Staged angioplasty using a full-length balloon catheter to achieve maturation of arteriovenous fistulas.

PURPOSE: To evaluate the efficacy of staged full-length balloon-assisted maturation (BAM) for the maturation of arteriovenous fistulas (AVFs) on entire segmental veins, including stenosis, causing primary AVF failure. METHODS: This study included patients who underwent AVF surgery using an autogenous vein between February 2020 and June 2021 and received staged angioplasty with a full-length balloon catheter. To minimize balloon overlap and the risk of barotrauma to the immature vein, serial-staged upsizing balloon angioplasty with a long balloon catheter covering the entire vein segment was employed approximately 2 weeks apart. RESULTS: Twenty-three patients (mean age, 69.50 years; mean follow-up, 620.62 days) with average diameters of the radial artery and cephalic vein at 2.14 ± 0.5 mm and 2.43 ± 0.5 mm, respectively, were enrolled. In the first procedure, the average AVF diameter and flow were 4.03 ± 0.57 mm and 438.08 ± 220.95 mL/min, respectively, with juxta-anastomotic stenosis (JAS) present in 61.5% of cases. After staged full-length BAM, the average fistula diameter and flow improved to 5.95 ± 0.86 mm and 717.52 ± 305.95 mL/min, respectively. Maturation was achieved in 87% of the cases. No hematomas or ruptures occurred around the arterialized veins. Despite successful maturation and cannulation, 65.2% of the patients required additional percutaneous transluminal angioplasty (PTA) during the follow-up period. The necessity for PTA was determined by the presence of JAS prior to the first staged full-length BAM, with an odds ratio of 11.74 (95% confidence interval: 1.31-104.96, P = 0.03). CONCLUSION: Staged full-length BAM can be safely used in patients with small veins requiring further maturation. Most patients achieved successful cannulation following maturation without post-procedural complications. CLINICAL SIGNIFICANCE: Staged full-length BAM is a safe and effective method for enhancing maturation in patients with underdeveloped small veins.

Impact of insertion into the left internal jugular vein in chemoport-associated infections: a retrospective single-center study of 1690 cases.

We analyzed chemoport insertion procedures to evaluate infectious morbidity and factors causing infection. This single-center retrospective study included 1690 cases of chemoport implantation between January 2017 and December 2020. Overall, chemoports were inserted in 1582 patients. The average duration of chemoport use was 481 days (range 1-1794, median 309). Infections occurred in 80 cases (4.7%), with 0.098 per 1000 catheter-days. Among the 80 cases in which chemoports were removed because of suspected infection, bacteria were identified in 48 (60%). Significantly more cases of left internal jugular vein punctures were noted in the infected group (15 [18.8%] vs. 147 [9.1%]; p = 0.004). Pulmonary embolism was significantly different between the infection groups (3 [3.8%] vs. 19 (1.2%), p = 0.048). The hazard ratio was 2.259 (95% confidence interval [CI] 1.288-3.962) for the left internal jugular vein, 3.393 (95% CI 1.069-10.765) for pulmonary embolism, and 0.488 (95% CI 0.244-0.977) for chronic obstructive pulmonary disease. Using the right internal jugular vein rather than the left internal jugular vein when performing chemoport insertion might reduce subsequent infections.

Rejoining Veins for Forced Maturation of Small-Caliber Arteriovenous Fistula.

BACKGROUND: To evaluate the efficacy of rejoining mainstream and accessory veins for forced maturation of autogenous arteriovenous fistula (AVF). METHODS: Twenty-three patients who underwent forced maturation through vein rejoining between January 2018 and September 2022 were included. In cases where AVF maturation failure due to the presence of accessory veins, rejoining was primarily considered when distinguishing the main branch becomes challenging. This difficulty typically occurs when the sizes of the 2 vessels are nearly equal and the combined diameters of these veins exceed 6 mm. RESULTS: The mean age and follow-up duration were 57.39 ± 16.22 years and 965.65 ± 573.42 days, respectively. Rejoining of both arterial and venous cannulation sites was performed in 11 patients (47.8%), and rejoining of only the venous cannulation site or only the arterial cannulation site was performed in 11 patients (47.8%) and 1 patient (4.3%), respectively. The mean vein size was 0.35 ± 0.06 cm before rejoining and 0.69 ± 0.07 cm after surgery, indicating a significant increase in size (P < 0.01), whereas the flow did not change significantly following rejoining surgery. Maturation and cannulation success was 100%. The 1-year primary patency rate after surgery was 82.0%. During the follow-up period, 34.8% of the patients required additional percutaneous transluminal angioplasty to maintain patency, and 2 patients (11.8%) had stenosis in the rejoined section. CONCLUSIONS: Rejoining surgery is an effective method for achieving AVF maturation in patients with accessory veins when identification of the mainstream vein is difficult, and this method may be considered when achieving maturation by sacrificing 1 vein is expected to be challenging.

Investigating the influence of collagen cross-linking on mechanical properties of thoracic aortic tissue.

Vascular diseases, such as abdominal aortic aneurysms, are associated with tissue degeneration of the aortic wall, resulting in variations in mechanical properties, such as tissue ultimate stress and a high slope. Variations in the mechanical properties of tissues may be associated with an increase in the number of collagen cross-links. Understanding the effect of collagen cross-linking on tissue mechanical properties can significantly aid in predicting diseased aortic tissue rupture and improve the clarity of decisions regarding surgical procedures. Therefore, this study focused on increasing the density of the aortic tissue through cross-linking and investigating the mechanical properties of the thoracic aortic tissue in relation to density. Uniaxial tensile tests were conducted on the porcine thoracic aorta in four test regions (anterior, posterior, distal, and proximal), two loading directions (circumferential and longitudinal), and density increase rates (0%-12%). As a result, the PPC (Posterior/Proximal/Circumferential) group experienced a higher ultimate stress than the PDC (Posterior/Distal/Circumferential) group. However, this relationship reversed when the specimen density exceeded 3%. In addition, the ultimate stress of the ADC (Anterior/Distal/Circumferential) and PPC group was greater than that of the APC (Anterior/Proximal/Circumferential) group, while these findings were reversed when the specimen density exceeded 6% and 9%, respectively. Finally, the high slope of the PDL (Posterior/Distal/Longitudinal) group was lower than that of the ADL (Anterior/Distal/Longitudinal) group, but the high slope of the PDL group appeared larger due to the stabilization treatment. This highlights the potential impact of density variations on the mechanical properties of specific specimen groups.

Benefit in physical function and quality of life to nonsurgical treatment of varicose veins: Pilot study.

BACKGROUND: Studies on varicose veins have focused its effects on physical function; however, whether nonsurgical treatments alter muscle oxygenation or physical function remains unclear. Moreover, the differences in such functions between individuals with varicose veins and healthy individuals remain unclear. AIM: To investigate changes in physical function and the quality of life (QOL) following nonsurgical treatment of patients with varicose veins and determine the changes in their muscle oxygenation during activity. METHODS: We enrolled 37 participants (those with varicose veins, n = 17; healthy individuals, n = 20). We performed the following measurements pre- and post-nonsurgical treatment in the varicose vein patients and healthy individuals: Calf muscle oxygenation during the two-minute step test, open eyes one-leg stance, 30 s sit-to-stand test, visual analog scale (VAS) for pain, Pittsburgh sleep quality index, physical activity assessment, and QOL assessment. RESULTS: Varicose veins patients and healthy individuals differ in most variables (physical function, sleep quality, and QOL). Varicose veins patients showed significant differences between pre- and post-nonsurgical treatment- results in the 30 sit-to-stand test [14.41 (2.45) to 16.35 (4.11), P = 0.018), two-minute step test [162.29 (25.98) to 170.65 (23.80), P = 0.037], VAS for pain [5.35 (1.90) to 3.88 (1.73), P = 0.004], and QOL [39.34 (19.98) to 26.69 (17.02), P = 0.005]; however, no significant difference was observed for muscle oxygenation. CONCLUSION: Nonsurgical treatment improved lower extremity function and QOL in varicose veins patients, bringing their condition close to that of healthy individuals. Future studies should include patients with severe varicose veins requiring surgery to confirm our findings.

Venous adventitial cystic disease is a very rare disease that can cause deep vein thrombosis: A case report.

BACKGROUND: Venous adventitial cystic disease (VACD) is a rare disease characterized by cysts, filled with a gelatinous mucous substance similar to joint fluid, in the adventitia of blood vessels adjacent to the joints. It is often misdiagnosed as deep vein thrombosis (DVT), femoral varices, venous tumors, or lymphadenopathy. CASE SUMMARY: A 69-year-old woman visited our hospital with a complaint of swelling in the right lower extremity. The patient was diagnosed with DVT and prescribed apixaban at an outpatient clinic. After 3 wk, the patient was hospitalized again because of sudden swelling in the right lower extremity. We diagnosed VACD and performed surgery for cyst removal as well as patch angioplasty and thrombectomy of the right common femoral vein. The patient received anticoagulants for 6 mo and has been doing well without recurrence for 1 year postoperatively. CONCLUSION: Recurrent VACD requires complete removal of the connections to the joint cavity to prevent recurrence.

Gut microbiota differences induced by Toxoplasma gondii seropositivity in stray cats in South Korea.

T. gondii is a highly prevalent parasite worldwide, with cats serving as its final host. However, few studies have investigated the impact of T. gondii infection on cat gut microbiota. Therefore, this study examined the influence of T. gondii infection on the gut microbiota of stray cats and identified potential pathogens in their feces. This study examined T. gondii infection through blood of stray cats and the influence of microbiota in their feces using 16S rRNA gene amplicon sequencing. The results revealed significant differences in gut microbiota composition and diversity between the T. gondii seropositive and seronegative groups. Seropositive samples displayed a lower number of operational taxonomic units and reduced Shannon index than the seronegative samples. The seropositive and seronegative groups exhibited enrichment of taxa, including Escherichia and Enterobacteriaceae and Collinsella, Bifidobacterium, and Roseburia, respectively. Furthermore, potential pathogen species, including Campylobacter, Escherichia, and Streptococcus, were identified in the fecal samples. These findings suggest that T. gondii infection significantly impacts gut microbiota composition and diversity in stray cats. Additionally, an increased potential pathogen load, represented by Escherichia spp., was observed. These results underscore the importance of monitoring the prevalence of zoonotic pathogens in stray cats, as they can serve as reservoirs for zoonotic diseases.

Is Prone Position [18F]FDG PET/CT Useful in Reducing Respiratory Motion Artifacts in Evaluating Hepatic Lesions?

Prone position is useful in reducing respiratory motion artifacts in lung nodules on 2-Deoxy-2-[18F] fluoro-D-glucose ([18F]FDG) positron emission tomography/computed tomography (PET/CT). However, whether prone position PET/CT is useful in evaluating hepatic lesions is unknown. Thirty-five hepatic lesions from 20 consecutive patients were evaluated. The maximum standardized uptake value (SUVmax) and metabolic tumor volume (MTV) of both standard supine position PET/CT and additional prone position PET/CT were evaluated. No significant difference in SUVmax (4.41 ± 2.0 vs. 4.23 ± 1.83; p = 0.240) and MTV (5.83 ± 6.69 vs. 5.95 ± 6.24; p = 0.672) was observed between supine position PET/CT and prone position PET/CT. However, SUVmax changes in prone position PET/CT varied compared with those in supine position PET/CT (median, -4%; range: -30-71%). Prone position PET/CT was helpful when [18F]FDG uptake of the hepatic lesions was located outside the liver on supine position PET/CT (n = 4, SUVmax change: median 15%; range: 7-71%) and there was more severe blurring on supine position PET/CT (n = 6, SUVmax change: median 11%; range: -3-32%). Unlike in lung nodules, prone position PET/CT is not always useful in evaluating hepatic lesions, but it may be helpful in individual cases such as hepatic dome lesions.

Comparison between Kissing Stents and Direct Surgical Bypass for Aortoiliac Occlusive Disease.

Background: The optimal management strategy for aortoiliac occlusive disease (AIOD) remains debatable. This study compared early and late outcomes between direct surgical bypass and kissing stents for AIOD treatment. Methods: We retrospectively reviewed data, including age, sex, risk factors, comorbidities, symptoms, TransAtlantic Inter-Society Consensus (TASC) II classification, operation time, perioperative complications, in-hospital mortality, and length of hospital stay, from a cohort of 46 patients treated for AIOD (24 with kissing stents and 22 with direct surgical bypass) at Pusan National University Hostpital from January 2007 to December 2016. The primary, assisted primary, and secondary patency rates in both groups were compared. Results: The hospital stay (direct surgical bypass vs. kissing stents: 16.36±5.19 days vs. 9.08±10.88 days, p=0.007) and operation time (direct surgical bypass vs. kissing stents: 316.09±141.78 minutes vs. 99.54±37.95 minutes, p<0.001) were significantly shorter for kissing stents. Kaplan-Meier analysis revealed that the primary, assisted primary, and secondary patency rates in the direct surgical bypass group were 95.5%, 95.5%, and 95.5%, respectively, at 1 year; 86.4%, 86.4%, and 95.5% at 3 years; and 77.3%, 77.3%, and 95.5% at 5 years. The primary, assisted primary, and secondary patency rates in the kissing stent group were 100.0%, 100.0%, and 100.0%, respectively, at 1 year; 95.8%, 95.8%, and 100.0% at 3 years; and 95.8%, 95.8%, and 100.0% at 5 years. Conclusion: Except for special cases wherein endovascular revascularization is difficult, kissing stents are more advantageous for TASC II C and D lesions.

Overlapping stent insertion for a treatment-resistant seroma after arteriovenous fistulation using prosthetic grafts.

An arteriovenous fistula was required for permanent vascular access in a patient undergoing hemodialysis due to progressive chronic kidney disease associated with short bowel syndrome. In the present report, we discuss the case of a patient who underwent arteriovenous grafting because there was no proper native vein as a route, following which a seroma developed near the arterial anastomosis. Despite several surgical treatments, seroma not only recurred but also affected dialysis by compressing the graft. A stent was inserted into the graft to withstand the pressure from the seroma, and because one stent could not withstand the pressure, the stent overlapped where it received the most compression. Since then, the patency of graft has been well maintained for more than 2 years. Increasing the radial force of overlapping stents would be an alternative plan to help solve the problematic repeated compressible seroma despite multiple surgical treatments.

Acute limb ischemia after minimally invasive cardiac surgery using the ProGlide: A case series.

BACKGROUND: We report two cases of acute femoral artery occlusion following the use of ProGlide in minimally invasive cardiac surgery and insertion of large-bore catheters through the common femoral artery. This will add to the existing body of literature by highlighting the possible complications associated with the use of ProGlide and reiterate that the use of the sono-guided ProGlide skill will reduce the incidence of these complications. CASE SUMMARY: A 78-year-old man underwent minimally invasive cardiac surgery for severe aortic valve stenosis. After the operation, the puncture site of the common femoral artery was closed using ProGlide. The next morning, after regaining consciousness, he complained of pain, motor weakness (grade 2), and coldness in the right lower extremity. A 65-year-old man underwent minimally invasive cardiac surgery for a large secundum atrial septal defect (5 cm × 5 cm). After the operation, the puncture site of the common femoral artery was closed using ProGlide. After extubation, the patient complained of paresthesia of the right thigh. Both the patients underwent emergency surgery for acute occlusion of the common femoral artery. CONCLUSION: If the sono-guided ProGlide skill is used, complications can be prevented, and ProGlide can be safely used.

Comparing carotid endarterectomy and carotid artery stenting: retrospective single-center analysis.

BACKGROUND: Extracranial cerebrovascular diseases represent approximately 20% of ischemic stroke cases. Carotid endarterectomy (CEA) was the gold standard procedure for carotid artery stenosis treatment until the introduction of carotid artery stenting (CAS) in the 1980s. While there have been several multicenter randomized trials comparing CEA and CAS, a more efficacious procedure has not been conclusively distinguished. This study reports the results of CAS versus CEA in patients with symptomatic or asymptomatic carotid stenosis and compares them with those from other studies. METHODS: This study is a single-center retrospective study and included patients who underwent CAS and CEA as elective surgery between January 2012 and December 2020. The final analysis included patient baseline characteristics, postoperative complications, and patient outcomes. RESULTS: The 235 patients included were assigned to the CAS (n=128) and CEA (n=107) groups. Within 30 days postoperatively, no significant differences were noted in myocardial infarction [n=1, 0.8% (CAS); n=1, 0.9% (CEA); P=0.899], cerebral infarction [n=4, 3.1% (CAS); n=1, 0.9% (CEA); P=0.247], and patient mortality [n=1, 0.8% (CAS); n=0, 0% (CEA); P=0.247]. CONCLUSIONS: In elective surgery, CAS and CEA had the same effect of preventing cerebral infarction with no difference in postoperative complications.

Skin perfusion pressure for predicting access-related hand ischemia following arteriovenous fistula surgery based on the brachial artery.

BACKGROUND: Access-related hand ischemia (ARHI) is a major complication of arteriovenous fistula (AVF). This study aimed to assess the predictive efficacy of skin perfusion pressure (SPP) measurement for ARHI by examining the relationship between SPP and ARHI development and progression after AVF surgery. METHODS: Twenty-five patients (16 men and 9 women) who underwent AVF surgery based on the brachial artery between January 2018 and December 2018 were included. The pre- and postoperative SPP values were measured on the day of surgery. ARHI occurrence and severity were measured within 3 days and at 6 months after surgery. Receiver operating characteristic curve analysis was used to evaluate the prediction model of ARHI, and the cutoff points for the calculated coefficients were determined. RESULTS: There was a significant correlation between the occurrence of immediate ARHI and the SPP gradient (p = 0.024). An SPP gradient value >50 mmHg had sensitivity and specificity values of 53.85% and 91.67%, respectively, in predicting the occurrence of immediate ARHI. A postoperative SPP <48 mmHg was significantly correlated with the occurrence of 6-month ARHI (p = 0.005), with sensitivity and specificity values of 71.43% and 83.33%, respectively. CONCLUSION: The SPP gradient and postoperative SPP values may be effective clinical predictors of ARHI occurring immediately and 6 months after surgery, respectively, with high specificity. These findings could allow clinicians to diagnose and begin early interventions to help prevent ischemic tissue damage in hemodialysis patients following AVF surgery.

Failure to preserve the internal iliac artery during abdominal aortic aneurysm repair is associated with mortality and ischemic complications.

OBJECTIVE: Open or endovascular repair of abdominal aortic aneurysms (AAAs) can involve sacrifice of the internal iliac artery (IIA). In the present study, we investigated the effect of IIA exclusion on ischemic complications and overall mortality. METHODS: The data from 326 patients who had undergone elective open surgical or endovascular treatment of a nonruptured AAA from January 2010 to December 2019 in a tertiary hospital were retrospectively reviewed. Ischemic complications included buttock claudication, spinal ischemia (including paraparesis), ischemic colitis, lower limb paresthesia, and skin necrosis. Their duration and mortality during the study period were investigated. RESULTS: Nearly 50% of patients (148; 45.4%) had undergone endovascular aortic aneurysm repair and 178 (54.6%) had undergone open surgery. The median patient age was 78 years (range, 31-94 years). The median follow-up period was 1140 days (range, 0-4757 days). Of the 326 patients, 50 (15.3%) had died during follow-up. The bilateral IIAs were preserved in 187 patients (57.4%), a single IIA in 86 patients (26.4%), and no IIA in 53 patients (16.3%). Ischemic complications occurred in 57 patients (17.5%). Multivariable analysis revealed failure to preserve the bilateral IIAs (hazard ratio [HR], 8.65; 95% confidence interval [CI], 4.31-17.36; P < .01), management of the IIA (HR, 3.05, 95% CI, 2.17-4.28; P < .01), and hyperlipidemia (HR, 2.09; 95% CI, 1.04-4.17; P = .04) affected the occurrence of ischemic complications. Furthermore, univariable analysis revealed that patients had experienced more ischemic complications when a single IIA (HR, 6.97; 95% CI, 3.74-13.02; P < .01) or none of the IIAs had been preserved (HR, 8.88; 95% CI, 4.12-19.16; P < .01) than when both IIAs were preserved. Moreover, multivariable analysis revealed that stage 5 chronic kidney disease (HR, 2.7; 95% CI, 1.09-6.14; P = .03), age >75 years (HR, 2.48; 95% CI, 1.12-5.49; P = .03), cerebrovascular accident (HR, 1.95; 95% CI, 1.00-3.78; P = .05), and failure to preserve the bilateral IIAs (HR, 1.91; 95% CI, 1.02-3.46; P = .04) were associated with higher mortality after AAA repair. CONCLUSIONS: IIA exclusion is a risk factor for ischemic complications and overall mortality. Thus, preservation of the IIA as much as possible during AAA repair is recommended.

Nerve Cable Graft Interposition in Patients with Brachial Plexus Schwannoma: Case Reports.

Schwannomas are rare benign tumors that develop in Schwann cells lining peripheral nerves. Schwannomas of the brachial plexus are especially rare, accounting for 5% of all cases. Although several treatments can be considered, the exact method of treatment is unclear owing to the scarcity and sporadic occurrence of schwannomas. Tumor resection is performed in most cases, and nerve damage is inevitable in cases of neuroinvasive schwannoma. In this case series, we present our successful use of transposition of cable-grafted nerves for the treatment of schwannomas. We performed cable-grafted nerve interposition in addition to tumor resection, leading to increased recovery of nerve damage. To relieve postoperative symptoms and minimize sequelae, precise surgical tumor resection followed by nerve interposition using a cable-grafted nerve may be recommended.

Ipsilateral ultrasound-monitoring technique for reducing malpositions of peripherally inserted central catheters in the intensive care unit.

BACKGROUND: We performed ultrasonographic examinations of the ipsilateral internal jugular vein after placement of peripherally inserted central catheters (PICCs) and found that more than half of malpositions of PICC went to the head through the ipsilateral internal jugular vein. We aimed to reduce malpositions of PICCs in settings where fluoroscopy is not available. METHODS: This retrospective study had a case-control, single-center study design. From January to June 2018, PICCs were inserted with the patient's arm abducted without the use of ultrasonography to identify the presence of the PICC in the ipsilateral internal jugular vein (procedure A). From July to December 2018, PICCs were inserted in a similar fashion; however, ultrasonography was employed to detect the catheter tip in the ipsilateral internal jugular vein (procedure B). RESULTS: There were 794 placements of PICCs in 650 patients. Procedures A and B were performed in 418 and 376 patients, respectively. Malpositioning of PICC tips occurred significantly less often in procedure B than in procedure A (2.4% vs. 5.7%, P=0.02). CONCLUSIONS: In a setting without fluoroscopy, insertions of PICCs can be performed with the arm abducted at 90°. Ultrasound monitoring for the presence of the catheter in the ipsilateral internal jugular vein can help with correct positioning, thereby reducing the occurrence of catheter tip malpositions.