Early-cannulation arteriovenous grafts: Multidisciplinary learning is essential to optimize outcomes.

BACKGROUND: It is likely that there will be an increasing role for early-cannulation arteriovenous grafts (ecAVG) with a wider recognition of the need to tailor vascular access to avoid futile procedures and unnecessary TCVC. However, experience of these products is not common and limited to early surgical adopters, with little information on the systemic changes and multi-disciplinary care needed to optimize outcomes. The aim of this study was to report the impact of a multi-disciplinary approach on quantifiable outcomes. METHODS: A retrospective analysis of a prospectively maintained database of 295 ecAVG implanted over an 8-year time-period was performed. Indicative outcomes were chosen to reflect nephrology (patient selection), nursing care (cannulation complications of infection and pseudoaneurysm) and radiology (thrombosis) on cumulative impact (functional patency) over three distinct time periods. RESULTS: The incidence of ecAVG increased 10-fold over the three time periods. The use of ecAVG changed significantly from salvage tertiary access to TCVC avoidance and salvage of existing AVF. Nursing complications reduced markedly with significantly fewer over-cannulation episodes and pseudo-aneurysms. With an improved pro-active surveillance programme, the time to first thrombosis doubled and the risk of thrombosis halved. Ultimately this resulted in significantly improved functional patency with a risk of ecAVG loss less than one-third by the last time-period. CONCLUSIONS: All aspects of ecAVG use require scrutiny and critical appraisal. Failure or success is not simply achieved by performing good technical surgery with an efficacious product, but by the care taken across a wide range of elements spanning case selection, implantation, use and maintenance.

Pre-procedure imaging planning for dialysis access in patients with end-stage renal disease using ultrasound and upper extremity computed tomography angiography: a narrative review.

Background and Objective: The incidence of patients with end-stage renal disease (ESRD) and subsequent need for dialysis is continuously rising. The detailed preoperative planning and careful creation of a functioning access for hemodialysis as a bridge to transplant or as a long-term solution, has a crucial role to reduce vascular access associated morbidity and mortality and improve quality of life of the ESRD patient population. In addition to a detailed medical workup including physical exam, a variety of imaging modalities exist to support further decision making with regard to the best suited vascular access for each individual patient. These modalities provide both, a comprehensive anatomical overview of the vascular tree and specific pathologic findings, which may increase the likelihood of access failure or insufficient access maturation. This manuscript aims to provide a comprehensive review of current literature and an overview of the different imaging modalities in vascular access planning. Additionally, we provide a step-by-step planning algorithm for hemodialysis access creation. Methods: After searching in PubMed and Cochrane database of systematic review, we reviewed eligible English literatures published up to 2021, including guidelines and meta-analyses, retrospective and prospective cohort studies. Key Content and Findings: Duplex ultrasound is widely accepted as first line imaging tool for preoperative vessel mapping. However, this modality has its inherent limitations, therefore specific questions can be assessed using digital subtraction angiography (DSA) or venography and computed tomography angiography (CTA). These modalities are more invasive, are associated with radiation exposure and require nephrotoxic contrast agents. Magnetic resonance angiography (MRA) may be an alternative in selected centers with available expertise. Conclusions: Pre-procedure imaging recommendations are mainly based on retrospective (register-) studies and case-series. Prospective studies and randomized trials are primarily related to access outcomes in ESRD patients who underwent preoperative duplex ultrasound. Comparative prospective data related to invasive DSA and non-invasive cross-sectional imaging (CTA or MRA) are lacking.

A telemedicine communication exchange network in Gorno-Badakhshan Autonomic Oblast in collaboration with Swiss Surgical Teams.

INTRODUCTION: The purpose of this article is to report on the implementation of a telemedicine network serving as a second opinion pool for a surgeon in a remote area of a developing country. METHODS: This study involved an international collaboration between two members of Swiss Surgical Teams at a tertiary referral hospital and a surgeon in a remote area in Gorno-Badakhshan Autonomic Oblast, Tajikistan, which established a second opinion pool discussing diagnostics and therapeutic options via a messenger application. A retrospective analysis of response times was performed using a series of 50 challenging cases. RESULTS: The median time to receive a first telemedical response from any of the two contacts was 24 min (interquartile range 6-73). Urgent and emergent pathologies accounted for 57% of cases. The suggested treatment was carried out in 90% (n = 44) of cases. CONCLUSIONS: Timely and convenient telemedicine support to provide diagnostic and therapeutic reassurance and improve treatment quality for patients presenting to a general and vascular surgeon in the large and remote region of Gorno-Badakhshan Autonomic Oblast can be installed via a messenger application.

Application and implications of a standardised reporting system for arteriovenous access graft infection.

INTRODUCTION: The perception that arteriovenous graft infection (AVGi) is frequent and severe is not based on contemporary data from large units using modern AVG. Furthermore, older reports compounded misperceptions by using non-standardised reporting that prevents easy comparison against the alternative modalities. The aim of this article is to use a recently published reporting scheme to analyse the frequency, management and outcome of AVGi in a large series of sequential early-cannulation AVG with long-term follow-up. METHODS: A single-center series analysis was performed of 277 early-cannulation AVG with minimum 1-year follow-up (total 120,082 days). Infections relating to the AVG were classified, root-cause analysed and the outcomes presented. RESULTS: Sixteen percent of all AVG implanted (51 episodes) developed infection related to the AVG. Primary AVGi (related to the insertion procedure or within 28 days) occurred in 9 (3%); secondary AVGi (related to AVG in use) occurred 33 times (rate 0.27/1000 haemodialysis days), at a mean of 382 days, and tertiary AVGi (in AVG no longer in use) occurred nine times. Only 1/3 of all AVGi led to bacteraemia, and ½ did not lead to loss of functional access. SUMMARY: AVG infection is not common, caused a systemic infection in only one-third, did not lead to metastatic infection, and importantly, was treatable without loss of access in one-half of all cases. Using an objective system that discriminates between aetiology and outcome allows a more complete objective understanding of relative infection risks and outcomes for AVG that can inform discussions with patients requiring vascular access for haemodialysis.

Open aneurysm repair in patients with concomitant abdominal aortic aneurysm and aorto-iliac occlusive disease is associated with a high mortality and surgical complication rate.

AIM OF THE STUDY: To evaluate whether the outcome after open aneurysm repair combined with aorto-femoral bypass in patients with concomitant abdominal aortic aneurysm (AAA) and aorto-iliac occlusive disease (AIOD) is inferior to open aneurysm repair for isolated AAA or aorto-femoral bypass for isolated AIOD. METHODS: We performed a retrospective analysis of 30-day mortality, 1-year mortality and surgical complications of consecutive patients undergoing elective aneurysm repair, aorto-femoral bypass or a combination of these at two vascular surgery departments from 2003 to 2013. Potential risk factors were investigated by multivariable analysis. RESULTS: Overall, 511 patients underwent open repair for isolated AAA, 104 aorto-femoral bypass for isolated AIOD and 46 open AAA repair combined with aorto-femoral bypass for concomitant AAA and AIOD. Surgical complications occurred in 17% of AAA, 23% of AIOD and 37% of combined patients (odds ratio [OR] combined vs AAA 2.76, 95% confidence interval [CI] 1.43-5.34; p = 0.003). Colon ischaemia occurred in 3.7% of AAA, 2.9% of AIOD and 13% of combined patients (incicidence rate ratio [IRR] combined vs AAA 3.27, 95% CI 1.37-7.81; p = 0.01). The 30-day mortality was 3.1% in AAA, 4.8% in AIOD, and 11% in combined patients (IRR combined vs AAA 3.17, 95% CI 1.26-7.96; p = 0.01). One-year mortality was 5.7% in AAA, 5.8% in AIOD and 15% in combined patients (IRR combined vs AAA 2.50, 95% CI 1.17-5.35; p = 0.02). CONCLUSIONS: Combined AAA repair and aorto-femoral bypass has a significantly higher 30-day mortality and postoperative complication rate than isolated AAA repair. Patients with concomitant AAA and AIOD thus represent a high-risk population, which should be considered when deciding on the indication for AAA treatment.

External stenting and disease progression in vein grafts 1 year after open surgical repair of popliteal artery aneurysm.

OBJECTIVE: Open surgical repair remains the gold standard treatment for popliteal artery aneurysms (PAA). The objective of this study was to evaluate the safety of external stenting and its medium-term effect on vein graft disease after open PAA repair. METHODS: Between December 2017 and September 2019, 12 consecutive patients with PAA underwent open surgical repair with externally stented saphenous vein grafts. Duplex ultrasound scanning of the grafts was performed at discharge and at 3, 6, and 12 months after the procedure to evaluate graft patency, average lumen diameter and lumen uniformity. RESULTS: Eleven patients underwent aneurysm ligation and bypass grafting and one patient was treated with aneurysm exclusion and interposition of a venous segment. External stenting of the vein graft was successful in all patients. The mean follow-up time was 12 months (range, 7-17 months), with a primary patency rate of 100% and no graft revisions or reinterventions. The mean lumen diameters at 3, 6, and 12 months were 5.9 ± 1.2 mm, 5.7 ± 0.8 mm, and 5.7 ± 0.7 mm, respectively, with no significant changes between 3 and 6 (P = .34) and between 6 and 12 months (P = .34). The coefficient of variance at 3, 6, and 12 months was 8.2 ± 9.3, 9.4 ± 7.2, and 10.4 ± 8.9, respectively, with no significant change between 3 and 6 months (P = .78) or 6 and 12 months (P = .98). No mortality or amputations were recorded throughout the follow-up period. CONCLUSIONS: External stenting of vein grafts in open surgical repair of PAA is feasible and safe. This technique may potentially improve the outcomes of surgical repair in patients with PAA.

Ultrasound-Guided Percutaneous Arterial Puncture and Closure Device Training in a Pulsatile Model.

OBJECTIVE: The current study assesses the feasibility of in vitro practice of percutaneous puncture techniques in a pulsatile flow-model. DESIGN: Prospective, controlled, randomized study. SETTING: The percutaneous access to endovascular aortic repair is considered safe, but success rates may be dependent on surgeon experience with the technique. PARTICIPANTS: Fourteen vascular surgery trainees and consultants were enrolled and randomized to a study or control group with both groups receiving instructions by a tutor on how to perform ultrasound guided percutaneous puncture and closure using a suture-mediated closure device. The study group received additional hands-on training on a pulsatile flowmodel of the groin and the performance of both groups was then graded. Study group participants were timed during and after their training on the model. RESULTS: The study group achieved higher overall grading than the control group on a 5-point scale with higher scores indicating a better performance (mean overall scores 4.0 ± 0.7 versus 2.8 ± 1.0, respectively; p = 0.03). Experienced participants (more than 20 punctures performed before the study) achieved higher overall scores than trainees (3.8 ± 0.4 versus 2.5 ± 0.8, respectively; p = 0.01). Five participants in the study group could deploy and close the ProGlide closure device correctly without the help of a tutor while being graded (71% in the study versus 0% in the control group; p = 0.02). Study group participants improved their overall score from 3.2 ± 0.9 to 4.0 ± 0.7 during training (p = 0.02). Time needed to complete the puncture and closure reduced from 456 seconds on average before, to 302 seconds after training (p < 0.001). CONCLUSIONS: Study group participants could improve their overall score while working on the simulator. More experienced participants performed better during the simulation, which may indicate the model to be life-like and a potential skills assessment tool. Simulation training may be a valuable adjunct to traditional forms of training when teaching an endovascular technique but is limited by its reliance on simulators and demo devices.

Early Cannulation ePTFE Arteriovenous Access Grafts are Associated with a Low Incidence of Pseudoaneurysm Formation.

BACKGROUND: Pseudoaneurysm formation is common in standard thin-walled polytetrafluoroethylene (sPTFE) grafts, occurring in up to 10% of grafts, and is reported as the most common cause of graft loss for grafts more than 2 years old. The Gore® Acuseal™ graft is an early cannulation graft, needled before incorporation, and thus may be especially prone to pseudoaneurysm formation. In addition, as this is a relatively new product, there are limited data on long-term outcomes such as pseudoaneurysm. We report one center's experience of the incidence and etiological factors associated with pseudoaneurysm formation over 5 years and 265 grafts. METHODS: A total of 265 Acuseal grafts were placed in the last 5 years. All patients had prospective data entered into an electronic searchable patient record. Surveillance was performed with 3 monthly imaging (digital subtraction angiography or ultrasound), clinical examination, and hemodynamic performance. Data examined included the incidence, causative factors, and outcomes of pseudoaneurysm. RESULTS: Eleven grafts (4.15%) developed a pseudoaneurysm, with 2 patients developing significant hemorrhage. The median time to development of a pseudoaneurysm was 25 months interquartile range (IQR, 20-28 months). Several common etiological factors were identified. All but one patient had overuse of needling sites (n = 10; 90.9%). Other factors associated with pseudoaneurysm formation were inadequate surveillance (n = 9; 81.8%), venous outflow stenosis (n = 9; 81.8%), and anticoagulation/dual antiplatelet therapy (n = 7; 63.6%). Management included observation and needle rotation (n = 5; 45.5%), stent grafting (n = 3; 27.3%), or excision (n = 1; 9.1%) of the pseudoaneurysm. Surgical or endovascular augmentation of the venous outflow was required in 9 patients (81.8%). Graft ligation and explantation were required in 5 patients (45.5%) with graft preservation achieved in 6/11 patients (54.5%). CONCLUSIONS: Pseudoaneurysm formation occurs less frequently in Acuseal grafts compared with historical data for standard PTFE grafts. Pseudoaneurysm formation did not occur in any graft within the first 13 months after implantation, suggesting early cannulation before incorporation is not by itself a risk factor for pseudoaneurysm development. Poor needling, venous stenosis, inadequate surveillance, and anticoagulation/dual antiplatelet therapy are remediable factors, and graft preservation is possible. Acuseal is a robust graft with lower rates of pseudoaneurysm formation on long-term follow-up than standard PTFE grafts.

Arteriovenous Access Graft Infection: Standards of Reporting and Implications for Comparative Data Analysis.

There is presently a lack of organization and standardized reporting schema for arteriovenous graft (AVG) infections. The purpose of this article is to evaluate the various types of treatment modalities for access site infections through an analysis of current publications on AVG. Key proposals are made to support standardization in a data-driven manner to make infection reporting more uniform and thereby facilitate more meaningful comparisons between various dialysis modalities and AVG technologies.

Nectin-4 Expression Is an Independent Prognostic Biomarker and Associated With Better Survival in Triple-Negative Breast Cancer.

Background: Triple-negative breast cancer (TNBC) represents about 10-20% of all invasive breast cancers and is associated with a poor prognosis. The nectin cell adhesion protein 4 (Nectin-4) is a junction protein involved in the formation and maintenance of cell junctions. Nectin-4 has previously shown to be expressed in about 60% of TNBC as well as in TNBC metastases, but to be absent in normal breast tissue, which makes it a potential specific target for TNBC therapy. Previous studies have shown an association of Nectin-4 protein expression with worse prognosis in TNBC in a small patient cohort. The aim of our study was to explore the role of Nectin-4 in TNBC and confirm its impact on survival in a larger TNBC patient cohort. Material and Methods: We performed immunohistochemical staining for Nectin-4 on a tissue microarray encompassing 148 TNBC cases with detailed clinical annotation and outcomes data. Results: A high expression of Nectin-4 was present in 86 (58%) of the 148 TNBC cases. In multivariate survival analysis, high expression of Nectin-4 was associated with a significantly better overall survival when compared with low expression of Nectin-4 (p < 0.001). Nectin-4-high expression was also significantly associated with a lower tumor stage (p = 0.025) and pN0 lymph node stage (p = 0.034). Conclusion: Our results confirm that expression of Nectin-4 serves as a potential prognostic marker in TNBC and is associated with a significantly better overall survival. In addition, Nectin-4 represents a potential target in TNBC, and its role in molecular defined breast cancer subtype should be investigated in larger patient cohorts.

Endoscopic Superficialisation of Haemodialysis Arteriovenous Fistulas in Obese Patients - Safety, Feasibility, and Outcomes.

OBJECTIVE: The aim was to evaluate the safety and feasibility of endoscopic superficialisation (ES) in patients with deeply located cephalic veins in well matured arteriovenous fistulae (AVF) and to present functional outcomes. METHODS: All patients with cannulation difficulties due to a deep lying cephalic vein of more than 6 mm but with an otherwise matured AVF with a straight needle access segment of at least 6 cm were included in this retrospective study. Procedure related safety, defined as completion of ES with no need for conversion to open surgery, and feasibility in terms of cephalic vein depth reduction were assessed. The primary endpoint was three successfully performed haemodialysis sessions using the endoscopically superficialised AVF during a minimum follow up of 12 months. RESULTS: From June 2013 to August 2017, 12 patients with a mean body mass index of 33.5 ± 3.9 kg/m2 underwent ES as a second stage procedure following radiocephalic (n = 5) or brachiocephalic AVF (n = 7) creation. All procedures were conducted endoscopically. Ultrasound imaging 12 weeks post-operatively documented a reduction in the depth of the cephalic vein from a mean of 10.1 ± 1.4 mm to 4.3 ± 0.8 mm. The mean duration of the ES was 69 ± 26.0 min with 67% performed under locoregional anaesthesia. In all but one patient with a cephalic vein of poor wall quality leading to recurrent haematoma, haemodialysis was performed successfully following ES. CONCLUSIONS: Endoscopic superficialisation of the cephalic vein is a safe and effective technique. Providing good functional results, ES represents an alternative approach for second stage superficialisation in obese patients.

Infiltration by myeloperoxidase-positive neutrophils is an independent prognostic factor in breast cancer.

PURPOSE: Myeloperoxidase (MPO) is an enzyme secreted by neutrophil granulocytes as a result of phagocytosis during inflammation. In colorectal cancer, tumour infiltration by MPO expressing cells has been shown to be independently associated with a favourable prognosis. In this study, we explored the role of MPO-positive cell infiltration and its prognostic significance in invasive breast cancer. METHODS: We performed immunohistochemical staining for MPO on multiple tissue microarrays comprising a total of 928 human breast cancer samples with detailed clinical-pathological annotation and outcome data. RESULTS: MPO-positive cell infiltration (≥ 5 cells/tissue punch) was found in 150 (16%) of the 928 evaluable breast cancer cases. In univariate survival analyses, infiltration by MPO-positive cells was associated with a significantly better overall survival (p < 0.001). In subset univariate analyses, the infiltration by MPO-positive cells was associated with significantly better overall survival in the Luminal B/HER2-negative subtype (p = 0.005), the HER2 enriched subtype (p = 0.011), and the Triple Negative subtype (p < 0.001). In multivariate analysis, MPO expression proved to be an independent prognostic factor for improved overall survival (p < 0.001). CONCLUSIONS: This is the first study to show that infiltration of MPO-positive cells is an independent prognostic biomarker for improved overall survival in human breast cancer.

Endovascular Retrieval of Intracaval Cement: A Fishing Net Technique.

PURPOSE: To describe a novel endovascular technique for intracaval cement retrieval after spinal surgery. TECHNIQUE: We produced a replica of the intracaval cement fragment and a 3D print to plan the endovascular procedure. A woven caval filter was modified with two drawstring sutures to be used as fishing net. We used a 10F sheath in the right internal jugular vein to place the caval filter proximal to the floating fragment, and a 24F sheath in the right femoral vein was the working access. After the deployment of the caval filter, the following steps were performed through the 24F sheath: (A) The drawstring sutures were snared and retrieved to the skin surface in the groin; (B) the fragment was secured with two snare catheters from the femoral access and one through the lumen of the caval filter; (C) the fragment was broken off with a snared guide wire at the base; (D) the smallest fragment was removed directly with the snare; (E) the larger dislodged fragment was controlled within the periprocedural caval filter by tightening the drawstring and removed through the 24F sheath. CONCLUSION: Cement fragments located in the inferior vena cava after cement-augmented spinal surgery procedures can be safely removed by the described fishing net technique.

Case report of an intracaval leiomyomatosis 10 months after complete hysterectomy.

INTRODUCTION: Intravenous leiomyomatosis (IVL) is a rare smooth muscle tumor, usually found in women with tumors of the reproductive organs, such as uterus myomatosous. Surgically, this case belies the call for sternotomy and two-stage surgery in caval IVL extending to the right atrium: we suggest one-stage median laparotomy as a minimal procedure with maximal benefit. PRESENTATION OF CASE: We present the case of a 60-year-old postmenopausal woman with suspected intravenous leiomyomatosis of the right internal iliac vein. The patient had undergone hysterectomy and bilateral adnexectomy for uterus myomatosous in September 2015, where an IVL limited to the veins of the uterus and the right adnex had been diagnosed. No further medical treatment had been implemented. IVL of the inferior vena cava was diagnosed when a CT scan of the abdomen was performed due to an infected abdominal seroma in June 2016. Although histologically benign, we found this case of IVL to be clinically aggressive because of its expansion to the heart. This may lead to thromboembolic complications (e.g. pulmonary embolism) or signs of right sided cardiac failure. The patient was asymptomatic, but because of the extension of the intracaval thrombus to the heart, we decided to operate and performed thrombectomy via a median laparotomy. The patient left the hospital shortly after on newly started oral anticoagulation. DISCUSSION: For caval IVL without intracardiac attachment, the extraction via laparotomy without sternotomy is the treatment of choice. It calls for an interdisciplinary approach and careful surgical planning. CONCLUSION: There is no inherent need for sternotomy in IVL extending to the right atrium. A one-year follow-up with sonographic control is advised. Medium term oral anticoagulation should be considered. This work has been reported in line with the SCARE criteria Agha et al. (2016). The SCARE Statement: Consensus-based surgical case report guidelines. Agha RA, Fowler AJ, Saeta A, Barai I, Rajmohan S, Orgill DP; SCARE Group. Int J Surg. 2016 Oct;34:180-186 [1].

A Giant Neurovascular Lower Limb Fillet Flap Can Simultaneously Cover Pelvic and Abdominal Defects.

The first description of simultaneous pelvic and abdominal soft-tissue reconstruction with a giant lower limb fillet flap after hip exarticulation and open abdomen is presented. The unfortunate circumstances of a 67-year-old female patient are described leading to soft-tissue necrosis over a periprosthetic femur fracture and open abdomen after emergency implantation of an aortic bifemoral Y-prosthesis because of thrombotic obliteration of the aortic bifurcation. After removal of the hip prosthesis, the neurovascular pedicled myocutaneous fillet flap of the entire left leg was raised and folded proximally at the level of the exarticulated joint of the hip and set into the pelvic and abdominal defect. A giant pedicled neurovascular myocutaneous fillet flap raised over the entire lower extremity is a safe, effective, durable, and sensation-preserving treatment to reconstruct combined pelvic and abdominal soft-tissue defects.