Renal Cell Carcinoma With Tumor Thrombus: A Case Series in Puerto Rico.

INTRODUCTION:  Renal cell carcinoma (RCC) is one of the most common types of kidney cancer. While RCC tends to present as a localized tumor, a notable proportion may present with distant metastasis. In some instances, RCC may also present with intravascular tumor extension, often called tumor thrombus (TT). Its presence confers a worse prognosis and has important implications for the tumor's staging and treatment. Despite extensive documentation of RCC TT in the US, limited data exists regarding its presentation, management, and outcomes in Puerto Rico (PR). This study aims to broaden the available information on RCC TT, emphasizing surgical management and outcomes. We also provide descriptive data on patient demographics and clinical presentation to improve decision-making among clinicians caring for Puerto Rican men and women. METHODS:  In this single-center, retrospective study, we evaluated patients who underwent partial or total nephrectomy at Saint Luke's Episcopal Medical Center between 2018 and 2022. Data was abstracted from electronic health records (EHR). Patients without documented evidence of TT during the peri-operative period were excluded from the study. A total of 220 patient records were evaluated, of which 12 met the inclusion criteria for the study. Cases were categorized using the latest RCC TT guidelines. Central tendency measurements were used to describe the sample distribution. The mean was considered to make assumptions regarding the prevalent observations, and the median was considered to rule out possible outliers. Categorical data were evaluated using proportion analyses, including TT extension level and BMI variables. Fisher's exact test evaluated the association between the World Health Organization/International Society of Urological Pathology (WHO/ISUP) grade and TT extension level. RESULTS:  Most patients lacked TT-related symptoms. The most severe presenting symptom was a pulmonary embolism (8.3%). Hypertension (83.3%), BMI greater than 25 at the time of diagnosis (75%), and type 2 diabetes mellitus (66.7%) were the most common comorbid conditions within our cohort. Nearly 75% of patients underwent laparoscopic radical nephrectomy with TT resection. One left-sided level III case was managed by laparoscopic-assisted open radical nephrectomy with a right subcostal incision. There were zero intraoperative complications and two postoperative complications. The histopathological reports of all cases were consistent with clear cell carcinoma, and half of the cases (n=6) were WHO/ISUP G4. All patients are alive and free of disease. CONCLUSION:  RCC is a common renal neoplasm in PR that can present with intravascular tumor extension. Our findings do not establish a definitive association between BMI, tumor size, WHO/ISUP grading, and TT extension level. Our study shows that laparoscopic removal of RCC TT is a safe and effective approach. However, the generalizability of our findings is limited by the study's design and sample size. Future research should focus on identifying predictive markers, establishing effective screening protocols, and determining if our hybrid approach has comparable outcomes to the standard open approach.

Human gelatin thrombin matrix with rifampin for the treatment of prosthetic vascular graft infections.

We aim to describe and report on a novel graft preservation technique using a human gelatin thrombin matrix with rifampin for the treatment of vascular graft infections. Eight patients with vascular graft infections were included, one with bilateral infections, for a total of nine cases from January 2016 through June 2021. All the patients underwent wound exploration and placement of human gelatin thrombin matrix with rifampin. No deaths or allergic reactions had been reported at the 30-day follow-up, with only one major amputation. The graft and limb salvage rates were 77.8% at the 1-year follow-up. The mean time to a major amputation was 122 days, and the mean time to graft excision was 30 days.

Transcatheter Arterialization of Deep Veins in Chronic Limb-Threatening Ischemia.

BACKGROUND: Approximately 20% of patients with chronic limb-threatening ischemia have no revascularization options, leading to above-ankle amputation. Transcatheter arterialization of the deep veins is a percutaneous approach that creates an artery-to-vein connection for delivery of oxygenated blood by means of the venous system to the ischemic foot to prevent amputation. METHODS: We conducted a prospective, single-group, multicenter study to evaluate the effect of transcatheter arterialization of the deep veins in patients with nonhealing ulcers and no surgical or endovascular revascularization treatment options. The composite primary end point was amputation-free survival (defined as freedom from above-ankle amputation or death from any cause) at 6 months, as compared with a performance goal of 54%. Secondary end points included limb salvage, wound healing, and technical success of the procedure. RESULTS: We enrolled 105 patients who had chronic limb-threatening ischemia and were of a median age of 70 years (interquartile range, 38 to 89). Of the patients enrolled, 33 (31.4%) were women and 45 (42.8%) were Black, Hispanic, or Latino. Transcatheter arterialization of the deep veins was performed successfully in 104 patients (99.0%). At 6 months, 66.1% of the patients had amputation-free survival. According to Bayesian analysis, the posterior probability that amputation-free survival at 6 months exceeded a performance goal of 54% was 0.993, which exceeded the prespecified threshold of 0.977. Limb salvage (avoidance of above-ankle amputation) was attained in 67 patients (76.0% by Kaplan-Meier analysis). Wounds were completely healed in 16 of 63 patients (25%) and were in the process of healing in 32 of 63 patients (51%). No unanticipated device-related adverse events were reported. CONCLUSIONS: We found that transcatheter arterialization of the deep veins was safe and could be performed successfully in patients with chronic limb-threatening ischemia and no conventional surgical or endovascular revascularization treatment options. (Funded by LimFlow; PROMISE II study ClinicalTrials.gov number, NCT03970538.).

Hilar Renal Artery Aneurysm Repair Using Coil Embolization and Covered Stent.

INTRODUCTION:: Little has been reported regarding endovascular therapy with stent of renal artery hilar aneurysms. To that end, we herein report the outcomes of 3 hilar renal artery aneurysms (RAA) treated with an endovascular technique that makes use of a covered stent and coil embolization in the repair of hilar RAA and deem using this technique is better than traditional open approach with back-table repair and autotransplatation. METHODS:: Since November 2014, 3 consecutive patients have been referred to the vascular surgery service for evaluation of a right RAA; these patients' aneurysms were diagnosed with a CT arteriogram prior to evaluation. These patients, typically treated with open surgery, were deemed to be candidates for endovascular repair and were treated as follows: (1) cannulation of the right Common Femoral Artery with a selective arteriogram of the right renal artery, (2) covered stent to dominant hilar artery branch, and (3) coil embolization of the remaining branches/tributaries. Perioperative outcomes and quality measures were analyzed and compared. RESULTS:: The aneurysms were successfully covered and excluded as confirmed by a completion arteriogram. There were no perioperative morbidities (ie, acute kidney injury, endoleak, etc), and all 3 patients were discharged home the same days of their interventions. At their follow-up visits, the patients were free of symptoms and had normal renal functions as well as Computed tomography angiography (CTA) confirming successfully excluded aneurysms and no endoleaks. CONCLUSION:: The technique we used demonstrated excellent outcomes with minimal comorbidities and preservation of renal function. As with many endovascular interventions, our technique compared favorably to traditional open technique in terms of technical feasibility, decreased length of stay, faster recovery, maintaining renal function, and reduced complication rates.

The impact of a rapid imaging protocol in acute cholecystitis-prospective cohort study.

INTRODUCTION: In this study we assess the impact of a "rapid imaging protocol" (RIP) on outcomes in patients with suspected acute cholecystitis (AC). METHODS: From January 2017 to January 2018, a prospective cohort study was implemented using a RIP with hepatoscintigraphy (HIDA) or CT scan (first available, goal within 4 h) in patients (n = 52) presenting with highly suspected AC and a clinical feature score of ≥1. For the latter, the following presenting features were scored as follows: 1 point for WBC count ≥10,000 (109/L), 1.5 points for glucose ≥140 (mg/dl), and/or 1 point for age ≥50 yrs. The historical control was all patients admitted with suspected AC in a 1.5-year period (n = 117) under our previous "delayed imaging protocol" (DIP), which used US ± HIDA (post-admission) in select patients. Primary end points included: compare outcome and quality measures between the groups, evaluate diagnostic imaging performance for AC, and evaluate our proposed clinical feature score in the setting of AC. RESULTS: Histopathologic features consistent with AC was more frequent in patients in the RIP (64% vs 39%, p = 0.008). The pooled positive predictive value of HIDA and CT scan for AC were 85% vs 94%, respectively. The RIP was associated with a significant reduction in time to surgery, length of stay, and conversions to open (p < 0.001, respectively). A clinical feature score of 3.5 predicted the likelihood of AC in 95% of the cases (x2 for linear trend = 42, p < 0.001). CONCLUSION: A protocol centered around rapid identification, defined clinical criteria (i.e. clinical feature score), and confirmation with non-user dependent imaging modalities has resulted in favorable outcomes. CT may be the study of choice when the likelihood of AC is high because it is superior at identifying severity.

Symptomatic, unilateral, isolated, complete persistent sciatic vein.

Persistent sciatic vein is a rare anomaly of mesodermal development. When found, it is often associated with varicosities in abnormal distributions, pain, limb congestion, and hypertrophy. In this report, we describe a case of an isolated, complete persistent sciatic vein with an atypical anatomy and onset.

Hybrid operative thrombectomy is noninferior to percutaneous techniques for the treatment of acute iliofemoral deep venous thrombosis.

OBJECTIVE: Hybrid operative thrombectomy (HOT) is a novel technique for the treatment of acute iliofemoral deep venous thrombosis (IFDVT) and is an alternative to percutaneous techniques (PTs) that use thrombolytics. In this study, we compare perioperative and intermediate outcomes of HOT vs PT as interventions for early thrombus removal. METHODS: From July 2008 to May 2015, there were 71 consecutive patients who were treated with either PT (n = 31) or HOT (n = 40) for acute or subacute single-limb IFDVT. HOT consisted of surgical thrombectomy with balloon angioplasty with or without stenting by a single incision and fluoroscopically guided retrograde valve manipulation to extract the thrombus. PT included catheter-directed thrombolysis with or without pharmacomechanical thrombectomy using the Trellis-8 system (Bacchus Vascular, Santa Clara, Calif). Patients who presented with bilateral DVT (n = 4), inferior vena cava involvement (n = 8), or venous gangrene (n = 1) were excluded. Perioperative outcomes, quality measures, and thrombus resolution were compared between the two treatment groups. Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification, Villalta score, and venous duplex ultrasound at intermediate follow-up were also analyzed. RESULTS: The left limb was the most common site of the IFDVT overall. Technical success (≥50% resolution) was 100% for both groups, and >80% resolution was achieved in all patients treated with HOT. There were eight major bleeding events in the PT group compared with three in the HOT group (P = .04). PT patients had a significantly longer length of stay (13 vs 10 days; P = .028) compared with HOT. At 2-year duplex ultrasound examination, there was no difference between HOT and PT in mean reflux times at the femoral-popliteal segment. At 2 years, 85% and 87% of the patients (HOT vs PT, respectively) had not developed post-thrombotic syndrome, and there was no difference between the groups for mean Villalta score (2.1 ± 1.9 vs 2.3 ± 2; P = .79). CONCLUSIONS: PT and HOT have demonstrated good outcomes in the perioperative and intermediate periods. HOT is noninferior to PT as a technique for early thrombus removal and has the advantages that thrombus resolution is established in one operation and length of stay is significantly decreased. HOT avoids thrombolytic therapy, which may reduce major bleeding events.

Clinical implications of hepatobiliary scintigraphy and ultrasound in the diagnosis of acute cholecystitis.

BACKGROUND: We assess the performance of ultrasound (US) and hepatobiliary scintigraphy (HIDA) as confirmatory studies in acute cholecystitis (AC) and demonstrate our current imaging protocol's impact on outcomes. STUDY DESIGN: Between January 2013 to July 2014, 117 patients were admitted through the emergency room with a preliminary diagnosis of AC. Overall, 106/117 (91%) of the patients received US preadmission and 34/117 (29%) received a HIDA post admission. Primary end points included: 1) diagnostic test reliability for AC, and 2) outcome and quality measures (time to surgery, LOS, costs, etc.). RESULTS: Laparoscopic cholecystectomy was performed in 96/117 (82%) and open cholecystectomy in 21/117 (18%) of the patients. Overall, histopathologic features consistent with AC was present in 46/117 (39%). AC alone was present in 23/117 (20%), and AC superimposed on chronic cholecystitis was present in 23/117 (20%). For AC, US had a sensitivity and specificity of 26% and 80%, respectively. HIDA scan had a sensitivity and specificity of 87% and 79%, respectively. Time to surgery (TTS) was 4 vs 2.3 days in patients who received HIDA vs US alone (p = 0.001), and length of stay (LOS) was 6.7 vs 4.3 days, respectively (p = 0.001). Age >50 years, glucose >140 (mg/dl), and WBC count >10 (×109 /L) were statistically significant independent variables associated with AC. CONCLUSION: HIDA scan is superior to US as a diagnostic study in the setting of AC. Our current protocol of delayed HIDA (post-admission) was associated with increased TTS, LOS, and overall costs. Early confirmation with HIDA in high risk patients may hasten treatment allocation and improve outcomes in the setting of AC.

Symptomatic iliofemoral deep venous thrombosis treated with hybrid operative thrombectomy.

During the past 15 years, strategies that promote immediate and complete thrombus removal have gained popularity for the treatment of acute-onset iliofemoral deep venous thrombosis. In this case report, we describe a novel operative approach to venous thrombus removal known as hybrid operative thrombectomy. The technique employs a direct inguinal approach with concomitant retrograde advancement of a balloon catheter by femoral venotomy. Moreover, it provides effective thrombus removal through a single incision, with or without stent placement, and has the advantage of a completion venogram.

The quantitative benefit of isolated, segmental, pharmacomechanical thrombolysis (ISPMT) for iliofemoral venous thrombosis.

BACKGROUND: Early thrombus removal in patients with iliofemoral deep venous thrombosis (IFDVT) reduces postthrombotic morbidity. Preserving valve function and relieving venous obstruction prevents deterioration of quality of life and loss of economic potential. The preferred method for treating IFDVT is catheter-directed thrombolysis (CDT). Recently, isolated segmental pharmacomechanical thrombolysis (ISPMT) has emerged as a treatment option for patients with extensive IFDVT. The purpose of our study is to determine whether there are advantages to using ISPMT as the primary treatment for patients with iliofemoral IFDVT and, if so, to quantify those advantages relative to CDT. METHODS: Forty-three patients with IFDVT were treated with percutaneous CDT between May 2003 and June 2007. Twenty-one patients (27 limbs) were treated with CDT and 22 patients (25 limbs) were treated with ISPMT +/- CDT. Demographics, extent of thrombus, procedural details, and thrombus resolution were recorded. RESULTS: Treatment time (55.4 vs 23.4 hours; P < .0001) and dose of rt-PA (59.3 vs 33.4 mg; P = .0009) were decreased and overall lytic success (60% vs 80%; P = .0016) increased with ISPMT. Adjunctive venoplasty and stenting, complications, hospital length-of-stay (LOS), and intensive care unit LOS were similar between groups. CONCLUSION: ISPMT offers more effective thrombus removal in less time and with a reduced dose of thrombolytic agent. However, decreased treatment time did not translate into decreased hospital or ICU stay. Longer-term follow-up is required to determine whether improved thrombus resolution translates to better functional outcome and reduced postthrombotic morbidity.

Use of the abdominal aorta as an alternative access site for thoracic aortic stent graft placement.

The treatment of thoracic aortic pathology has undergone a paradigm shift in recent years, with a trend toward less invasive endovascular techniques and away from open surgical repair. Reports on the successful use of endografts in the thoracic aorta have demonstrated decreased morbidity and mortality of these procedures compared with traditional open repair. However, some patients are not candidates for an endovascular approach because of a short proximal landing zone, arch angulation, luminal irregularities, or a large diameter of the transverse arch and the proximal descending aorta. Other patients are excluded because of distal pathology or anatomic irregularities. This article presents 2 patients with thoracic aortic pathology, and both had inadequate proximal landing zones and small, calcified iliac arteries prohibiting femoral or iliac access. Successful repair of these patients was achieved by a staged procedure using a brachiocephalic debranching technique, followed by direct infrarenal aortic cannulation through a limited celiotomy.