Rapid intervention team strategy improves intervention quality for patients undergoing hemodialysis with arteriovenous shunt dysfunction or failure.

BACKGROUND: Vascular access dysfunction is a great burden for hemodialysis patients. Early intervention of a dysfunctional arteriovenous shunt is associated with higher technical success and may improve midterm patency. This trial aimed to estimate the feasibility of a new system, the "rapid intervention team" (RIT) strategy. METHODS: We recruited hemodialysis patients who visited our hospital because of arteriovenous shunt dysfunction or failure to undergo an RIT strategy from September 1, 2019 to December 31, 2022. In addition, we included a control group comprising patients who underwent percutaneous intervention for arteriovenous shunt dysfunction or failure before this strategy was implemented from February 1, 2017 to December 31, 2022. Case number, time to intervention, all-cause mortality, cumulative survival rate, and number of patients who required temporary dialysis catheter insertion and recreation were compared between the two groups. The primary endpoints were double-lumen insertion, a composite outcome involving permanent catheter insertion, and the need for recreation. The secondary endpoint was all-cause mortality. RESULTS: We enrolled 1054 patients, including 544 (51.6%) and 510 (48.4%) in the RIT and control groups, respectively. Even with the coronavirus disease of 2019 (COVID-19) pandemic, the number of cases significantly increased after the implementation of the RIT strategy (from 216 in 2019 to 828 in 2022, p for trend <0.001). The RIT group had a shortened time to intervention ( p for trend <0.001). The implementation of the RIT strategy was significantly associated with a reduced risk of insertion of a temporary double-lumen catheter and recreation of vascular access (1% vs 6% and 1% vs 28%, respectively; both p < 0.01). The cumulative survival rate was not significantly different between the RIT and control groups ( p = 0.16). CONCLUSION: The implementation of the RIT strategy improves the quantity and quality of percutaneous transluminal intervention for arteriovenous shunt dysfunction or failure in patients undergoing hemodialysis.

Three-stage approach for aortoesophageal fistula after Roux-en-Y esophagojejunostomy.

Surgical management of post-esophagojejunostomy aortoesophageal fistula (AEF) has been scarcely reported, but is universally fatal. This report described a case of AEF after total gastrectomy with Roux-en-Y esophagojejunostomy and adjuvant chemoradiotherapy for gastric cardiac cancer. A three-stage hybrid approach was used to successfully manage this complication. First, thoracic endovascular aortic repair curbed bleeding. Second, radical fistula resection eradicated infected areas and adjacent structures. Third, esophageal reconstruction using an ileocolonic conduit restored gastrointestinal continuity. This strategy could be safely feasible for managing post-esophagojejunostomy AEF.

Safety Time and Optimal Temperature of Unilateral Antegrade Cerebral Perfusion in Acute Type A Aortic Dissection: A Single-Center 15-Year Experience.

Background: The optimal level of hypothermia and safe time of unilateral antegrade cerebral perfusion (uACP) in acute type A aortic dissection (ATAAD) repair remain controversial. Objectives: To analyze the association of uACP time and circulatory arrest temperature with surgical outcomes of ATAAD. Methods: We retrospectively analyzed 263 patients who had undergone ATAAD repair between 2006 and 2020 using uACP. The patients were stratified by three chronologically equivalent periods (period 1, 2006 to 2010; period 2, 2011 to 2015; period 3, 2016 to 2020) to demonstrate the decade-long evolution of surgical strategy and outcomes. Results: The mean age of the patients was 59.4 ± 12.5 years, and 68.8% were male. The hospital mortality rates were 15.1%, 12.9%, and 11.0% from period 1 to 3 (p = 0.740). The median circulatory arrest temperatures were 20, 23, and 25 °C (p < 0.001), respectively, and the median uACP times were 72, 59, and 41 minutes (p < 0.001). The incidence rates of postoperative permanent neurologic deficits were 13.2%, 10.9%, and 18.3% (p = 0.312), and those of transient neurologic deficits were 9.4%, 10.9%, and 11.9% (p = 0.936), respectively. Multivariate logistic regression analysis showed that uACP time ≥ 60 minutes was an independent predictor of hospital mortality rather than postoperative stroke. ROC curve analysis estimated an optimal cutoff value of 52 minutes of uACP time when the circulatory arrest temperature was ≥ 25 °C to predict hospital mortality (area under the curve: 0.72). Conclusions: Unilateral antegrade cerebral perfusion time was associated with hospital mortality after ATAAD surgery. A safe threshold of 50 to 60 minutes of uACP should be considered.

Simultaneous Thrombolysis and Extracorporeal Membrane Oxygenation for Acute Massive Pulmonary Emboli.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been used in patients with circulatory collapse or extremely unstable hemodynamics caused by acute massive pulmonary embolism (PE). The effectiveness of simultaneous thrombolytic therapy has been rarely investigated in these patients after being stabilized with ECMO. METHODS: From January 2008 to December 2018 consecutive patients with acute massive PE requiring ECMO supported in a tertiary medical center were included for retrospective analysis. RESULTS: Thirteen patients with PE underwent ECMO implantation and received subsequent thrombolytic therapy as a definite treatment for PE. All patients survived their ECMO courses to a successful decannulation, with a mean ECMO support duration of 6.23 ± 4.69 days. Eleven patients (84.62%) survived to hospital discharge. All survivors were alive during follow-up, although 2 patients (18.2%) had permanent dysfunctional neurologic complications. Major bleeding complications occurred in 4 patients (30.77%), whereas no patient had intracranial hemorrhage. Systemic thrombolysis showed comparable outcomes of catheter-directed thrombolysis in our patients who underwent ECMO. CONCLUSIONS: Thrombolysis-based therapeutic strategy under ECMO could be a relatively safe and effective definitive treatment for patients with acute massive PE, even for those who were resuscitated. Bleeding complications remain a major concern and should be monitored and managed immediately.

Outcomes of coronary artery bypass grafting in patients with inflammatory rheumatic diseases: an 11-year nationwide cohort study.

OBJECTIVE: Patients with inflammatory rheumatic diseases have an increased risk of developing coronary atherosclerosis. However, outcomes of surgical revascularization in these patients have been rarely studied. We aimed to determine whether, or which, inflammatory rheumatic diseases may pose effects on mortality and adverse cardiac outcomes after coronary artery bypass grafting. METHODS: By using the National Health Insurance Research Database of Taiwan, we identified 40,639 adult patients who underwent first-time coronary artery bypass grafting between 2000 and 2010. Among these patients, 101 had rheumatoid arthritis, 56 had systemic lupus erythematosus, and 73 had ankylosing spondylitis. The odds ratios (ORs) of operative mortality and hazard ratios (HRs) of overall mortality and adverse cardiac outcomes after coronary artery bypass grafting (ie, myocardial infarction and repeat revascularization) in relation to rheumatoid arthritis, systemic lupus erythematosus, and ankylosing spondylitis were estimated. RESULTS: With adjustment for potential confounders including patient characteristics, hospital levels, and combined surgery, systemic lupus erythematosus was an independent predictor for operative mortality (adjusted OR, 2.63; 95% confidence interval [CI], 1.04-6.65; P = .04) and ankylosing spondylitis was marginally associated with operative mortality (adjusted OR, 2.41; 95% CI, 0.99-5.88; P = .054). Systemic lupus erythematosus was a significantly independent predictor for overall mortality during the follow-up period (adjusted HR, 2.23; 95% CI, 1.51-3.31; P < .0001) and might increase the risk of repeat revascularization (adjusted HR, 1.89; 95% CI, 0.97-3.68; P = .06). Neither rheumatoid arthritis nor ankylosing spondylitis was significantly associated with overall mortality and adverse cardiac outcomes. CONCLUSIONS: Our study may help surgeons and physicians recognize the potential risks inherent to systemic lupus erythematosus and ankylosing spondylitis when conducting coronary artery bypass grafting and providing follow-up care.

Secondary aortocolic fistula: case report and review of the literature.

A secondary aortoenteric fistula (SAEF) is relatively rare after abdominal aortoiliac reconstructive surgery. Most SAEFs are associated with a graft prosthesis, and rectum involvement is rarely reported. We report a rectal SAEF after aortoiliac aneurysmorrhaphy, i.e., oversewing the artery without a graft. A 62-year-old man had an appendicitis-related infected right common iliac artery aneurysm and sterile left aortoiliac arterial aneurysm. Six weeks after an appendectomy with a right iliac aneurysmectomy, left aortoiliac reduction aneurysmorrhaphy, and femorofemoral bypass grafting, he developed repeated bloody stool. Abdominal computed tomography and colonoscopy findings strongly indicated communication between the native aortic or iliac arteries and the rectal lumen. Emergency surgery-left infected aortoiliac artery excision, oversewing the aortic stump, right axillofemoral bypass, and sigmoid protectomy with an end-colostomy-was performed. Unfortunately, the aortic stump developed a pseudoaneurysm 6 weeks after the second laparotomy. During the third emergency laparotomy, more of the stump was amputated and wrapped in the omentum. At 45-month follow-up, the patient was well and without infection recurrence or leg ischemia. This case is a reminder that even patients without a graft prosthesis are at risk for SAEF after any aortoiliac surgery. We also comprehensively reviewed the English literature from 1960 to 2008 on prosthesis-free SAEF patients.

Modified exchange technique for management of dysfunctional tunneled hemodialysis catheters in the presence of exit-site infection: a quality improvement report.

BACKGROUND: Over-the-wire exchange is a standard treatment for patients with tunneled hemodialysis catheters (THCs) that fail to maintain sufficient extracorporeal blood flow. However, this well-known procedure is unsuitable in the presence of exit-site infection (ESI). In such cases, a modified exchange technique with introduction of the new THC through a remote exit site and the preexisting subcutaneous tunnel may be a solution. STUDY DESIGN: Quality improvement report. SETTING & PARTICIPANTS: Since 2005, a total of 28 consecutive dysfunctional THCs with ESI in 23 patients who did not have tunnel infection or bacteremia before the procedures was included. QUALITY IMPROVEMENT PLAN: Introduction of the new THC through a remote exit site and preexisting subcutaneous tunnel. MEASUREMENTS: Technical success, perioperative complications, infection rates, and catheter function were recorded for analysis. RESULTS: There was only 1 failure, giving an overall technical success rate of 96%. The other 27 exchanged THCs achieved satisfactory flow during subsequent hemodialysis, and the ESI gradually resolved within 2 weeks. Although 8 episodes of new ESI occurred, no subcutaneous tunnel infection or bacteremia occurred within 120 days. Bedridden patients had more occurrences of new ESIs than nonbedridden patients (6 of 9 versus 2 of 13 patients; P = 0.03). Primary catheter patency rates were 100% at 30 days, 82% at 90 days, and 77% at 120 days. Secondary catheter patency rates were 100% at 30 days, 91% at 90 days, and 91% at 120 days. LIMITATION: A small number of cases and comparison with previous studies of THC exchange. CONCLUSIONS: For dysfunctional THCs with ESI, exchange through remote exit sites and preexisting subcutaneous tunnels is feasible and can be used repeatedly for patients prone to ESI, such as the bedridden. This modified exchange technique is also preferable for operators who question the sterility of previous exit sites and are reluctant to use the over-the-wire technique.

Successful conservative management with positive end-expiratory pressure for massive haemothorax complicating pacemaker implantation.

Haemothorax resulting from injury to a great vessel is a potential complication during transvenous pacemaker implantation that can be caused by perforation by the electrode. If the amount of bleeding is massive, control needs thoracotomy. We report on a 70-year-old man who had a massive haemothorax following transvenous pacemaker implantation. This complication was controlled successfully by using positive end-expiratory pressure (PEEP). We conclude that this simple but reproducible experience may offer effective haemostasis for a massive haemothorax caused by transvenous catheter perforation.

Correction of tetralogy of fallot with absent pulmonary valve syndrome in a young infant using a bicuspid equine pericardial tube.

Absent pulmonary valve syndrome (APVS) is an uncommon variant of tetralogy of Fallot (TOF), which manifests morphologically as vestigial pulmonary valve cusps at the right ventricle-pulmonary trunk junction. The aneurysmally dilated pulmonary arteries may compress the tracheobronchial tree and cause severe respiratory distress in the neonatal or infant stage. Early surgical correction in these patients is necessary despite the high operative mortality rate. A 1-day-old male neonate suffered from progressive shortness of breath after birth. Echocardiography confirmed the diagnosis of TOF with APVS. The marked dilatation of pulmonary arteries resulted in airway compression in addition to heart failure. Total surgical correction was performed at 40 days of age, using a homemade bicuspid equine pericardial tube for right ventricular outflow reconstruction. The short-term follow-up echocardiogram demonstrated good motility of the pericardial leaflet. However, patients receiving this type of valved conduit require meticulous long-term follow-up.