomena primarily in young smokers. The authors present a review of the cases followed in consultation in their department until 2009, intending to review and interpret the most relevant epidemiological data, as well as forms of presentation. The diagnosis was based on the following criteria: history of smoking, onset of symptoms before 50years of age, infra popliteal artery occlusive disease, involvement of the upper limbs or migratory phlebitis and no other risk factors for atherosclerosis. We evaluate and describe also the therapeutic options used in all cases, both medical treatment, smoking cessation and the surgical options held (revascularization, amputation or sympathectomy). The progression of the disease and its important relationship with the maintenance of tobacco use was also evaluated, comparing amputation levels and rates. After a careful review of the current literature on the subject, we conclude that the results are similar to other published series and the pathogenesis of this disease remains to be fully elucidated.

Development and characterization of nanostructured lipid carriers for cannabidiol delivery.

This study evaluated the physicochemical characteristics of nanostructured lipid carriers (NLCs) as a potential vehicle for cannabidiol (CBD), a lipophilic molecule with great potential to promote health benefits. NLCs were produced using hemp seed oil and fully-hydrogenated soybean oil at different proportions. The emulsifiers evaluated were soybean lecithin (SL), Tween 80 (T80) and a mixture of SL:T80 (50:50). CBD was tested in the form of CBD-rich extract or isolate CBD, to verify if it affects the NLCs characteristics. Based on particle size and polydispersity, SL was considered the most suitable emulsifier to produce the NLCs. All lipid proportions evaluated had no remarkable effect on the physicochemical characteristics of NLCs, resulting in CBD-loaded NLCs with particle size below 250 nm, high CBD entrapment efficiency and CBD retention rate of 100% for 30 days, demonstrating that NLCs are a suitable vehicle for both CBD-rich extract or isolate CBD.

Isolation and Identification of Lichen Photobionts Collected from Different Environments in North of Portugal and Evaluation of Bioactivities of Their Extracts.

Lichens are organisms constituted by a symbiotic relationship between a fungus (mycobiont) and a photoautotrophic partner (photobiont). Lichens produce several bioactive compounds; however, the biotechnological exploitation of this organism is hampered by its slow growth. To start studying the possibility of exploiting lichens as alternative sources of bioactive compounds, eighteen lichens were collected in the north of Portugal in order to isolate and study the bioactivity of their photobionts. It was possible to isolate and cultivate only eight photobionts. Three of them, LFR1, LFA2 and LCF3, belong to the Coelastrella genus, the other two (LFA1 and LCF1) belong to the Chlorella genus and for the remaining three photobionts, LFS1, LCA1 and LCR1, it was impossible to isolate their microalgae. These only grow in consortium with bacteria and/or cyanobacteria. All extracts showed antioxidant activity, mainly at a concentration of 10 mg.mL-1. LFS1, a consortium extract, showed the highest antioxidant power, as well as the highest concentration of phenolic compounds (5.16 ± 0.53 mg of gallic acid equivalents (GAE).g-1). The extracts under study did not show significant antibacterial activity against Escherichia coli, Listeria or Salmonella. The Coelastrella sp. and LFA1 extracts showed the highest hyaluronidase inhibition. The LFR1 extract at a concentration of 5 mg.mL-1 showed the highest anti-inflammatory activity (79.77 ± 7.66%). The extracts of Coelastrella sp. and LFA1 also showed greater antidiabetic activity, demonstrating the high inhibitory power of α-amylase and α-glucosidase. LFR1 at a concentration of 5 mg.mL-1, due to its selective cytotoxicity inhibiting the growth of cancer cells (Caco-2 cells), is a promising anticancer agent.

Enhancing cannabidiol bioaccessibility using ionic liquid as emulsifier to produce nanosystems: Characterization of structures, cytotoxicity assessment, and in vitro digestion.

The emulsifying potential of a biocompatible ionic liquid (IL) to produce lipid-based nanosystems developed to enhance the bioaccessibility of cannabidiol (CBD) was investigated. The IL (cholinium oleate) was evaluated at concentrations of 1 % and 2 % to produce nanoemulsions (NE-IL) and nanostructured lipid carriers (NLC-IL) loaded with CBD. The IL concentration of 1 % demonstrated to be sufficient to produce both NE-IL and NLC-IL with excellent stability properties, entrapment efficiency superior to 99 %, and CBD retention rate of 100 % during the storage period evaluated (i.e. 28 days at 25 °C). The in vitro digestion evaluation demonstrated that the NLC-IL provided a higher stability to the CBD, while the NE-IL improved the CBD bioaccessibility, which was mainly related to the composition of the lipid matrices used to obtain each nanosystem. Finally, it was observed that the CBD cytotoxicity was reduced when the compound was entrapped into both nanosystems.