RESUMO
Introduction: Aneurysmorrhaphy, described as reduction aneurysmoplasty, partial aneurysmectomy, or vessel wall recalibration, can be considered a suitable surgical plan for true aneurysms of arteriovenous fistulas (AVFs), allowing for a dynamic approach to reconstruction of aneurysmal AVFs of different severities, ensuring salvage of the native access. Report: Six challenging cases of AVF aneurysms are presented, some with extremely dilated and tortuous megafistulas, for which three surgical technique variations were performed. The patients had a mean age of 59.2 years, 50% were female, with brachiocephalic (n = 5, 83.3%) or brachiobasilic (n = 1, 16.7%) AVFs. The fistulas were created an average of 4.67 years previously, and the aneurysms had an average maximum diameter of 37.5 mm (range 25-60 mm). Surgical indications were rupture risk, thrombosis, or outflow stenosis compromising haemodialysis, infections, and concerns for quality of life (affected by post-puncture bleedings, disfiguring aesthetics, pain, and discomfort). The surgical techniques were simple aneurysmorrhaphy (n = 3, 50%), aneurysmorrhaphy with partial excision of aneurysmal segment with end to end anastomosis of venous ends (n = 2, 33.3%), and aneurysmorrhaphy with establishment of new venous outflow (n = 1, 16.7%). All AVFs were patent post-operatively and at follow up (mean 5.6 months, median one month). Haemodialysis was resumed through the AVFs at a mean of 2.17 weeks post-operatively, with placement of an alternative route for haemodialysis in the meantime. No patients experienced post-operative complications. Discussion: Experience with the more challenging cases shows that aneurysmorrhaphy can still be considered an acceptable, flexible, and pertinent method for salvage of megafistulas, giving the surgeon the much needed versatility to adapt to anatomical and pathological variations, with high patency rates and minimal complications, especially when other treatment options are not possible in complicated cases. AVF salvage through aneurysmorrhaphy allows for a dynamic approach to the reconstruction of severely tortuous, dilated veins, ensuring patency of the native AVF.
RESUMO
INTRODUCTION: The COVID-19 pandemic has taken many forms and continues to evolve, now around the Omicron wave, raising concerns over the globe. With COVID-19 being declared no longer a "public health emergency of international concern (PHEIC)," the COVID pandemic is still far from over, as new Omicron subvariants of interest and concern have risen since January of 2023. Mainly with the XBB.1.5 and XBB.1.16 subvariants, the pandemic is still very much "alive" and "breathing." METHODS: This review consists of five highly concerning questions about the current state of the COVID Omicron peak. We searched four main online databases to answer the first four questions. For the last one, we performed a systematic review of the literature, with keywords "Omicron," "Guidelines," and "Recommendations." RESULTS: A total of 31 articles were included. The main symptoms of the current Omicron wave include a characteristically high fever, coughing, conjunctivitis (with itching eyes), sore throat, runny nose, congestion, fatigue, body ache, and headache. The median incubation period of the symptoms is shorter than the previous peaks. Vaccination against COVID can still be considered effective for the new subvariants. CONCLUSION: Guidelines recommend continuation of personal protective measures, third and fourth dose boosters, along with administration of bivalent messenger RNA vaccine boosters. The consensus antiviral treatment is combination therapy using Nirmatrelvir and Ritonavir, and the consensus for pre-exposure prophylaxis is Tixagevimab and Cilgavimab combination. We hope the present paper raises awareness for the continuing presence of COVID and ways to lower the risks, especially for at-risk groups.