Comparison of catheter patency between surgical inside-out technique and conventional femoral approach for tunneled cuffed catheter placement in patients with thoracic central venous occlusion.

Objective: Femoral tunneled cuffed catheters (TCCs) can provide long-term hemodialysis access for patients with exhausted upper extremity access sites due to thoracic central venous occlusion. However, the use of femoral vein catheters (FVCs) has reportedly been associated with the risk of infection, malfunction, and discomfort. An inside-out technique will facilitate chest TCC placement by intentional retrograde extravascularization of the proximal occluded venous stump into the mediastinum. Next, the wire and small catheter are exteriorized to the skin at the base of the neck with a small skin incision. Then, the hemodialysis catheter is railed back down to the right atrium. With this technique, we placed the tip of the catheter into intrathoracic superior vena cava or brachiocephalic vein. In the present study, we compared the catheter patency of the inside-out technique vs a standard approach for FVC placement. Methods: The present randomized controlled trial was conducted from May to December 2020. We included 22 patients requiring long-term hemodialysis with failed recanalization of thoracic central venous occlusion. The patients were randomized into the surgical inside-out (S-inside-out) group and FVC group. Results: The S-inside-out and FVC groups included 10 and 12 patients, respectively. All 22 patients had undergone successful catheter placement. Catheter survival function was significantly higher for the S-inside-out group than for the FVC group (100% vs 50%, respectively; P = .017). In addition, the EQ-5D utility score was significantly better for the S-inside-out group (P = .008). Four cases of catheter infection occurred in the FVC group, but no catheter infection was found in the S-inside-out group. Procedural-related complications occurred in two patients; one case each of hemothorax and stroke in the S-inside-out group. Conclusions: Use of the S-inside-out technique facilitated upper chest TCC placement for hemodialysis patients with exhausted access sites. This technique provided better catheter survival function, a better quality of life, and a lower infection rate, which outweighed the procedure risk.

Angiosarcoma in arteriovenous fistula after kidney transplantation.

Angiosarcoma is a rare complication of both functioning and nonfunctioning fistulas. It is an aggressive soft tissue sarcoma arising from vascular or lymphatic endothelial cells. We report a case of angiosarcoma from a nonfunctional fistula in a kidney transplantation patient receiving immunosuppressive drugs. The patient had presented with arm pain mimicking a thrombosed arteriovenous fistula.

Vascular pythiosis of carotid artery with meningitis and cerebral septic emboli: A case report and literature review.

Vascular Pythiosis caused by Pythium insiodiosum rarely involves carotid artery. A case of concealed ruptured pseudoaneurysm of the carotid artery with neck abscesses, and cerebral septic emboli is described. Patient presented with large pulsatile neck mass that failed to response to surgery, antifungals and immunotherapeutic vaccine. Residual unresectable disease leads to death in the patient. Pythiosis should be considered as a differential diagnosis of head and neck infection.

Clinical results of biologic prosthesis: A systematic review and meta-analysis of comparative studies.

BACKGROUND: Biologic prosthesis (BP) has been reported as a safe alternative to polytetrafluoroethylene (PTFE) in vascular reconstruction. However, efficacy of BP remains controversial. We, therefore, conducted a systematic review to summarize previous available evidences comparing the BP and PTFE in terms of clinical outcomes. MATERIALS AND METHODS: A literature search of the MEDLINE and Scopus was performed to identify comparative studies reporting outcomes of BP, PTFE, and/or autologous veins graft (VG) in vascular access for hemodialysis or femoropopliteal bypass. The outcome of interest was graft patency. Two reviewers independently extracted data. Meta-analysis with a random-effect model was applied to pool a risk ratio (RR) across studies. RESULTS: Among 584 articles identified, 11 studies (4 randomized controlled trials (RCT) and 7 cohorts) comprising 2627 patients were eligible for pooling. Seven studies compared BP with PTFE and 3 studies compared PTFE with VG. Among BP vs PTFE, pooling based on 3 RCTs yielded the pooled RR of 1.54 (95% CI: 1.10, 2.16), indicating 54% higher graft patency in VG than PTFE. Adding the 7 cohorts in this pooling yield similar results with the pooled RR of 1.29 (95% CI: 1.15, 1.45). The pooled RR of graft patency for BP vs VG was 0.74 (95% CI, 0.55, 1.00), indicating 26% lower graft patency in BP than VG. CONCLUSIONS: Our first meta-analysis indicated that the biosynthetic prosthesis might be benefit over PTFE by increasing graft patency. An updated meta-analysis or a large scale randomized control trial is required to confirm this benefit.

Deep venous thrombosis in surgical intensive care unit: prevalence and risk factors.

BACKGROUND: Critically ill patients are at high risk for developing venous thromboembolism. The objective of this study was to determine the prevalence of, and risk factors for, lower extremity deep vein thrombosis (DVT) among critically ill surgical patients in Thailand. MATERIALS AND METHODS: Patients older than 15 years who were admitted to a surgical intensive care unit (ICU) of a tertiary care hospital were enrolled. Bilateral lower extremity compression Doppler ultrasonographic examination was performed to detect DVT within 14 days of ICU admission. Demographic data, primary disease, operative intervention, co-morbidities, acute physiology and chronic health evaluation (APACHE) II score and the length of ICU stay were tested for association with the presence of DVT. RESULTS: Among the 190 first-time admitted ICU patients with a mean APACHE II score of 9.2 +/- 6.0 (range, 0-29), 20 patients had DVT (prevalence of 10.5%). Thromboprophylaxis was not given to any patient. The only independent and significant risk factor for DVT was a longer ICU stay. Age, sex, APACHE II score, presence of comorbidities and operative intervention were not associated with the presence of DVT. CONCLUSION: The prevalence of DVT in critically ill patients in a Thai surgical ICU was approximately 10.5%. Further research is needed to evaluate the risks and benefits of venous thromboprophylaxis in Thai patients.

An appraisal of invertograms and distal colostograms in the management of anorectal malformations.

OBJECTIVES: To determine the accuracy of two main radiologic tools currently employed in the clinical management of anorectal malformations, the invertogram and the distal colostogram. The data will be useful as a basis for quality assurance as well as for future comparisons in case there are innovations to be considered. MATERIAL AND METHOD: Radiological materials and clinical records of infants with anorectal malformations operated on in Songklanagarind Hospital from 1995 to 2001 were retrieved. Each record was blindly reviewed by two radiologists and one pediatric surgeon. Using operative findings as the gold standard, the accuracy of an invertogram in diagnosing low anomalies and the accuracy of a distal colostogram in screening cases that needed a laparotomy and in detecting internal fistulas were determined. The quality of the films was also categorized and poor quality studies were excluded from the analysis. Cases of common cloaca were not included in the level reading analysis. RESULTS: Radiologic materials from 59 patients were examined, including 26 invertograms and 49 distal colostograms. Among 52 cases whose neonatal history could be traced, 29 (55.8%) cases exhibited clinical evidence of anomalies level. Two invertograms and 5 colostograms were graded as poor quality and excluded from the analysis. The overall sensitivity of invertograms in detecting low anomalies was 33.3%, whereas, specificity was 66.7%. Analyzing only infants with a blind rectal pouch, the sensitivity and specificity to detect low anomalies were 33.3% and 75.0%, respectively. The sensitivity of distal colostograms in detecting a fistula was 60.0% in males and 62.5% in females. Distal colostograms diagnosed 'high-type anomalies' in 7 cases and correctly detected 2 cases of vesical fistula which needed APSARP. No prostetic-urethral fistulas showed a radiological high level. CONCLUSION: The study found poor diagnostic sensitivity of invertograms in detecting low type anomalies which deserved primary anoplasty. However, the data support the role of a distal colostogram in diagnosing high anomalies, despite its low sensitivity in detecting urethral fistulas.