Tortuous Carotid Arteries and Their Clinical Implications: A Report of Two Cases.

The tortuous carotid artery is a rare anatomic abnormality defined as vascular elongation leading to an altered course. It can be discovered incidentally or have clinically significant manifestations. The most common location is the internal carotid artery or, less commonly, the common carotid artery. Bilateral tortuous carotid arteries can also occur, leading to "kissing carotids" where the carotid arteries are juxtaposed. We describe two cases of carotid artery tortuosity in patients with risk factors associated with its development. One case is of a 91-year-old female presenting with a cerebrovascular accident and an incidental finding of tortuosity of the right common carotid artery mimicking the appearance of "kissing carotids." The other case concerns a 66-year-old female with a symptomatic tortuous left internal carotid artery. This report aims to inform clinicians of the differences in the anatomical features, pathogenesis, and possible clinical implications of these variants.

Carl Toldt Centennial, Surgeon and Anatomist.

Carl Florian Toldt was an Austrian anatomist who made meaningful contributions worldwide and defined what is one of the most important surgical landmarks in abdominal surgery. Through his research studies, the embryologic dissection plane known as the "White Line of Toldt" represents an important anatomical landmark that helps to mobilize either the ascending or descending colon. His career spanned over 45 years, beginning in Verona and continuing to Prague and Vienna. He was an author of several innovative books and scientific articles regarding micro- and macroscopic anatomy. In addition, he received numerous recognitions and prizes for his work, making him an essential figure in the medical scientific community. Even a street in Vienna, Karl-Toldt-Weg, is named in his honor. The purpose of this historical article is to celebrate and honor Toldt 100 years following his death, remembering his scientific contributions to the medical and surgical fields and giving thanks for his numerous accomplishments. This article brings light to the man behind the eponym.

Evidence to support a drain-free strategy in kidney transplantation using a retrospective comparison of 500 consecutively transplanted cases at a single center.

INTRODUCTION: Routine placement of surgical drains at the time of kidney transplant has been debated in terms of its prognostic value. OBJECTIVES: To determine whether the placement of a surgical drain affects the incidence rate of developing wound complications and other clinical outcomes, particularly after controlling for other prognostic factors. METHODS: Retrospective analysis of 500 consecutive renal transplant cases who did not (Drain-free, DF) vs. did (Drain, D) receive a drain at the time of transplant was performed. The primary outcome was the development of any wound complication (superficial or deep) during the first 12 months post-transplant. Secondary outcomes included the development of superficial wound complications, deep wound complications, DGF, and graft loss during the first 12 months post-transplant. RESULTS: 388 and 112 recipients had DF/D, respectively. DF-recipients were significantly more likely to be younger, not have pre-transplant diabetes, receive a living donor kidney, receive a kidney-alone transplant, have a shorter duration of dialysis, shorter mean cold-ischemia-time, and greater pre-transplant use of anticoagulants/antiplatelets. Wound complications were 4.6% (18/388) vs. 5.4% (6/112) in DF vs. D groups, respectively (P = 0.75). Superficial wound complications were observed in 0.8% (3/388) vs. 0.0% (0/112) in DF vs. D groups, respectively (P = 0.35). Deep wound complications were observed in 4.1% (16/388) vs. 5.4% ((6/112) in DF vs. D groups, respectively (P = 0.57). Higher recipient body mass index and ≥ 1 year of pre-transplant dialysis were associated in multivariable analysis with an increased incidence of wound complications. Once the prognostic influence of these 2 factors were controlled, there was still no notable effect of drain use (yes/no). The lack of prognostic effect of drain use was similarly observed for the other clinical outcomes. CONCLUSIONS: In a relatively large cohort of renal transplant recipients, routine surgical drain use appears to offer no distinct prognostic advantage.

Dislodged Nephrostomy Catheter: An Unusual Case of Idiopathic Transposition of Nephrostomy Catheter From Transplanted Kidney to Adjacent Small Bowel Loop: A Case Report.

A 72-year-old man with a past medical history notable for deceased renal transplant presented to the interventional radiology department for routine right lower quadrant renal transplant nephroureteral catheter exchange. The nephroureteral catheter was placed in 2016 because of the presence of a hematoma causing partial page kidney and hydronephrosis. An antegrade nephrostogram was notable for opacification of the small bowel instead of the renal collecting system. The patient then subsequently developed urinary retention and intractable abdominal pain. Because of the combination of events, it was deemed necessary for laparotomy and surgical repair of the small bowel. Intraoperative findings were notable for small bowel adhesion to the abdominal wall but otherwise no evidence of acute inflammatory changes. In this case report, we describe the first case of an idiopathically dislodged nephrostomy catheter to the small bowel from a transplanted kidney and its successful management.

Arterial reconstruction with donor iliac vessels during kidney transplantation in a patient with severe atherosclerosis.

Atherosclerosis is common in patients with end-stage renal disease. Severe calcification of the iliac vessels is expected in the growing pool of kidney transplant candidates. Thus, transplant surgeons must constantly develop alternative operative strategies to deal with the technical challenges that this condition confers. This case report aims to highlight a reconstructive vascular technique to salvage a completely calcified recipient external iliac artery using a deceased donor's arterial iliac allograft from the same donor as the renal allograft in a 59-year-old man, as an effective method to decrease vascular complications.

Hand-assisted laparoscopic nephrectomy in a high risk overweight donor with left-sided IVC, and previous abdominal surgery.

INTRODUCTION: The extension of donor eligibility criteria represents one of the possible ways to increase the organ shortage, thus decreasing the waiting time for kidney transplantation. Expectedly, this strategy is associated with a growing number of more technically demanding living donor nephrectomy procedures requiring careful assessment, and sound surgical experience in order to avoid intraoperative complications. CASE PRESENTATION: After a thorough evaluation through preoperative imaging, we performed a hand-assisted left laparoscopic living donor nephrectomy in a 56 year-old overweight patient with history of prior abdominal surgery, harboring a left-sided inferior vena cava (IVC). DISCUSSION/CONCLUSION: This case describes our comprehensive approach in this complex surgical scenario to preserve donor safety and provide an optimal kidney graft.

Pulmonary tumor embolization as early manifestation in patients with renal cell carcinoma and tumor thrombus: Perioperative management and outcomes.

BACKGROUND: Renal cell carcinoma (RCC) with tumor thrombus extending into the inferior vena cava (IVC) occurs in 4%-10% of cases. Within this subset, pulmonary tumor embolism (PTE) appears in approximately 0.9%-2.4% of cases. We wanted to review our experience in managing patients with RCC with IVC involvement and a preoperative diagnosis of PTE. METHODS: A total of seven patients presented at our center between January, 2005 and January, 2015 with RCC, IVC involvement, and PTE (diagnosed either by chest computerized tomography angiography or preoperative transesophageal echocardiogram). Each patient underwent a radical nephrectomy and tumor thrombectomy using an organ transplant-based approach. RESULTS: Surgical removal of the PTE was performed in three patients (tumor embolectomy in two cases, right lower lobe resection in one case); the PTEs in four patients were considered to be too small to undergo surgical resection. PTE pathology found neoplastic cells in each patient that had surgical removal. No postoperative complications were observed in any of the seven patients. All four patients who were metastasis-free preoperatively (with 2/4 having tumor embolectomy performed) developed distant metastasis; median time-to-developing metastatic disease was 6.5 months. With a median follow-up of 19 months, three deaths because the disease have occurred. CONCLUSION: Although RCC with IVC tumor thrombus complicated by PTE may not be catastrophic in most cases, it appears to be associated with an increased risk of developing metastatic disease. In addition, as the PTEs appear to contain neoplastic cells, pulmonary artery embolectomy at the time of nephrectomy should be performed whenever possible.

Vascular Reconstructions in Living Unrelated Kidney Transplant Using Donor Ovarian Vein and Recipient Inferior Epigastric Artery with Simultaneous Enucleation of a Complex Cyst.

Increasing the organ donor pool and solving the recipient demands continue to be one of the challenges in transplantation. We report our experience in transplanting a living donor kidney requiring complex vascular reconstructions and an enucleation of complex cyst. A 57-year-old male patient underwent a living unrelated kidney transplant. The living donor kidney was procured through a laparoscopic hand-assisted right donor nephrectomy. After vascular stapling, the kidney had a short upper pole arterial branch, a short renal vein (3 mm), and a complex upper pole cyst. The renal vein was elongated using the donor ovarian vein and the short upper pole artery was extended using the recipient inferior epigastric artery and anastomosed to the main renal artery. The renal allograft vessels were anastomosed end-to-side to the external iliac vessels. The complex cyst was removed performing an enucleation with a rim of normal tissue and reconstruction of the calyceal system. This case represents three different surgical reconstructions in order to make the organ available for transplantation. In some circumstances, complex vascular reconstruction of living donor kidney with removal of complex cyst represents a strategy to expand the donor pool.