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

End-stage renal disease patients with Iliocaval venous obstruction are normally nom viable recipients for kidney transplantation. We report a case of a 34-year-old male patient in hemodialysis as renal replacement therapy for six years due to IgA 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. Exhaustion of venous access sites was already previously documented. After multidisciplinary discussion the patients was proposed to endovascular Iliocaval reconstruction aiming 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. Post operative period was uneventful. After 12 months the patient remained free from kidney replacement therapies with a serum creatinine of 1.3mg/dL. At the best of our knowledge this is the first clinical description of 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.

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.

Laparoscopic Resection of a Splenic Artery Aneurysm with Vascular Reconstruction During Pregnancy.

Splenic artery aneurysms (SAA) are more frequent in women and have a high rupture risk during pregnancy, with catastrophic outcomes. It is advisable to treat these aneurysms in pregnant and fertile women, whatever their diameter, given their increased risk for rupture. There are several therapeutic approaches: endovascular surgery using coil embolization or stent graft coverage; laparoscopic or open surgical resection with arterial reconstruction and ligation followed by splenectomy when necessary. This paper aims to report the successful treatment of SAA in second-trimester pregnant women using a laparoscopic approach with aneurysm resection and arterial reconstruction. This is a unique report of a minimally invasive approach with arterial reconstruction in a pregnant woman, thus reducing the risk of spleen infarction and potentially avoiding splenectomy.

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.

Hybrid Retrograde Celiac Artery Stenting for Acute Mesenteric Ischemia after Gastric Surgery.

BACKGROUND: Celiac artery (CA) occlusions/stenosis is infrequently associated with liver ischemia due to its unique vascularization, where portal vein provides about 75% of liver's perfusion. Collateral flow from gastroduodenal artery also provides, in most cases, enough blood supply to prevent ischemic hepatitis. In cases where these collateral pathways are compromised, severe liver ischemia can occur. METHODS: We present a case of acute mesenteric ischemia following gastric surgery that was treated with a hybrid retrograde CA stenting. RESULTS: We report a case of a 72-year-old male, who underwent gastric surgery for gastric cancer. On fourth postoperative day, he presented with acute abdomen, and on laparotomy, a partial duodenal suture dehiscence was found and suture closed. Owing to worsening of patient's clinical condition, with associated ischemic hepatitis, 2 days later, a computed tomography angiography was performed that showed a superior mesenteric artery (SMA) occlusion at its origin with an associated, severe, ostial stenosis of the CA. On laparotomy, irreversible visceral ischemia was found, which led to total colectomy, resection of 50 cms of small bowel, and splenectomy. Liver ischemia was also confirmed. Femoral access was used to try to cannulate the CA and cross its stenosis, without success. Taking advantage of the open abdomen, we then opted to place a 5F sheath in the splenic artery stump. From this retrograde approach, stenosis traversal was easy, and the CA was ballooned and stented with reperfusion of almost all the liver. Despite these efforts, patient died because of multiorganic failure, 8 days later. CONCLUSIONS: Ischemic hepatitis is a rare but serious complication of CA/SMA occlusive disease. Its occurrence is at increased risk after surgeries, where collateral flow is compromised. The endovascular treatment is currently the preferred approach to treat visceral arteries occlusive disease; however, antegrade CA cannulation can be tricky, and in an open abdomen scenario, retrograde approach from the splenic artery can be an additional resource. This case demonstrates the flexibility of endovascular techniques and that they can provide useful solutions even during open surgery.

Internal Carotid Artery Tortuosity as a Rare Cause of Dysphagia: Case Report and Literature Review.

Abnormalities in the morphology of internal carotid artery are commonly identified but their natural history is not well known. Rarely, vascular abnormalities can cause mass effect causing dysphagia. We report the case of a patient presenting with long-standing dysphagia and choking during swallowing of solid food caused by an internal carotid artery tortuosity undergoing surgical treatment at our institution and we review the available literature.

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.

Percutaneous Treatment Pseudo-Aneurism of the Hand in Hemophilic Patient.

INTRODUCTION: Pseudo aneurysms of the hand are infrequent lesions, usually associated with perforating trauma. The diagnosis is based on clinical suspicion and image confirmation of a pulsatile swelling. Various treatment modalities are currently described in the literature. METHODS: Presentation of a clinical case and discussion of the treatment strategy instituted. RESULTS: Clinical case: Man, 35 years old, with hemophilia A. History of perforating trauma of the palmar face of the right hand 3 weeks ago, having been sutured in the local hospital. Since then he notices a pulsatile swelling in the palm of the hand associated with paresthesias and decreased sensitivity in the index finger. A pseudo-aneurysm with 2x3cm was observed, partially thrombosed, and with probable origin in the palmar arch or in the common digital artery. He underwent angiography demonstrating the patency of the palmar arch but without perfusion of the pseudo-aneurysm, and the control dupplex scan showed complete thrombosis of the false aneurysm. After 2 months of follow-up, the dupplex scan was repeated and repermeabilization of the pseudo-aneurysm was verified. The patient was then treated with percutaneous Doppler-guided thrombin injection. Immediate thrombosis of the lesion was found, with no evidence of ischemic complications. He remained asymptomatic under clinical surveillance. CONCLUSION: For small pseudo-aneurysm conservative non- -interventional treatment with external compression may be effective. Conventional surgical treatment with simple ligation or arterial reconstruction may be indicated in larger pseudo-aneurysm. Recently, endovascular techniques such as coil embolization have also been described. Hemophilia A is a genetic disease of recessive hereditary transmission linked to the X chromosome, with deficiency of factor VIII of the coagulation cascade, which manifests with increased risk of hemorrhage. In this particular case, given the risk of hemorrhage, we chose minimally invasive percutaneous treatment, with clinical and imagological success and no complications. Percutaneous treatment by ecodoppler- guided injection of thrombin is an effective and safe treatment, particularly in pseudo-aneurysm associated with surgical risk factors.

Antiphospholipid Syndrome and Acute Postpartum Limb Ischemia.

INTRODUCTION: The diagnosis of Antiphospholipid syndrome (APS) implies the identification of antiphospoholipid antibodies and arterial/venous thrombosis or pregnancy loss. During pregnancy, there is an increased risk of thrombotic complications. METHODS: Present a case of acute lower limb ischemia in a patient with APS during postpartum period Materials/ Methods: review of a clinical case and available literature Results: Patient diagnosed with APS (triple antibody positive and antecedent of 3 previous abortions) underwent cesarean at 29 weeks of gestation. She was medicated with aspirin 00mg/day and enoxaparin 60mg/day and had discharge on the second postoperative day. After 3 days she came to the emergency department with acute limb ischemia. AngioCT revealed thrombosis of the right iliac axis and pulmonary thromboembolism. Endovenous hypocoagulation with unfractionated heparin was immediately started. Due to the high thrombotic risk associated with any type of surgical intervention and improvement of ischemia with hypocoagulation, it was decided to postpone surgical revascularization. At the 10th day of hospitalization angioCT was repeated with maintenance of the iliac thrombosis and clinically the patient had severe claudication and ankle-arm index of 0.26. On the 16th day of hospitalization (after 5 plasmapheresis sessions), she was submitted to trans-femoral thrombectomy, with a good femoral pulse at the end of the procedure. On the 3rd postoperative day we detected pulse loss and angioCT confirmed re-thrombosis of the iliac axis and an oclusion of the popliteal artery. A new attempt at revascularization was made and a new transfemoral thrombectomy was performed, with immediate pulse recovery. We performed intraoperative angiography that confirmed occlusion of the popliteal artery and we proceeded trans-popliteal thrombectomy. Intraoperative control angiography revealed permeability of ilio- -femoro-popliteal axes with some defects of filling of the crural arteries (anterior tibial and peroneal arteries). After the procedure the patient become assymptomatic, with an ankle-arm index of 0.55 (with normal flow in femoral and popliteal artery but monophasyc flow in distal arteries) and had discharged medicated with aspirin, antivitaminik K and corticoid. CONCLUSION: The beneficial/risk of revascularization surgery should be well considered as well as the timing in which it should be performed. Plasmapheresis is important to minimize the thrombotic risk associated with the surgical procedure. Intra-operative angiography is essencial since arterial thrombosis can occur in several sectors, which can conditionate the success of revascularization procedure.

Hybrid approach in a case of persistent sciatic artery aneurysm.

Persistent sciatic artery is a rare congenital vascular malformation with a reported incidence between 0.03% and 0.06%. An 82-yr-old woman presented to our institution with right acute lower limb ischemia compatible with a cardioembolic etiology. A popliteal embolectomy was performed to the patient, and at the end of the procedure, she had bilateral lower limb distal pulses. Six months after the procedure, the patient complained with right lower limb rest pain, an angiography and a computed tomography angiography were performed showing a sciatic artery aneurysm with 4.6 cm of diameter and patency of the sciatic artery to the popliteal artery. A femoropopliteal bypass and retrograde coil embolization of the sciatic aneurysm through the popliteal artery and distal sciatic artery ligation were performed. The patient was discharged 7 days after the procedure, and she remains asymptomatic. Our patient had a complete type of persistent sciatic artery with aneurysmatic degeneration. Correction of the distal ischemia with aneurysm exclusion was achieved with a simple noncomplicated hybrid procedure.

Intrastent HeROgraft deployment as a catheter-sparing procedure.

Current vascular access (VA) practice adopts arteriovenous fistulas (AVF) as first option for haemodialysis, relegating arteriovenous grafts (AVG) for patients with exhausted upper limb venous patrimony. The Hemodialysis Reliable Outflow graft (HeRO®) is a device assuring direct venous outflow to the right atrium, thus avoiding central venous obstructive disease. Its use together with early access grafts avoids the need for central venous catheters (CVC) bridging periods. We report the deployment of the HeRO device using a previous stentgraft as pathway for the placement of the outflow component, in a patient with no-option for further autogenous upper limb access. This technique spared the usual central vein's exit point for the HeRO graft and, using an early-access dialysis graft, allowed for next-day successful haemodialysis.

Application of Pulsed Electric Fields to Pilot and Industrial Scale Virgin Olive Oil Extraction: Impact on Organoleptic and Functional Quality.

The quality of virgin olive oil (VOO) is largely determined by the technology used in the industrial process of extracting the oil. Technological innovations within this field aim to strike a proper balance between oil yield and the optimal chemical composition of VOO. The application of pulsed electric fields (PEF) that cause the electroporation of the plant cell membranes favors a more efficient breakage of the olive fruit tissue, which in turn could facilitate the extraction of the oil and some of its key minor components. Pilot-scale and industrial extraction tests have been conducted to assess the effect of PEF technology on the oil extraction yield and on the organoleptic and functional quality of VOO. The best results were obtained by combining the PEF treatment (2 kV/cm) with short malaxation times and a low processing temperature. Under these conditions, PEF technology could decisively improve the oil yield by up to 25% under optimal conditions and enhance the incorporation of phenolic and volatile compounds into the oils. The PEF treatment neither affected the physicochemical parameters used to determine the commercial categories of olive oils, nor the tocopherol content. Similarly, the sensory evaluation of the PEF-extracted oils by means of a panel test did not detect the appearance of any defect or off-flavor. In addition, the intensity of positive attributes (fruity, bitter and pungent) was generally higher in PEF oils than in control oils.

Combined Ultrasound and Pulsed Electric Fields in Continuous-Flow Industrial Olive-Oil Production.

The aim of the present study is to develop a new industrial process for the continuous-flow extraction of virgin olive oil (VOO) using the non-thermal ultrasound (US) and pulsed electric field (PEF) treatments. These technologies have been tested both separately and in combination, with the aim of making the malaxation step unnecessary. The ultrasound-assisted extraction (UAE) and PEF treatments are both effective technologies for VOO production and have been well documented in the literature. The present study combines a new continuous-flow set-up, with four US units and PEF treatment. The industrial-plant prototype is able to improve VOO yields, thanks to powerful non-thermal physical effects (acoustic cavitation and electroporation), from 16.3% up to 18.1%. Moreover, these technologies increased the content of nutritionally relevant minor components, which, in turn, improves VOO quality and its commercial value (overall tocopherols and tocotrienols improved from 271 mg/kg under the conventional process to 314 mg/kg under the US process). The combined UAE and US-PEF process also increased the extraction yield, while overcoming the need for kneading in the malaxation step and saving process water (up to 1512 L per working day). Continuous-flow US and PEF technologies may be a significant innovation for the VOO industry, with benefits both for oil millers and consumers. The VOO obtained via non-thermal continuous-flow production can satisfy the current trend towards healthier nutrient-enriched products.

Arterial percutaneous angioplasty in hemodialysis access: Endovascular treatment of hand ischemia.

BACKGROUND: Hemodialysis access-induced distal ischemia consists of symptomatic extremity malperfusion after vascular access creation. It is usually caused by discordant vascular resistance, with arteriovenous shunting of a high blood volume from arterial into venous system and subsequent hand hypoperfusion. Less often, hemodialysis access-induced distal ischemia is caused by arterial stenosis. In these cases, access frequently has normal/low flow, radial pulse is usually absent and not recoverable with vascular access digital compression, diabetes is often present, and percutaneous transluminal angioplasty can be critical for access and limb salvage. METHODS: Retrospective study conducted between June 2011 and February 2018 of patients with vascular access submitted to arterial percutaneous transluminal angioplasty for limb-threatening ischemia. RESULTS: Twenty-nine patients were referred for arterial angiography after hemodialysis access-induced distal ischemia diagnosis and physical examination or ultrasound findings suggestive of arterial disease. In 11 patients, percutaneous transluminal angioplasty was not technically feasible. Among 18 treated patients, 83.3% had diabetes and 60% had skin ulcerations. Target arteries were radial (11), brachial (7), axillar (2), ulnar (2), and subclavian (1). Clinical success, defined as arteriovenous maintenance and wound healing/pain resolution, was observed in 12 patients (66.7%). Concomitant procedures included adjuvant banding (n = 2) and finger amputation (n = 1), and one reintervention was performed. No intra- or postoperative complications were reported. CONCLUSION: Hemodialysis access-induced distal ischemia is a serious complication of hemodialysis vascular access, with multifactorial etiology. Correct and timely diagnosis is crucial for maintaining access and limb salvage. Percutaneous transluminal angioplasty is a minimally invasive procedure that may be effective and long-lasting in carefully selected patients with ischemic complaints.

Addressing Infra-popliteal Thrombus in Iliofemoral DVT: The Criss-Cross Technique.

PURPOSE: The purpose of this work was to describe the results of a technique of simultaneous antegrade and retrograde vascular access ("criss-cross") to the popliteal vein to achieve venous recanalization in patients with acute, extensive, iliofemoral DVT with concomitant popliteal and calf vein thrombosis. MATERIALS AND METHODS: Seven patients were treated using this technique, in three patients as a bailout option after failed posterior tibial vein puncture and in four as a first option. Antegrade popliteal venous access was performed according to the usual technique using duplex ultrasound (DUS) guidance and thrombolysis (CDT), or thrombectomy (PMT) was performed. Following this, the retrograde sheath was placed under DUS guidance, a tibial vein was selectively catheterized and CDT, and/or a PMT was performed. RESULTS: Three patients underwent isolated CDT, another three had associated PMT, and one patient underwent iliofemoral PMT and catheter thromboaspiration of the popliteal and calf veins. Median thrombolysis duration was 72 h (24-72 h). SIR grade III thrombolysis was achieved in six patients and grade II in one patient. All patients underwent subsequent stenting of their iliac vein lesions. Minor complications were observed in two patients (ecchymosis), while one patient developed a hematoma on the popliteal fossa. CONCLUSION: This "criss-cross" technique represents a safe alternative to the distal (anterior or posterior tibial) vein access both as a bailout option after failed distal venous access as well as a primary approach due to its potential advantage of clearing larger thrombus volume. Experience in ultrasound-guided popliteal vein puncture is crucial to avoid complications. LEVEL OF EVIDENCE: Case series, Level IV.

Radio-cephalic arteriovenous fistula recovered with drainage through the brachial vein.

Dysfunction of arteriovenous access for hemodialysis is a challenge for the vascular surgeon. Some patients have complex vascular access with problems that are difficult to solve. Careful analysis of the vascular network with ultrasound and dissection of the veins during surgery can help to identify the best option for each access. We introduce and discuss the case of creation of a radio-cephalic fistula with outflow into the brachial vein in 64-year-old hemodialysis male patient. This technique enables extending fistula patency, arterializing the brachial vein, and improves cost efficiency.