Surgical resection and graft replacement for primary inferior vena cava leiomyosarcoma: A multicenter experience.

OBJECTIVE: Primary leiomyosarcoma of the inferior vena cava (IVC) is best managed with surgical resection when technically feasible. However, consensus is lacking regarding the best choice of conduit and reconstruction technique. The aim of the present multicenter study was to perform a comprehensive assessment through the VLFDC (Vascular Low Frequency Disease Consortium) to determine the most effective method for caval reconstruction after resection of primary leiomyosarcoma of the IVC. METHODS: A multicenter, standardized database review of patients who had undergone surgical resection and reconstruction of the IVC for primary leiomyosarcoma from 2007 to 2017 was performed. The demographics, periprocedural details, and postoperative outcomes were analyzed. RESULTS: A total of 92 patients (60 women and 32 men), with a mean age of 60.1 years (range, 30-88 years) were treated. Metastatic disease was present in 22%. The tumor location was below the renal veins in 49 (53%), between the renal and hepatic veins in 52 (57%), and above the hepatic veins in 13 patients (14%). The conduits used for reconstruction included ringed polytetrafluoroethylene (PTFE; n = 80), nonringed PTFE (n = 1), Dacron (n = 1), autogenous vein (n = 1), bovine pericardium (n = 4), and cryopreserved tissue (n = 5). Complete R0 resection was accomplished in 73 patients (79%). In-hospital mortality was 2%, with a median length of stay of 8 days. The primary patency of PTFE reconstructed IVCs was 97% and 92% at 1 and 5 years, respectively, compared with 73% at 1 and 5 years for the non-PTFE reconstructed IVCs. The overall 1-, 3-, and 5-year survival for the entire cohort were 94%, 86%, and 65%, respectively CONCLUSIONS: The findings from our multi-institutional study have demonstrated that complete en bloc resection of IVC leiomyosarcoma with vascular surgical reconstruction in selected patients results in low perioperative mortality and is associated with excellent long-term patency. A ringed PTFE graft was the most commonly used conduit for caval reconstruction, yielding excellent long-term primary patency.

Non-healing leg ulcers in a patient with dystrophic calcification and crest syndrome: a challenging clinical case.

The management of non-healing leg ulcers in patients with CREST syndrome and subdermal calcification is rarely reported in medical literature. Only one similar case was found in the literature (1). Dealing with such patients can be a challenge for wound specialists. In this article, we discuss the clinical progress of an interesting case of extensive non-healing leg ulcers in a CREST patient with dystrophic calcification. The combination of systemic physiological deficits and immune compromise, along with the local physical abnormalities associated with the wound pose a complex multifactorial aetiological mix. There is no conclusive data on the optimal management of these wounds in CREST patients. It seems that ablation of the calcific deposits may offer some hope.

Practicality and importance of selected endothelial dysfunction measurement techniques: review.

The measurement of endothelial dysfunction (ED) has importance in that it indicates the presence of coronary artery disease (Kuvin et al. in J Am Coll Cardiol 38(7):1843-1849, 2001) in addition to acting as a predictor of future adverse events (Halcox et al. in Circulation 106:653-658, 2002). Various tools, methods, and metrics exist that can provide an indicator of endothelial dysfunction. Given the significance of ED, it is of utmost importance to find a measurement technique that is reliable, while defining a metric providing a framework for an overall system that is practical, accurate, and repeatable. Success would provide a tool for the early detection of cardiovascular disease not only moving patients that are currently classified as asymptomatic to symptomatic, but also providing a method to monitor the efficacy of treatments.

Selective placement of autogenous arteriovenous fistulae in an over 80-year-old population.

INTRODUCTION: With improved life expectancy and quality of life, elderly patients constitute a progressively larger fraction of consumers utilising renal replacement therapy (RRT). Although substantial data exist for younger cohorts, minimal evidence exists for outcomes of arteriovenous fistula (AVF) and central catheters (CVC) placed in those patients over 80 years. We examined outcomes of primary AVF placement in this cohort to ascertain durability and benefits of AVF in the over 80-year-old population. METHODS: Retrospective analysis was undertaken of all autogenous AVFs and CVCs placed in patients aged over 80 years at Gold Coast University Hospital between March 2010 and February 2016. Prospectively collected demographic data, co-morbidities and operative factors were analysed. RESULTS: Sixty-five AVF and 12 CVC patients were identified. Mean age at intervention was 83.9 years and 76% of the patients were male. The majority of procedures were autogenous radio-cephalic AVF; median post-operative length of stay was 2 days. Cumulative AVF patient survival at 12 and 24 months was 82% and 72%, respectively. This was significantly better than survival rates of CVC patients, with 12-month survival of 45%. Primary patency at 6, 12 and 24 months was 58%, 39% and 31%. There were 113 follow-up procedures in 41 patients required to maintain patency. CONCLUSIONS: Although patency rates are inferior and re-intervention rates higher than in younger patients, AVF can be a durable option for RRT in selected elderly patients with improved mortality rates compared with CVC. Age alone should not preclude primary AVF placement.

Quantifying radionuclide signatures from a γ-γ coincidence system.

A method for quantifying gamma coincidence signatures has been developed, and tested in conjunction with a high-efficiency multi-detector system to quickly identify trace amounts of radioactive material. The γ-γ system utilises fully digital electronics and list-mode acquisition to time-stamp each event, allowing coincidence matrices to be easily produced alongside typical 'singles' spectra. To quantify the coincidence signatures a software package has been developed to calculate efficiency and cascade summing corrected branching ratios. This utilises ENSDF records as an input, and can be fully automated, allowing the user to quickly and easily create/update a coincidence library that contains all possible γ and conversion electron cascades, associated cascade emission probabilities, and true-coincidence summing corrected γ cascade detection probabilities. It is also fully searchable by energy, nuclide, coincidence pair, γ multiplicity, cascade probability and half-life of the cascade. The probabilities calculated were tested using measurements performed on the γ-γ system, and found to provide accurate results for the nuclides investigated. Given the flexibility of the method, (it only relies on evaluated nuclear data, and accurate efficiency characterisations), the software can now be utilised for a variety of systems, quickly and easily calculating coincidence signature probabilities.

Technical skills continue to improve beyond surgical training.

BACKGROUND: There is growing focus on surgical technical competence and the means by which we are able to measure it. Ongoing studies have shown a plateau effect with increasing experience of the operator. The aim of this study was to assess the technical competence of five groups of surgeons with increasing experience and validate a new rating tool for use in surgical assessment. METHODS: Fifty surgeons performed a saphenofemoral junction ligation on a synthetic groin model. The procedure was videotaped, blinded, and reviewed independently by three assessors. Performance was assessed using a previously validated global rating scale of generic surgical skill. In addition, each procedure was rated with the procedure-specific Imperial College Evaluation of Procedure-Specific Skill (ICEPS) rating scale to establish the construct validity (ability to differentiate on the basis of skill) and inter-observer reliability. RESULTS: Both rating scales showed improved scores with ascending grades (P < .001) and demonstrated a high inter-observer reliability both for generic and procedure-specific skill (alpha = 0.97 and alpha = 0.96, respectively). Total operative scores demonstrated significant differences between surgeons in postgraduate years 1 and 2 and surgeons in years 3 and 4 and also between newly appointed and experienced consultants (P < .041). Procedure-specific performance showed a plateau effect at the registrar level. Generic skill continued to improve, and significant differences were seen between newly appointed and senior consultants (P < .026). CONCLUSION: This study shows that surgical performance continues to improve significantly beyond consultancy, and the data suggest that generic and procedural performance continue to improve, with significant improvement in the former with increasing experience. The ICEPS rating scale demonstrates construct validity and a high inter-observer reliability supporting its use in formative and summative assessment.

Three-dimensional reconstruction of autologous vein bypass graft distal anastomoses imaged with magnetic resonance: clinical and research applications.

High-resolution magnetic resonance imaging was combined with computational modeling to create focused three-dimensional reconstructions of the distal anastomotic region of autologous vein peripheral bypass grafts in a preliminary series of patients. Readily viewed on a personal computer or printed as hard copies, a detailed appreciation of in vivo postoperative features of the anastomosis is possible. These reconstructions are suitable for analysis of geometric features, including vessel caliber, tortuosity, anastomotic angles, and planarity. Some potential clinical and research applications of this technique are discussed.