Good outcomes for arteriovenous fistula with buttonhole cannulation for chronic hemodialysis in children and adolescents.

BACKGROUND: Arteriovenous fistula (AVF) is the preferred access for chronic hemodialysis (HD) in children and adolescents, but central venous catheter use is still high. METHODS: Retrospective chart review of children and adolescents with AVF created between January 2003 and December 2015 was performed to assess primary failure (PF), maturation time, functional primary and functional cumulative patency, and potential risk factors for AVF dysfunction. RESULTS: Ninety-nine AVF were created in 79 patients (54% male; 7-24 years; 16-147 kg) by experienced surgeons. Duplex ultrasonography vein mapping was used to assist with site selection. PF occurred in 17 AVF (17%) in 14 patients. Patient age, gender, ethnicity, underlying disease, time on dialysis, and AVF site were not associated with PF or patency. Coagulation abnormality was positively associated with PF (p = 0.03). Function was achieved in 82 AVF (83%) in 77 patients (97%). Median maturation time was 83 days (range 32-271). AVF were accessed via buttonholes. Functional primary patency was 95%, 84%, and 53% at 1, 2, and 5 years. Overall 1- and 2-year functional cumulative patency was 95%, but lower for small patients 16-30 kg (88%) and those greater than 80 kg (91%). The 5-year patency rate was 80%, but significantly lower for 16-30 kg (59%) and greater than 80 kg (55%). Risk analysis showed significantly better patency for 31-45 kg and 46-80 kg groups (p < 0.01), non-obese BMI (p = 0.01), and buttonhole self-cannulation (p = 0.03). CONCLUSIONS: This study provides more information about successful AVF with buttonhole cannulation in pediatric hemodialysis patients lending additional support for AVF use in pediatrics. A higher resolution version of the Graphical abstract is available as Supplementary information.

Robotic Postchemotherapy Retroperitoneal Lymph Node Dissection for Testicular Cancer.

BACKGROUND: Postchemotherapy retroperitoneal lymph node dissection (pcRPLND) is mandated in patients with nonseminomatous germ cell tumor found to have residual masses after chemotherapy. Performed via the open approach, pcRPLND can incur significant perioperative morbidity. OBJECTIVE: To demonstrate the feasibility of robotic pcRPLND (r-pcRPLND) and provide evidence for its selection criteria. DESIGN, SETTING, AND PARTICIPANTS: A retrospective search identified 93 patients undergoing pcRPLND between April 2007 and March 2018, comprising 30 r-pcRPLND and 63 open pcRPLND (o-pcRPLND) procedures performed by a single surgeon. INTERVENTION: r-pcRPLND and o-pcRPLND. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Baseline clinicopathologic characteristics and intraoperative variables including operating room (OR) time, estimated blood loss (EBL), resection of adjacent organs, and intraoperative consultation with other surgical services were recorded. Hospital length of stay (LOS) and perioperative complications were assessed as per the Clavien-Dindo classification, and oncologic outcomes such as nodal yield, histologic distribution, pathologic staging, time to recurrence, and cancer-specific survival were compared. RESULTS AND LIMITATIONS: r-pcRPLND was performed in a well-selected cohort with lower clinical stage (p=0.006), favorable International Germ Cell Cancer Collaborative Group classification (p=0.01), and smaller retroperitoneal mass (p=0.001). o-pcRPLND required more frequent bilateral template dissection (88.9% vs 43.3%; p<0.001), resection of adjacent organs (36.5% vs 10%; p=0.007), consultation with other surgical services (46% vs 2%; p<0.001), and auxiliary procedures (54.0% vs 20%; p=0.003) to achieve complete oncologic control. OR time was similar between the two groups (o-pcRPLND 375min vs r-pcRPLND 388min; p=0.16) and EBL was significantly lower in r-pcRPLND (234 vs 825ml; p<0.001). Median LOS was significantly shorter after r-pcRPLND (2 vs 7d; p<0.001). A total of 31 patients (33%) suffered postoperative complications, of whom 18 (19.4%) had major complications. Nodal yield was similar (o-pcRPLND 23 vs r-pcRPLND 24; p=0.8). The distribution of lesion histology (necrosis/teratoma/GCT) was also similar pcRPLND (o-pcRPLND 25.4%/57.1%/17.4% vs r-pcPLND 33.3%/50%/16.7%; p=0.51). Overall, tumor recurred in 15 patients (16.1%), including three following r-pcRPLND (10%), all outside the operative field. On univariate analysis, surgical approach was not a significant predictor of time to recurrence (p=0.34). One limitation was that antegrade ejaculation was not assessed. CONCLUSIONS: With rigorous patient selection, r-pcRPLND can be safely performed and may reduce perioperative morbidity while maintaining oncologic proficiency. PATIENT SUMMARY: Resection of residual retroperitoneal mass after chemotherapy in patients with metastatic testicular cancer can be performed safely via a robotic approach. Robotic surgery can reduce the morbidity of the procedure.

Percutaneous retrograde left external carotid artery coil embolization for management of hemorrhage from a persistent proatlantal intersegmental artery type 2.

Persistent fetal communications between the carotid and vertebrobasilar systems are rare and most often discovered incidentally. We present the case of a patient with oropharyngeal cancer status post chemotherapy, radiation therapy, and surgical resection who developed acute oropharyngeal hemorrhage on postoperative day 36, originating from branches of the ligated external carotid artery stump by retrograde flow through a proatlantal intersegmental artery type 2. This hemorrhage was successfully controlled with coil embolization through percutaneous access of the external carotid artery without recurrence at 1-year follow-up.

Phlegmasia cerulea dolens following internal hemipelvectomy: Case report and literature review.

Phlegmasia cerulea dolens (PCD) results from near complete venous thrombosis and occlusion in an extremity resulting in pain, cyanosis, and edema and potentially death. While PCD can result from a variety of mechanisms including trauma, iatrogenic instrumentation, the majority of cases occur in the setting of malignancy. PCD is often managed medically with anticoagulation. However, in certain circumstances, surgical intervention may be warranted. Here, we present a unique case of phlegmasia cerulea dolens occurring following an internal hemipelvectomy requiring emergent surgical intervention to salvage life and limb. A review of the literature regarding diagnosis and treatment is also presented.

Risk of bleeding after ultrasound-guided jugular central venous catheter insertion in severely thrombocytopenic oncologic patients.

INTRODUCTION: We sought to assess the incidence and risk factors of bleeding after ultrasound-guided internal jugular (USGIJ) catheter insertion in severely thrombocytopenic cancer patients, as safe platelet (PLT) count threshold remains controversial. METHODS: Retrospective study of 52 patients with hematologic malignancies and severe thrombocytopenia who underwent USGIJ catheter insertion between 2014 and 2016. Group A included patients with prophylactic PLT transfusion and Group B without. Statistical analysis was performed. RESULTS: Group A included 28 patients and Group B 24. Baseline characteristics were equally distributed. Median catheter size was 12 Fr and tunneled in 20/52 patients. Median PLT count was not statistically different between the groups, before transfusion and after the procedure. Postoperative minor bleeding occurred in 10/52 patients, similar between groups. Lower PLT count, larger catheter caliber and trend for AML diagnosis were identified as risk factors for bleeding. Age, gender, BMI, renal dysfunction and tunneled insertion were not significant. CONCLUSION: Incidence of minor bleeding is low in severely thrombocytopenic patients after USGIJ catheter insertion. Prophylactic platelet transfusion may be reserved for patients with identified risk factors.

Imaging work-up and endovascular treatment options for aorto-enteric fistula.

Aorto-enteric fistula (AEF) is a rare life-threatening condition. Early recognition and diagnosis are of paramount importance to improve outcome. In this article four cases of AEF with relevant pre- and post-procedural images are presented to demonstrate the utility of cross-sectional imaging in the work-up of AEF. The literature is reviewed to describe the typical presentation of AEF, the diagnostic work-up of AEF, and the different methods used to treat AEF. Endovascular repair of AEF is gaining increasing attention due to its decreased short-term mortality compared to open surgical techniques.

Nonmaturing Fistulae: Epidemiology, Possible Interventions, and Outcomes.

Autogenous arteriovenous fistulae are the best method for prolonged, successful dialysis access. However, a substantial limitation of dialysis fistulae is their high primary failure rate, estimated to be as high as 70% for radiocephalic fistulae. Fistula maturation is influenced by demographic risk factors as well as anatomical barriers, the latter of which can be readily identified by noninvasive ultrasound imaging and physical examination. These barriers can be categorized as inflow problems (native arterial disease, arteriovenous anastomotic stenosis, and juxta-anastomotic stenosis) or outflow problems (proximal venous stenosis or collateral veins). Venous stenoses represent the most commonly observed barrier to fistula maturation. By treating these barriers with a systematic approach, interventionalists can significantly improve the likelihood of a fistula's usability for dialysis.

Development of a predictive model for 6 month survival in patients with venous thromboembolism and solid malignancy requiring IVC filter placement.

PURPOSE: Our purpose was to develop a predictive model for short-term survival (i.e. <6 months) following inferior vena cava filter placement in patients with venous thromboembolism (VTE) and solid malignancy. METHODS: Clinical and laboratory parameters were retrospectively reviewed for patients with solid malignancy who received a filter between January 2009 and December 2011 at a tertiary care cancer center. Multivariate Cox proportional hazards modeling was used to assess variables associated with 6 month survival following filter placement in patients with VTE and solid malignancy. Significant variables were used to generate a predictive model. RESULTS: 397 patients with solid malignancy received a filter during the study period. Three variables were associated with 6 month survival: (1) serum albumin [hazard ratio (HR) 0.496, P < 0.0001], (2) recent or planned surgery (<30 days) (HR 0.409, P < 0.0001), (3) TNM staging (stage 1 or 2 vs. stage 4, HR 0.177, P = 0.0001; stage 3 vs. stage 4, HR 0.367, P = 0.0002). These variables were used to develop a predictive model to estimate 6 month survival with an area under the receiver operating characteristic curve of 0.815, sensitivity of 0.782, and specificity of 0.715. CONCLUSIONS: Six month survival in patients with VTE and solid malignancy requiring filter placement can be predicted from three patient variables. Our predictive model could be used to help physicians decide whether a permanent or retrievable filter may be more appropriate as well as to assess the risks and benefits for filter retrieval within the context of survival longevity in patients with cancer.

Volume Flow Measurements in Arteriovenous Dialysis Access in Patients with and without Steal Syndrome.

Introduction. Dialysis associated steal syndrome (DASS) constitutes a serious risk for patients undergoing vascular access operations. We aim to assess the measured volume flow using ultrasound in patients with clinically suspected steal syndrome and determine differences in flow among types of arteriovenous (AV) access. Methods. Patients with permanent hemodialysis access with and without ischemic steal underwent duplex ultrasound (US) exams for the assessment of volume flow and quantitative evidence of hemodynamic steal. Volume flow was measured in the proximal feeding artery. Results. 118 patients underwent US of which 82 (69.5%) had clinical evidence of steal. Women were more likely to develop steal compared to men (chi-squared test P < 0.04). Mean volume flow in patients with steal was 1542 mL/min compared to 1087 mL/min (P < 0.002) in patients without evidence of steal. A significant difference in flow volumes in patients with and without steal was only seen in patients with a brachial-cephalic upper arm AV fistula (AVF) (P < 0.002). When comparing different types of access with steal, brachial-cephalic upper arm AVFs had higher volume flows than the upper extremity AV graft (AVG) group (P = 0.04). Conclusion. In patients with DASS, women were more likely to develop steal syndrome. Significantly higher volume flows were seen with brachial-cephalic upper arm AVF in patients with steal compared to those without. A physiologic basis of this US finding may be present, which warrants further study into the dynamics of flow and its relationship to the underlying peripheral arterial pathology in the development of ischemic steal.

Limb salvage in women.

The prevalence of peripheral arterial occlusive disease (PAD) in women and men is equal. Studies to date present conflicting data of gender effects on the risk factors, clinical presentation, and treatment outcomes. Clinical trials have often failed to analyze results by gender or to recruit sufficient women to enable such an analysis. This review summarizes the management and outcome of limb salvage therapy with a particular focus in women.

Hybrid interventions in limb salvage.

Hybrid interventions have become an integral part of our strategy for limb salvage in patients with multilevel arterial occlusive disease. In this article, we describe the commonly used hybrid interventions and review their indications and outcomes. Iliac stenting and femoral endarterectomy are the two most frequently performed procedures in hybrid cases. Short- and long-term outcomes of hybrid interventions are at least comparable to conventional endovascular and surgical revascularization procedures. Hybrid revascularization offers the efficiency and convenience of a single-stage revascularization.

Diseases of the thoracic aorta in women.

Women have now equaled or surpassed men in the number of cardiovascular deaths per year in published statistics. In 2006, according to the National Center for Health Statistics and the Center for Disease Control, cardiovascular disease was the cause of death in 428,906 women (35% of all deaths in women) and in 394,840 men (33% of all deaths in men). Of those numbers, it was estimated that 5506 women (0.4% of all deaths in women) and 7732 men (0.6%) died because of aortic aneurysm or dissection. Currently, aortic disease ranks as the 19th leading cause of death with reported increases in incidence. Historically, aortic disease is thought to affect men more frequently than women with a varying reported gender ratio. Gender bias has long been implicated as an important factor, but often overlooked, in the analysis and interpretation of cardiovascular diseases outcome, in part, because of the under-representation of women in clinical trials and studies. In this section, we provide an up-to-date review of the epidemiology and management of common diseases of the thoracic aorta, focusing on the differences and similarities in women and men.

Subintimal placement of covered stent versus subintimal balloon angioplasty in the treatment of long-segment superficial femoral artery occlusion.

BACKGROUND: Subintimal endovascular intervention has been used widely in the treatment of symptomatic superficial femoral artery (SFA) occlusion. The relative effectiveness of subintimal placement of a covered stent (CS) versus balloon-only subintimal angioplasty (SIA) remains uncertain. METHODS: We performed a retrospective cohort study of consecutive patients with symptomatic SFA occlusions (>15 cm) who underwent subintimal endovascular intervention, either CS or SIA, in a single institution. Primary patency was the primary outcome. Secondary outcomes included complication rates, freedom from re-intervention, and limb salvage rates. Patency was ascertained with followup duplex or clinically. RESULTS: We evaluated 57 patients in the SIA group and 31 patients in the CS group. At 1 year the SFA primary patency for the SIA and CS groups was 28% versus 75% (P < .001), whereas the primary assisted patency was 37% versus 84% (P < .001), respectively. Need for bypass was 13% versus 0% (P = .05) in the SIA and CS groups, respectively. CONCLUSIONS: Placement of a covered stent improves patency after subintimal intervention for long SFA occlusion.

How optimal is the medical management of patients prior to major reconstructive vascular surgery? The results of a cross-sectional study.

BACKGROUND: Risk factor modification is important in patients with vascular disease. Guidelines suggest that this patient population benefits from a medical regimen of antiplatelets, statins, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors. MATERIALS AND METHODS: The medical regimen of consecutive patients who presented for major vascular surgery intervention over 18 months was examined. RESULTS: Of the 325 patients identified, 176 (54%) were on antiplatelet treatment, 197 (61%) were on a statin, 180 (55%) on beta-blockers, and 146 (54%) on ACE inhibitors. A high-risk subset of 94 smokers with known coronary artery disease, hypertension, and hyperlipidemia or diabetes was identified. In this subset, patients were more likely to be on pharmacologic risk factor modification. CONCLUSIONS: Despite recommendations, the pharmacologic risk factor modification of patients prior to vascular surgery remains suboptimal. Increased awareness of the problem and active participation of the vascular specialist are essential to improve compliance with established guidelines.

Emergent embolization of the gastroduodenal artery in the treatment of upper gastrointestinal bleeding. The experience from a surgeon-initiated interventional program.

BACKGROUND: Intractable nonvariceal upper gastrointestinal bleeding (UGIB) is associated with significant morbidity and mortality. Endovascular therapy is an alternative to surgery for high-risk patients. MATERIALS AND METHODS: Review of prospectively collected data from patients who underwent emergent gastroduodenal artery embolization for UGIB. RESULTS: Eight patients (mean age 68.5 years) were identified. They all had significant comorbidities and were deemed to be at high risk for surgical intervention. Endoscopy was performed in 7 patients. Active extravasation was present at the time of embolization in 5 (62.5%) patients. The technical success and clinical response rates were each 100%. The 30-day mortality rate was 12.5%. [corrected] There were no procedure-related complications. During mean follow-up of 9 months, 1 patient developed recurrent bleeding that was managed conservatively. COMMENTS: Endovascular embolization is a safe alternative to open surgical intervention after failed endoscopic treatment for UGIB. Surgeons with endovascular skills can perform this procedure with superior results.

Descending thoracic aortic dissection: evaluation and management in the era of endovascular technology.

Acute aortic dissection is a relatively uncommon but highly lethal condition. Without proper treatment, devastating consequences can occur due to aortic rupture, cardiac tamponade, or irreversible ischemia involving the spinal cord or the visceral organs. The treatment strategy of this condition is in part influenced by the location and the severity of aortic dissection as immediate surgical intervention is necessary in acute ascending aortic dissection, whereas medical therapy is the initial treatment approach in uncomplicated descending aortic dissection. Recent advances of endovascular technology have broadened the potential application of this catheter-based therapy in aortic pathologies, including descending thoracic aortic dissection. In this article, the etiology, pathogenesis, and classification of this condition are discussed. The diagnostic benefits of various imaging modalities for descending aortic dissection are also discussed. Current treatment strategies, including medical, surgical, and catheter-based interventions, are reviewed. Lastly, clinical experiences of endovascular treatment for descending aortic dissection and various endovascular devices potentially applicable for this condition are discussed.

Symptomatic aneurysm rupture without bleeding secondary to endotension 4 years after endovascular repair of an abdominal aortic aneurysm.

PURPOSE: To demonstrate the absence of bleeding from a ruptured abdominal aortic aneurysm (AAA) without evidence of endoleak following endovascular aneurysm repair (EVAR). CASE REPORT: A 72-year-old woman developed aneurysm enlargement 4 years after EVAR of an infrarenal AAA. During surgical exploration for abdominal pain and presumed aneurysm rupture, the ruptured aneurysm sac was found to be filled with gelatinous material without evidence of thrombus or active bleeding. CONCLUSION: This case provides insight into the natural history of endotension and indicates that conservative management even in the face of an expanding aneurysm is a valid management option for selected patients.