The clinical outcome of balloon-assisted maturation procedure between autogenous radiocephalic fistula and brachiocephalic fistula in a single-center experience.

OBJECTIVE: Balloon-assisted maturation (BAM) by an endovascular method plays an important role in treating an immature arteriovenous fistula. However, the results between radiocephalic fistula and brachiocephalic fistula were rarely reported. This retrospective study aimed to investigate the effectiveness and outcome of BAM in different sites of autogenous arteriovenous fistulas. METHODS: This single-center retrospective study included patients who underwent BAM procedures from January 2015 to December 2016. Of 148 patients, 117 and 31 patients had a radiocephalic fistula (RC) and a brachiocephalic fistula (BC), respectively. The primary outcome was BAM success. Data regarding fistula lesions, balloon types and size, frequency of procedures, and maturation time were collected for BAMs. The secondary outcome was the patency of a fistula in the follow-up period. RESULTS: No difference was observed in procedure of BAM frequency between the RC and BC groups. The total success rate was 77.7%, without significant difference between the RC and BC groups (81.20% vs 64.50%; P = .055). Within the procedures, the culprit lesion of juxta-anastomosis segment (73.5% vs 25.5%; P < .001) and arterial inlet (21.2% vs 7.8%; P = .04) were more common in the RC group, whereas the venous outlet was more common in the BC group (88.2% vs 57.7%; P < .001). Both groups had an equivalent patency rate after the BAM within the follow-up period (P = .272). CONCLUSIONS: BAM was an effective procedure for immature fistulas, without significant difference between RCs and BCs. Through the procedure, the culprit lesions causing non-maturation were found to be different between the two groups. The patency rate between the two groups after surgery seems to be equivalent within the follow-up period.

A poor outcome in non-occlusive thrombo-embolic limb ischaemia related to the dislocation of mural thrombus from an abdominal aortic aneurysm.

BACKGROUND: Acute thrombosis of an abdominal aortic aneurysm with acute limb ischaemia is an unusual complication and is associated with high mortality. Dislocation of the intrasaccular mural thrombus could be one of the mechanisms. For the most part, acute limb ischaemia presents with absent pulses, compatible with the clinical findings, which include pain, paraesthesia, and paralysis. Herein, we report a rare condition with detectable distal pulses in advanced limb ischaemia due to poor perfusion caused by the dislocation of mural thrombus from an abdominal aortic aneurysm. CASE PRESENTATION: A 74-year-old male patient with underlying hypertension and chronic renal disease presented at the emergency room with bilateral lower limb paralysis after falling on his back in the bathroom an hour prior. He reported numbness and weakness of his lower limbs, which was gradually worsening, over the past week. Physical examination showed cyanotic mottling of the lower limbs with paralysis. However, the dorsalis pedis pulse was intact. Computed tomography angiography showed a 7.3 cm abdominal aortic aneurysm containing highly irregular mural thrombus in the early phase, with slow perfusion of the contrast medium in the arteries below the bifurcation during the delayed phase. After traumatic spinal injury was excluded, an emergent endovascular aneurysm repair was performed. Although vital signs were initially stable post-surgery, both lower limbs were still paralysed and did not improve. He then experienced reperfusion injury with metabolic acidosis. There was no urine output despite intravenous hydration. Laboratory data included potassium 7.7 mEq/L, lactate 110 mg/dL, white blood cells 23,700/uL, and myoglobin 46,590 ng/mL. Even under critical medical care and continuous venovenous hemofiltration, his hemodynamic status worsened. He developed hypotension and needed endotracheal intubation because of loss of consciousness and respiratory failure. The patient finally died due to ventricular tachycardia even after several rounds of cardiopulmonary resuscitation with cardioversion. CONCLUSION: The unusual clinical presentation of detectable lower limb pulses in advanced limb ischaemia showed that poor blood perfusion related to dislocation of mural thrombus in abdominal aortic aneurysm might mislead clinicians and delay accurate diagnosis and treatment.

Elevation Transposition Method for Superficialization of the Basilic Vein Achieves Better Patency Rate than Tunnel Transposition.

BACKGROUND: To compare the tunnel transposition and elevation transposition methods used for superficialization of the basilic vein in terms of complication and patency rates. METHODS: This retrospective study included patients who underwent 2-stage basilic vein transposition between August 2016 and December 2019. Patients were categorized into brachial-basilic fistula tunnel transposition (n = 32) and elevation transposition (n = 21) groups using medical records. Primary patency was defined as a conduit that remains patent without any re-intervention to maintain patency. Primary assisted patency was defined as a conduit that has undergone intervention to maintain patency but has never been thrombosed. RESULTS: The distribution of baseline characteristics was similar between the 2 groups. Coronary artery disease was the only variable that was significantly different between the tunnel transposition and elevation transposition groups (31.1% vs. 4.8%, P = 0.035). The tunnel transposition group had a greater amount of blood loss (P < 0.001) and a longer period of hospitalization (P = 0.002) than the elevation transposition group. The rates of suture repair to stop bleeding from the conduit was significantly different between the tunnel transposition and elevation transposition groups (31.8% vs. 4.8%, P = 0.035), whereas those of other complications were not significantly different. The elevation transposition group had a significantly higher primary patency rate than the tunneled transposition group (P = 0.033); however, primary assisted patency was achieved in all patients (100%) in both groups. CONCLUSION: Elevation transposition might be a more reliable method than tunnel transposition for superficialization of a basilic venous fistula.

The surgical strategy for multilevel massive ossification of the posterior longitudinal ligaments.

Purpose: Creating enough decompression, favorable outcome, less complication, and maintain adequate lordosis and stability in the patients with cervical myelopathy due to multilevel massive ossification of the posterior longitudinal ligament (OPLL) still poses a challenge for surgeons. The aim of our study is to retrospectively evaluate our patients and try to seek a better surgical strategy. Methods: Between 2015 and 2019, 55 consecutive patients with multilevel massive OPLL underwent surgical treatment. Among these, 40 patients were treated with cervical laminectomy and then anterior decompression, fusion, and fixation (ADF), which was defined as group 1, and 15 patients were treated with cervical laminectomy and fixation simultaneously, which was defined as group 2. The patient's radiographic characteristics and postoperative outcomes were evaluated. Results: Better postoperative cervical sagittal lordosis and less long-term axial pain was achieved in group 1 (p < 0.001), though the functional outcome had no significant difference. In the multivariable analysis, anterior fixation accounts for independent factors for better cervical sagittal alignment (p < 0.001). No complications directly associated with cervical laminectomy were observed. Conclusion: In patients with cervical multilevel massive OPLL, laminectomy at compression level and then ADF depended on the severity and range of compression, but corpectomy of not more than two vertebral bodies is suggested, except K-line (+) and long-segment massive OPLL majorly involving the C2 and posterior laminectomy above and below the OPLL-affected levels with posterior fixation simultaneously.

Simultaneous acute limb ischemia related to acute Leriche syndrome and pulmonary embolism without existing patent foramen ovale: a case report.

BACKGROUND: Aortoiliac occlusion disease, also called Leriche syndrome, is characterized by atherothrombotic obliteration of the aortic bifurcation and bilateral common iliac arteries; typically, it has a chronic presentation. Pulmonary embolism is more related to venous thromboembolism rather than arterial thromboembolic events. Therefore, cases of simultaneous acute Leriche syndrome and pulmonary embolism are rare. Existing intracardiac right-to-left shunt were detected in most previous cases. Herein, we present the first likely documented case wherein acute Leriche syndrome and pulmonary embolism occurred simultaneously without a patent foramen ovale. CASE PRESENTATION: A 58-year-old man with hyperlipidemia and coronary artery disease presented with a 4-h history of bilateral lower limb numbness. He was a heavy smoker with a history of stroke. Computed tomography angiography revealed pulmonary embolism and aortoiliac artery occlusion. Although a massive thrombus straddled the bilateral pulmonary arteries, orthopnea was his only presentation, without right ventricle failure. Cyanosis of the affected limbs was noted, and muscle strength in both limbs had regressed to grade 1. Owing to acute limb ischemia, he underwent an emergency operation to salvage the limbs. On postoperative day 5, the general condition of both the legs improved; the muscle strength improved to grade 4. He was then transferred to the general ward and enoxaparin was continued. Computed tomography angiography was repeated to evaluate the pulmonary embolism on postoperative day 8; the thrombus remained lodged in the bilateral main pulmonary arteries. Owing to persistent orthopnea and chest tightness with intermittent tachycardia, he underwent a staged operation for the pulmonary embolism on postoperative day 13. During the surgery, intraoperative transesophageal echocardiography showed no patent foramen ovale or an existing right-to-left shunt. Postoperatively, he was closely monitored in the intensive care unit for 3 days and then transferred to the general ward for 10 days. A final computed tomography angiography performed on postoperative day 18 revealed thrombus resolution. He was then discharged on postoperative day 30 without any in-hospital complications. CONCLUSION: We present a case that might be the first documented report of acute Leriche syndrome co-occurring with pulmonary embolism without an existing patent foramen ovale.

Surgical result in non small cell lung cancer patients presenting with ground glass opacity predominant lesion less than 2 cm: Anatomic versus wedge resection.

BACKGROUND: Image characteristics of tumor, including tumor size and component are crucial for patients' survival. Patients who presented with ground glass opacity (GGO) was found less risk of intrapulmonary lymph node metastases and good survival. However, it is difficult to get tissue prove for small GGO lesion preoperatively because of its tiny size and the accuracy of intraoperation frozen section. Some patients received another operation for anatomic resection after malignancy has been confirmed and others refused reoperation and only received wedge resection. The aim of this study was tried to compare the treatment result between anatomic and wedge resection for non small cell lung cancer patients who present as small ground glass opacity (GGO) predominant lesion in pre-operation CT. METHODS: From January 2010 to May 2014, 500 non small cell lung cancer patients who underwent tumor resection were included. Patients who presented with small GGO predominant lesion in pre-operation CT were included and medical records were reviewed retrospectively. The survival status between anatomic and wedge resection was analyzed. RESULTS: 37 patients received anatomic resection (Group A) and 9 patients received wedge resection (Group B). Group B showed less staple usage (p = 0.01) and blood loss (p = 0.02). From view of pathology result, only less intrapulmonary lymph nodes was dissected was identified in group B. From view of survival, similar disease free and overall survival without statistical differences in both groups. CONCLUSION: Wedge resection may provide equivalent treatment result for patients who presented as peripheral GGO or GGO predominant lesions that less than 2 cm in size.

Total Resection of Infected Peripheral Hemodialysis Grafts Has a Favorable Impact on Outcomes.

BACKGROUND: Surgical resection could be an eradication treatment for patients with infected hemodialysis arteriovenous grafts (AVGs). This study aimed to investigate the outcomes of 3 surgical methods, including total resection, subtotal resection, and revision. METHODS: The patients who underwent surgical excision of infected AVGs performed at a single center from August 2012 to March 2019 were retrospectively analyzed. The following 3 surgical methods were used in our study: revision, subtotal resection, and total resection. Patients' demographics, medical history, perioperative details, reconstruction time, and follow-up data were collected. The outcomes including perioperative complications (within 30 days), mortality, reinfection rate of AVGs, with new access reconstruction or not, and the outcomes between reconstruction and nonreconstruction in the follow-up period were evaluated. RESULTS: Forty-one patients had infected AVGs in our study. Patients' mean age was 62 years, and 65.9% of the patients were female. The mean duration from the time of diagnosis to the operation was 14.4 days. Signs and symptoms at presentation included fever (51.2 %), swelling (43.9%), pain (58.5%), erythematous change (92.7%), and more severe features, such as altered consciousness (14.6%) and hypotension (12.2%). The pathological changes in the infected grafts included bleeding (29.3%), pus formation (73.2%), pseudoaneurysm (26.8%), and graft exposure (17.1%). Wound and graft cultures revealed an infectious etiology with fungi (7.3%), Pseudomonas aeruginosa (12.2%), Enterococcus spp. (2.4%), and Staphylococcus spp. (58.5%), with methicillin-resistant Staphylococcus aureus accounting for only 7.3%. Total resection, subtotal resection, and revision surgery were performed in 17.1%, 63.4%, and 19.5% of patients, respectively. Seven patients with complications required reoperation (17.1%), and adhesion ileus and hospital-acquired pneumonia occurred in only 2.4% and 7.3% of patients, respectively. During follow-up, most patients (82.9%) had reconstruction of the peripheral hemodialysis access with mean time of 64.3 (range: 21-92) days; mean time of use of new access was 90.5 days; and mean time of removal of catheter was about 106.3 days. Mortality rates in patients without and with reconstructed AV access during follow-up were 50% and 18%, respectively (P < 0.004). Eight cases (19.5%) had recurrence of AV access infections during follow-up; of these, 2 had revision surgery and 6 had subtotal resection. However, no patient with total resection had recurrent infections. CONCLUSIONS: The total resection group had no recurrent infection compared to the subtotal and revision groups. In addition, patients with reconstruction of peripheral hemodialysis access had a low mortality rate during the follow-up period.