Lessons learnt from an aggressive tumour masquerading as a neuropathic heel ulcer: a case report.

Cutaneous malignant melanoma (cMM) can develop at any site, but one-third of cases primarily affect the lower extremities, with ankle and foot lesions representing 3-15% of all cases. However, cMM may become a clinical conundrum when it presents as chronic ulceration that is clinically indiscernible from other lower extremity ulcers in patients with diabetes. We present the case of a 71-year-old female patient with a longstanding history of diabetes, hypertension, obesity, chronic kidney disease and heart failure who presented to our hospital with a fungating heel ulcer. The lesion was initially managed in another hospital as a neuropathic diabetic foot ulcer (DFU), treated by multiple local wound debridement. However, the ulcer progressed into a fungating heel lesion that interfered with the patient's mobility and quality of life. Consequently, the patient was referred to our specialist diabetic foot service for further management. Excisional biopsy of the lesion disclosed a cMM. Positron emission tomography/computed-tomography scanning revealed hypermetabolic ipsilateral inguinal lymphadenopathy, and a right cerebral metastasis for which palliative chemotherapy was initiated. Immunotherapy was considered, but the patient died before it was started. Atypical foot ulcers in patients with diabetes warrant a careful diagnostic approach, especially for recalcitrant cutaneous lesions not responding to standard therapies. Conscientious management, without undue delay in obtaining a histopathological diagnosis, might lead to early diagnosis of melanoma and potentially more favourable outcomes. This case highlights the importance of consideration of atypical foot lesions, in general practice in addition to referral centres, to try to identify alarming features and act accordingly.

Major lower extremity amputation: a contemporary analysis from an academic tertiary referral centre in a developing community.

BACKGROUND: We aimed to explore the surgical outcomes of major lower extremity amputation (MLEA) and influencing factors at an academic tertiary referral centre in north Jordan, optimistically providing a platform for future health care policies and initiatives to improve the outcomes of MLEA in Jordan. METHODS: Clinical records of patients who had undergone MLEA between January 2012 and December 2017 were identified and retrospectively reviewed. International Classification of Diseases codes were used to identify the study cohort from a prospectively maintained computerised database. We included adult patients of both genders who underwent amputations for ischemic lower limb (acute and chronic) and diabetic foot syndrome (DFS). We excluded patients for whom MLEA surgery was performed for other indications (trauma and tumors). Outcomes of interest included patient demographics and comorbidities, type of amputation and indications, length of hospital stay (LOS), the need for revision surgery (ipsilateral conversion to a higher level of amputation), and cumulative mortality rate at 1 year. The impact of the operating surgeon's specialty (vascular vs. non-vascular surgeon) on outcomes was evaluated. RESULTS: The study cohort comprised 140 patients who underwent MLEA (110 below-knee amputations [BKA] and 30 above-knee amputations [AKA]; ratio: 3:1; 86 men; 54 women; mean age, 62.9 ± 1.1 years). Comorbidities included diabetes, hypertension, dyslipidaemia, ischaemic heart disease, congestive heart failure, chronic kidney disease, stroke, and Buerger disease. The only associated comorbidity was chronic kidney disease, which was more prevalent among BKA patients (p = 0.047). Indications for MLEA included DFS, and lower limb ischaemia. Acute limb ischaemia was more likely to be an indication for AKA (p = 0.006). LOS was considerably longer for AKA (p = 0.035). The cumulative mortality rate at 1 year was 30.7%. Revision surgery rates and LOS improved significantly with increased rate of vascular surgeon-led MLEA. CONCLUSIONS: In developing countries, the adverse impact of MLEA is increased because of limited resources and increased prevalence of diabetes-related foot complications. Vascular surgeon-led MLEA is associated with decreased revision rates, LOS and possibly improved outcomes, particularly when it is performed for vascular insufficiency. It is important to formulate national health care policies to improve patient outcomes in these countries.

Blue Toe Syndrome in Behçet's Disease: A Case Report.

BACKGROUND Vascular Behçet's disease (VBD) is a rare but potentially life-threatening subtype of Behçet's disease that is characterized by multisystemic vasculitis. It primarily affects males with ancestry traced back to regions along the ancient Silk Road. Both arteries and veins, regardless of size, may exhibit complications, including aneurysmal degeneration or occlusion. While venous involvement is observed in two-thirds of VBD cases, arterial complications are notably the most severe and lethal. Arterial aneurysmal degeneration is more common than occlusive complications, with larger arteries being predominantly affected in VBD. Data regarding isolated small-vessel arterial occlusive disease in VBD are limited. Given the rarity of this presentation in this patient population, it becomes mandatory to thoroughly evaluate such patients to differentiate small-vessel vasculitis from other similar diseases, such as Raynaud's phenomenon, which has a different etiology and management and generally has a more benign course. Here, we delineate the concept of isolated small-vessel vasculitis as a cause of blue toe syndrome in patients with VBD. CASE REPORT This report describes a distinctive case of vascular Behçet's disease in a 51-year-old man who initially exhibited unilateral blue toe syndrome, which swiftly progressed to dry gangrene of the toes. Despite reports of large-vessel involvement, there is a paucity of data on isolated small-vessel vasculitis-induced digital ischemia in VBD. CONCLUSIONS This atypical case underscores the necessity of clinical discernment in differentiating inflammatory microvascular occlusive disease from vasospastic Raynaud's syndrome, both of which can complicate Behçet's disease.

Perioperative Vascular Access Mapping in Patients with Hemodialysis: A Comparative Study of Access Navigation and Selection in Jordan.

Purpose: This study aimed to elucidate the impact of three different mapping methods on the outcomes of arteriovenous fistula (AVF), including the traditional physical examination (PE) method, color duplex ultrasonography (CDU) mapping conducted by a radiologist (CDU-R), and CDU mapping performed by the operating surgeon (CDU-S). Patients and Methods: This retrospective study was conducted at a tertiary center in Jordan. Patients were divided into three groups based on the venous mapping method: PE, CDU-R, and CDU-S. Various outcomes were analyzed, including immediate technical success, clinical adequacy at 3 months, and 1-year patency rates. Additional demographic and clinical factors influencing access patency or contributing to early failure were also examined. Results: The study included 303 eligible patients: 100 in the PE group, 103 in the CDU-R group, and 100 in the CDU-S group. The overall immediate technical success rate was 72%, which was highest in the CDU-S group (95%, p < 0.001). Additionally, the CDU-S group had the highest clinical access adequacy rate (78%, p < 0.01). Notably, the mapping method also influenced the anatomical location of the AVF, as none of the patients in the radiologist group had a forearm AVF. CDU-R, forearm location, intraoperative arterial calcifications, and operative duration were identified as predictors of AVF failure. Conclusion: The results suggest that perioperative vascular mapping by the operating surgeon not only results in a higher rate of immediate success but also improves access adequacy and prevents unnecessary delays in providing an effective lifeline for hemodialysis patients. The present study highlights the burden of access failure in these patients and the evolving evidence surrounding preoperative vein mapping.

Clinical recurrence and antiplatelet drug resistance among patients with lower limb ischemia.

There is a high prevalence rate of peripheral artery disease worldwide, with estimated cases exceeding 200 million. Most patients are under-diagnosed and under-treated, and there is a lack of knowledge regarding the best therapeutic regimen and therapy duration, which leads to many cases of recurrence, complications, and amputations. This study aims to explore clinical recurrence, which was defined as the worsening of chronic peripheral artery disease requiring hospital admission, and its relationship with antiplatelet drug resistance among patients with lower limb ischemia. This cohort study includes both retrospective and prospective recruitment of patients with chronic lower limb ischemia. Platelet aggregation tests were offered to the patients. Between February 2018 and November 2020, 147 patients were recruited from King Abdullah University Hospital and followed up for at least 1 year. Platelet aggregation tests were done for 93 patients who agreed to participate in this part of the study. The prevalence of chronic lower limb ischemia was higher in young male patients who are current smokers with co-morbid diseases such as hypertension, diabetes mellitus, and/or dyslipidemia. There was a significant association only of clinical recurrence with younger age (P = .011) and with low platelets count in severe stages of the disease (P = .047). No significant association was found in terms of laboratory resistance. The clinical recurrence rates of chronic lower limb ischemia were higher in younger patients and among those with low platelet counts in the severe stages of the disease. Despite the laboratory responsiveness to anti-platelet therapy, we observed significant clinical resistance and increased recurrence rates.

The impact of partial and complete lockdown during the COVID-19 pandemic on acute surgical services: a retrospective cohort study.

PURPOSE: The burden of the coronavirus disease of 2019 (COVID-19) pandemic on the healthcare sector has been overwhelming, leading to drastic changes in access to healthcare for the public. We aimed to establish the impact of implemented government partial and complete lockdown policies on the volume of surgical patient admissions at a tertiary referral center during the pandemic. METHODS: A database was retrospectively created from records of patients admitted to the surgical ward through the emergency department. Three 6-week periods were examined: The complete lockdown period (CLP), which included a ban on the use of cars with the exception of health service providers and essential sector workers; A pre-COVID period (PCP) 1 year earlier (no lockdown); and a partial lockdown period (PLP) that involved a comprehensive curfew and implementing social distancing regulations and wear of personal protective equipment (e.g., masks) in public places. RESULTS: The number of patients admitted to the surgery ward was significantly higher in the PCP cohort compared to the CLP and PLP cohorts (p = 0.009), with a 42.1% and 37% decline in patients' admissions, respectively. Admission rates for patients with biliary pathologies and vascular thrombotic events increased. 30-day mortality rates did not differ significantly between the three periods (p = 0.378). CONCLUSIONS: While COVID-19 lockdown regulations had a significant impact on patient admission rates, surgical outcomes were not affected and the standards of care were maintained. Future protocols should strive to improve access to healthcare to avoid complications caused by delayed diagnosis and treatment.

Transmetatarsal amputations in patients with diabetes mellitus: A contemporary analysis from an academic tertiary referral centre in a developing community.

Transmetatarsal amputation (TMA) involves the surgical removal of the distal portion of metatarsals in the foot. It aims to maintain weight-bearing and independent ambulation while eliminating the risk of spreading soft tissue infection or gangrene. This study aimed to explore the risk factors and surgical outcomes of TMA in patients with diabetes at an academic tertiary referral center in Jordan. Medical records of all patients with diabetes mellitus who underwent TMA at King Abdullah University Hospital, Jordan, between January 2017 and January 2019 were retrieved. Patient characteristics along with clinical and laboratory findings were analyzed retrospectively. Pearson's chi-square test of association, Student's t-test, and multivariate regression analysis were used to identify and assess the relationships between patient findings and TMA outcome. The study cohort comprised 81 patients with diabetes who underwent TMA. Of these, 41 (50.6%) patients achieved complete healing. Most of the patients were insulin-dependent (85.2%). Approximately half of the patients (45.7%) had severe ankle-brachial index (ABI). Thirty patients (37.1%) had previous revascularization attempts. The presence of peripheral arterial disease (P<0.05) exclusively predicted poor outcomes among the associated comorbidities. Indications for TMA included infection, ischemia, or both. The presence of severe ABI (≤0.4, P<0.01) and a previous revascularization attempt (P<0.05) were associated with unfavorable outcomes of TMA. Multivariate analysis that included all demographic, clinical, and laboratory variables in the model revealed that insulin-dependent diabetes, low albumin level (< 33 g/L), high C-reactive protein level (> 150 mg/L), and low score of Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC, <6) were the main factors associated with poor TMA outcomes. TMA is an effective technique for the management of diabetic foot infection or ischemic necrosis. However, attention should be paid to certain important factors such as insulin dependence, serum albumin level, and LRINEC score, which may influence the patient's outcome.

A Periaortitis Patient Who Succumbed to COVID-19 While Undergoing Systemic Steroid Therapy: A Case Report and Literature Review.

BACKGROUND Periaortitis is an inflammatory condition that typically involves the infrarenal portion of the abdominal aorta. It is a rare disease usually occurring in middle-aged men. Coronavirus disease-2019 (COVID-19) is caused by the SARS-CoV-2 virus. The published literature on the management of steroid therapy in patients with periaortitis and infected with SARS-CoV-2 is lacking. The balance between the indispensable anti-inflammatory properties of steroids and their adverse immunosuppressive characteristics remains unclear in the current COVID-19 scenario, and most of the current practices in managing potentially autoimmune aortic conditions are extrapolated from patients with rheumatological disorders contracting COVID19 while undergoing maintenance steroid therapy. CASE REPORT This report describes the case of a 62-year-old man who presented with nonspecific lower abdominal pain, unremarkable clinical exam, significantly elevated CRP level, and positive antinuclear antibody test. A CT scan showed mild aortic aneurysmal dilatation with periaortic soft tissue thickening, and a PET scan confirmed the finding, showing active abdominal periaortitis. Accordingly, he was diagnosed with autoimmune periaortitis and was maintained on a high dose of systemic corticosteroids (35 mg prednisolone/d). Eight weeks later, he was readmitted to the intensive care unit with worsening respiratory symptoms due to SARS-CoV-2 infection confirmed by PCR test, and unfortunately died 44 days later due to COVID-19-induced respiratory failure and sepsis. CONCLUSIONS The lack of an international consensus on the management of SARS-CoV-2-positive, steroid-dependent patients with serious inflammatory aortic conditions mandates further investigations and thoughtful review of the guidelines for the management of steroid-dependent patients contracting SARS-CoV-2 infection. Additionally, a comprehensive analysis of the outcomes of these patients is essential.

Postoperatively determined high-risk histopathologic features in papillary thyroid carcinoma initially eligible for thyroid lobectomy: a game changer.

PURPOSE: Recent clinical practice guidelines consider thyroid lobectomy a viable alternative for low-risk papillary thyroid carcinoma PTC measuring 1-4 cm in size. We aimed to assess the likelihood of finding postoperatively determined high-risk histopathologic features that would lead to the recommendation of completion thyroidectomy. METHODS: A retrospective review of patients who underwent total thyroidectomy for PTC measuring 1-4 cm in size between Jan 2012 and Jan 2018 was conducted. Patients with pre-operative high-risk characteristics were excluded: history of radiation exposure, positive family history, clinically suspicious cervical lymphadenopathy, and gross extrathyroidal extension (ETE). A hypothetical group of 245 patients remained eligible for lobectomy. The pathology specimens from the cancer-containing lobes were evaluated for high-risk features: aggressive histology, capsular and/or vascular invasion, microscopic ETE, and multifocality. A subgroup analysis was performed with 2 cm being the cut-off size. RESULTS: The average age was 39 years with 73% being females. Mean cancer size was 16 mm. Evaluation of the cancer-containing lobe for high-risk features revealed: aggressive histology (33%), ETE (12%), capsular invasion (33%), vascular invasion (17%), and ipsilateral multifocality (30%). The cumulative risk of having ≥1 high-risk feature mandating completion thyroidectomy was 59%. The risk was considerably higher for lesions ≤2 cm compared to larger lesions (64% vs.48%; p = 0.049; RR = 1.3). CONCLUSIONS: A considerable proportion of patients initially eligible for lobectomy have high-risk features that only become evident at pathology. Therefore, a comprehensive approach is advocated to determine the extent of surgery for PTC incorporating patient preferences regarding risks and benefits.

Predictors of short-term mortality after rheumatic heart valve surgery: A single-center retrospective study.

BACKGROUND: Valve replacement surgeries holds risks of morbidity and mortality. MATERIALS AND METHODS: The study cohort included 346 patients who underwent different types of valve surgery, excluding redo and Bentall operations. All operations were performed through a median sternotomy using cardiopulmonary bypass. RESULTS: Mean patient age was 51.6 ± 16.1 years, and 51% were male. Approximately 21% had diabetes, and 44.6% were hypertensive. Aortic valve replacement (AVR) was performed in 125 patients (37%), mitral valve replacement (MVR) in 95 (28%), combined AVR and MVR in 42 (13%), AVR plus coronary artery bypass grafting (CABG) in 19 (6%), and MVR plus CABG in 32 (10%). Operative mortality was 5.8% (n = 20). In the bivariate-level analysis, older age, operation type, hypertension, emergency surgery, use of a biological valve in the aortic or mitral position, pump time greater than 120 min, and aortic clamp time greater than 60 min were significant predictors of 30-day mortality. Use of medications stratified by duration (less than or more than a month) was also shown to be a predictor of mortality. Use of angiotensin-converting enzyme inhibitors, digoxin, beta-blockers, statins, and loop diuretics was associated with mortality. Older age, emergency/salvage surgery, use of beta-blockers for less than 1 month preoperatively, and use of a biological valve in the aortic position were significant and independent predictors of 30-day mortality. CONCLUSION: Age, emergency valve surgery, use of a biological valve, use of beta-blockers for less than 1 month before surgery, type of surgery, EF<35%, pump time, and cross clamp time were all found to be independent predictors of mortality in patients undergoing valve surgery. Further prospective multicenter studies may be needed to provide a comprehensive assessment of mortality in patients undergoing valve surgery in Jordan.

Impact of the COVID-19 pandemic on the management of chronic limb-threatening ischemia in Northern Jordan: Case series and literature review.

INTRODUCTION: The novel COVID-19 pandemic has imposed unprecedented restrictions on healthcare services worldwide. In developing nations such as Jordan, appreciable impacts on healthcare delivery ensued owing to limited resources. As a result, managing chronic limb-threatening ischemia (CLTI) has been modified to accommodate altercations in the system. This study assessed the impact of the COVID-19 pandemic on managing patients with critical limb-threatening ischemia (CLTI) during the lockdown. METHODS: Objectives were accomplished by retrieving records of clinical data and perioperative results for patients diagnosed with CLTI at King Abdullah University Hospital between March 17 and June 1, 2020. Patients' demographics, Rutherford classification, type of intervention, and intervention variables during the outbreak were retrospectively analyzed (pandemic Group A) and compared with patients from the same period last year (control Group B). RESULTS: A total of 96 patients with CLTI were included in the study; Groups A and B consisted of 28 and 68 patients, respectively. The mean ages for Groups A and B were 62.8 and 60.2 years, respectively. Conservative management was applied to 53.6% (P < 0.01) of Group A patients, whereas endovascular revascularization was the primary approach in Group B (39.7%, P < 0.01). After the intervention, the majority of patients in Group A were classified as category six on the Rutherford classification system (46.4%, P < 0.01), whereas the majority in group B were classified as category five (55.9%, P < 0.01). CONCLUSIONS: The more unsatisfactory outcome of CLTI during the pandemic entails substantial measures to ensure conscientious virtual encounters and ambulatory community-based services during current and future pandemics. The endovascular-first policy should be endorsed in future pandemics as it is better at reducing aerosol transmission than standard surgical intervention. Moreover, endovascular procedures are minimally invasive and associated with favorable outcomes when medical optimization and hospital beds are limited.

Developing a tool that could reliably refute total thyroidectomy for solitary Bethesda IV thyroid nodules.

PURPOSE: To assess the reliability of a simple, accessible, cost-effective rule-out tool, for use in triaging patients with Bethesda IV nodules to appropriate surgery. METHODS: The diagnostic tool was assembled by combining the negativity for suspicious ultrasound features (irregular margins, microcalcification, and a taller-than-wide orientation), and mutational marker negativity (BRAF and NRAS). The tool, (US-/mutation-), was tested on 167 patients with solitary Bethesda IV nodules. The primary outcome was its negative predictive value (NPV) for lesions requiring total thyroidectomy (TT). The impact of mutational marker negativity, as part of the tool, was evaluated by comparing the NPV of (US-/mutation-) to that of (US-/mutation+). RESULTS: 10 out of 167 lesions were positive for a mutational marker. These underwent TT, and only 2/10 (20%) were benign, on final histology. In 6/8 malignant lesions, TT was concordant with current clinical guidelines. 157 patients comprised the negative study cohort, for both mutational markers and suspicious US features. These underwent thyroid lobectomy, and 17 cases resulted in malignancy, only 8 of which required completion thyroidectomy. Accordingly, the NPV of (US-/mutation-) for malignancy was 89% (140/157), and 95% (149/157) for malignancy requiring TT. However, the NPV of (US-/mutation+) was 20% for malignancy, and 40% for malignancy requiring TT. These differences were statistically significant (89% vs. 20%; p < 0.0001, and 95% vs. 40%; p < 0.0001). CONCLUSION: US-/mutation- is a reliable rule-out tool, with sufficient diagnostic accuracy to spare patients, with Bethesda IV nodules, an overly radical TT.

Energy-based devices in thyroid surgery-an overview.

In the mid-20th century Theodor Kocher standardized the conventional clamp-and-tie thyroidectomy, and a procedure that was banned or prohibited for so long was labeled as "extremely safe and efficient". Ever since, innovations and refinements in the field of thyroid surgery have focused on improving patient clinical outcome profiles, and offering patients procedures that are tailored to their concerns and desires without compromising the concepts of safety and efficacy. This led to a paradigm shift in thyroid surgery and the introduction of minimal access thyroid procedures. Unsurprisingly, this paralleled the constant technological evolution in surgical devices. Advanced energy-based devices were introduced into thyroid surgery more than a decade ago. Initially, their introduction was surrounded by sckepticism, and was considered a double-edged sword equally giving accolade and criticism. Ultimately, they have proved to be very useful in thyroid surgery, and pivotal to its evolution. In experienced hands, thyroid surgery performed using an advanced energy-based device is considered 'at least' as safe and effective as its conventional clamp-and-tie counterpart. Furthermore, it offers additional advantages that meet the best interest of the patient, surgeon, health care facility, and the society. This article provides an overview on the introduction of innovative technology into thyroid surgery.

Comparison of postoperative liver function between different dissection techniques during laparoscopic cholecystectomy.

AIM: In this study, we investigated and compared the effect of different types of dissector (Maryland vs Hook) on changes in liver function tests (LFTs) after laparoscopic cholecystectomy. PATIENTS & METHODS: The enrolled patients were divided into two groups. Group A patients underwent dissection by Maryland dissecting forceps, group B by Hook dissecting instrument. LFTs were measured preoperatively and at 1 day and 1 week, postoperatively. RESULTS: For both Maryland and Hook dissection, the 1-day postoperative values for total bilirubin, alanine aminotransferase and aspartate aminotransferase were significantly higher than the preoperative values. Also, there were no statistical differences between Hook and Maryland. CONCLUSION: The elevation of LFTs seems to be attributed to other factors.

Impact of COVID-19 on thyroid cancer surgery and adjunct therapy.

COVID-19 has profoundly modified the way healthcare is delivered. Jordan imposed lockdown and restrictive policies between March 17 and May 20, 2020. We aimed to assess the impact of such measures on thyroid cancer treatment plans. In the specified period, 12 patients were scheduled for surgery. Since papillary carcinoma was the preoperative diagnosis in all cases, radioactive iodine ablation (RIA) therapy was also planned 3-4 weeks following surgery after withdrawing thyroxine and achieving a thyroid stimulating hormone (TSH) level > 30 mU/L. Thyroxine withdrawal is the routine method applied for RIA in Jordan as it is less costly compared to the rapid method of exogenous stimulation using recombinant TSH. All surgical procedures were performed without delay since all patients were asymptomatic per flu-like illness and came from a region of low COVID-19 prevalence. These included total thyroidectomy (n = 11), bilateral therapeutic central compartment neck dissection (n = 7), lateral compartment neck dissection (n = 5). However, the RIA treatment plan was altered considerably according to the period in which they were operated. 6 out of the 7 patients operated in March changed to the stimulated method of RIA at a considerable additional extra cost. The seventh patient and the April patient opt to delay RIA until after lockdown. The remaining cases (operated in May) followed the usual withdrawal method as restrictions were due to an end. The restrictive measures applied during COVID-19 did not affect the safe and timely delivery of surgical care. However, it added a financial and psychological burden to the entire cancer management plan.

Analysis of the Peri-Operative Cost of Non-Traumatic Major Lower Extremity Amputation in Jordan.

PURPOSE: Non-traumatic major lower extremity amputation (NMLEA) is a commonly performed procedure that presents a substantial cost burden. Patients who undergo NMLEA are usually considered as a high-risk group with significant comorbidities, which translates into a protracted peri-operative course and increased health-care costs. The primary aim of this study was therefore to perform a contemporary peri-operative cost analysis of NMLEA performed in our center. We are a major tertiary referral hospital that provides vascular surgery services to the entire northern counties in Jordan. We also aimed to assess the various factors that influence the cost of NMLEA in less economically developed countries. METHODS: Records of all patients who underwent NMLEA at King Abdullah University Hospital between January 2012 and December 2017 were retrieved. Total inpatient cost was calculated and analyzed against different patients' variables. RESULTS: A total of 140 patients underwent NMLEA between 2012 and 2017 in our facility. Below-knee amputations accounted for 110 cases, while above-knee amputations included 30 patients. Approximately two-thirds of the cases (61.4%) were males, with average age of the patients being approximately 62.9 years. The commonest comorbidities were diabetes mellitus and hypertension, which were recorded in 89.3% and 80.3% of the patients, respectively. The average operative time was 133.0 ± 10.8 mins, and the average length of stay (LOS) was 6.7±0.4 days. The mean cost for amputations was 4904.7± 429.3 United States dollars. Multiple linear regression analysis demonstrated that LOS and admission-to-operation time were the independent predictors of cost. CONCLUSION: Delayed amputations and prolonged LOS remain the most important determinants for the peri-operative cost of NMLEA. When amputation is deemed inevitable, an expedited multidisciplinary approach may possibly reduce undue delays and result in cost-effective delivery of this age-old remedy.

Lesion Type Analysis of Hemodialysis Patients Who Underwent Endovascular Management for Symptomatic Central Venous Disease.

PURPOSE: Central venous lesions (CVLs) can adversely affect hemodialysis access maturation and maintenance, which in turn worsen patient morbidity and access circuit patency. In this study, we assessed several clinical variables, patient characteristics, and clinical consequences of symptomatic central vein stenosis and obstruction in patients who underwent renal replacement therapy in the form of hemodialysis. PATIENTS AND METHODS: The medical records of all hemodialysis patients with clinically symptomatic CVLs who underwent digital subtraction angiography treatment at King Abdullah University Hospital between January 2017 and December 2019 were retrieved. Patient characteristics and the clinical and anatomical features of CVLs were analyzed retrospectively. Pearson's chi-square tests of association were used to identify and assess relationships between patient characteristics and CVLs. RESULTS: The study cohort comprised 66 patients with end-stage renal disease who developed symptomatic central vein stenosis. Of the 66 patients, 56.1% were men, and their mean age was approximately 52 years. Most (62.1%) of the patients were determined to have a history of central catheter insertion into the jugular vein. Hypertension was the most common comorbidity (78.8%, p<0.001), followed by type 2 diabetes mellitus (47.0 %, p<0.01). The incidence of stenosis was found to be significantly higher in the brachiocephalic vein than in other central veins (43.9%, p<0.001). A repeated central catheter insertion in a patient was predictive of central venous occlusion (p<0.05). Stenotic lesions were found to be associated with a significantly higher success rate than occlusive lesions (91.2%, p<0.01). CONCLUSION: Multiple central venous catheters (CVCs) are found to be associated with occlusive CVLs and unfavorable recanalization outcomes. Multiple CVC should be avoided by creating a permanent vascular access in a timely fashion for patients with chronic kidney disease and by avoiding the ipsilateral insertion of CVC and AVF.

Endovascular Management of May-Thurner Syndrome in a Patient with Left-Sided Superior Vena Cava: A Case Report.

BACKGROUND May-Thurner syndrome (MTS) is a condition characterized by compression of the left common iliac vein (LCFV) between the right common iliac artery (RCIA) and the lumbar vertebrae. This anatomical entrapment typically affects young women and is mostly asymptomatic. High index of suspicion is required in cases of recurrent left-sided deep vein thrombosis (DVT) and severe leg pain. We describe a case of MTS in a young male patient with a left-sided superior vena cava (LSSVC) that was successfully managed by an endovascular approach. To the best of our knowledge, the coexistence of MTS and LSSVC anomaly has not been reported previously. CASE REPORT A 31-year-old man presented with a history of left-sided iliofemoral deep vein thrombosis and disabling venous claudication of 2 years' duration. Duplex ultrasound and computed tomography venogram (CTV) revealed evidence of MTS with chronic subtotal occlusion of the left common iliac vein (LCIV) with extensive venous collaterals. Venogram via the left femoral vein puncture confirmed the aforementioned findings. Retrograde recanalization of the occluded segment was attempted without success. Therefore, an antegrade approach via the right internal jugular vein was performed to facilitate recanalization. Surprisingly, venography revealed an LSSVC. The occluded CIV was successfully stented and the patient had complete resolution of his symptoms at 22-month follow-up. CONCLUSIONS MTS is a potentially treatable and often-overlooked pathology. In the era of expanded endovascular management of MTS, recognition of this coincidence is essential to prevent unwarranted mishaps during endovascular management when the jugular approach is used.

BRAFV600E mutation: a potential predictor of more than a Sistrunk's procedure in patients with thyroglossal duct cyst carcinoma and a normal thyroid gland.

To assess the utility of mutational markers in determining the most appropriate initial surgery for patients with thyroglossal duct cyst carcinoma (TGDCCa) and a normal thyroid gland. Our sample comprised 15 patients with a diagnosis of TGDCCa and a thyroid gland histologically negative for any malignant involvement, who underwent surgery between the years 1994 and 2017. Clinical records were reviewed and tissue specimens were genetically tested for the presence of the most commonly encountered mutational markers in differentiated thyroid cancer: BRAF, N-RAS, and H-RAS. The primary outcome of interest was the correlation between mutational marker positivity and the T-stage of the primary tumor and its potential implication on therapeutic decision making. All 15 cases were papillary carcinomas with a mean tumor size of 17 mm (2-40 mm). According to the 7th edition of the American Joint Committee on Cancer TNM staging system, these represented: T1 (n = 3), T2 (n = 1), and T3 (n = 11). Cancerous invasion of the pericystic soft tissue and/or hyoid bone was considered T3. BRAFV600E was the only mutational marker identified (7 in 15 cases). All BRAFV600E-positive lesions were T3, necessitating radioactive iodine ablation (RIA) therapy, therefore, total thyroidectomy. The correlation between BRAFV600E positivity and extracystic cancerous extension was statistically significant [1.0 (7/7) vs. 0.5 (4/8); p value = 0.0035]. BRAFV600E positivity seems to be predictive of locally advanced disease mandating RIA therapy. Therefore, it could serve as a preoperative tool that predicts the need for total thyroidectomy, in addition to Sistrunk's procedure.

Successful reversal of isolated delayed spinal cord ischemia following endovascular abdominal aneurysm repair.

A 74-year-old patient presented with isolated fecal incontinence 6 weeks following endovascular aneurysm repair. The delayed presentation of spinal cord ischemia was precipitated by commencement of alpha-blockers for benign prostatic hyperplasia. This case stresses that vulnerability to spinal cord perfusion is not limited to the perioperative period. In addition, systemic arterial pressure should be closely monitored in cases of marginal vascular insufficiency of the spinal cord.