Assessing the approach to a thrombosed AV graft.

The patency of the vascular access (VA) is a fight for the attending nephrologist. A retrospective observational study was conducted to compare the success rate of surgical versus endovascular technique percutaneous transluminal angioplasty (PTA) for graft thrombosis treatment. Of 3008 patients, 22.1% patients were dialyzed through grafts. Forty-five percent of all prevalent patients referred due to VA malfunction had a graft. For 18 months, 336 thrombosed grafts were submitted to surgery in 228 cases and to PTA in 126. PTA for thrombolysis included the Pharmaco-Mechanical Technique and the Arrow-Trerotola Device. Procedures were performed as outpatient, with an average delay of 1 day. Immediate success was 100% for surgery and 87.3% for PTA. The unassisted patency for thrombosed grafts for surgery/PTA was 265.12 ± 15.30/230.59 ± 19.83 days respectively, favoring surgery. The primary patency for thrombosed grafts treated by surgery/PTA at 30, 90, and 180 days was, respectively, 74.1%/81%, 63.2%/67.5%, and 53.9%/55.6% all in favor of PTA. AV grafts have a much higher rate of thrombosis than fistulas. Graft thrombosis can be dealt either by surgery or PTA, with identical success.

[Percutaneous thrombus aspiration in renal artery stenosis after renal transplantation]. / Aspiração de trombos por via percutânea em estenose da artéria renal após transplante renal.

We describe the case of a patient with chronic renal failure under hemodialysis for five years who, after renal transplantation, developed acute renal failure and hypertension refractory to medical therapy. Given the clinical and imaging (renal ultrasound and computed tomography) suspicion of renal artery graft thrombosis, invasive angiography was performed, which confirmed the diagnosis. The therapeutic approach consisted of percutaneous thrombus aspiration and subsequent balloon angioplasty of the entire artery, followed by stent implantation in a second procedure. The clinical course was uneventful with improvement of renal function and normalization of blood pressure. The case highlights the importance of percutaneous intervention in the management of patients with vascular complications after transplantation, with successful application of a procedure normally used in the setting of acute myocardial infarction - percutaneous thrombus aspiration and implantation of a drug-eluting vascular stent.

Salvage of malpositioned and malfunctioning peritoneal dialysis catheters by manipulation with a modified Malecot introducer.

Percutaneous peritoneal dialysis (PD) catheter manipulation successfully corrects displacement and contributes to catheter salvage. We describe a new device for the percutaneous treatment of malpositioned PD catheters, the modified Malecot introducer technique, which is an improvement over previous methods because its flexible consistency also allows the manipulation of swan-neck catheters. Twenty-one patients experienced catheter displacement managed by the new introducer: 12 males, average time in PD 13.7+/-23.2 months, six with "swan-neck" catheter, seven obese, and six with previous abdominal surgery. Catheter manipulation was technically successful in 19 of 21 cases (90.4%) by the end of the first week and in 15 cases (71.4%) at 1 month. An additional eight episodes of malposition occurred ranging from 10 to 300 days after the first manipulation. A second manipulation using the same introducer was performed and resulted in long-term patency in seven patients. No complications were reported. In the long-term follow-up, only one patient removed PD catheter for mechanical dysfunction. Overall survival of manipulated catheters was 32.7+/-23.4 months. Function at 1 month correlated with function by the first week (r=0.513; p=0.017) and the need of a second manipulation with age (r=0.494; p=0.027) but not with obesity or previous abdominal surgery. We conclude that manipulation using the modified Malecot introducer is a simple and effective procedure for the correction of malpositioned PD catheters. It also represents a new alternative for the management of displaced "swan-neck" catheters.

[Conservative surgery in pancreatic solid pseudo papillary tumor]. / Cirurgia conservadora no tumor sólido pseudopapilar do páncreas.

We report the case of a 18-year-old girl having a solid pseudopapillary pancreatic tumor. The patient underwent local enucleation of the tumor located on pancreatic head and remained free of recurrence on the 5th year of follow up. Surgical management is discussed.

[Splenic metastasis in ovary serous adenocarcinoma]. / Metástases esplénicas no adenocarcinoma seroso do ovário.

Splenic metastasis is rare, and is usually associated with disseminated malignancy. The primary tumours more frequently related with splenic metastasis are lung, breast, gynaecologic, specially ovary tumours, colon, rectum and melanoma. Isolated secondary splenic disease is rare, but it is described, often associated to ovary cancer. We report a 55 years old women with parenchymal splenic metastases of serous ovary cystadenocarcinoma in the 5th follow up year. This patient had positive peritoneal washings chytology but not macroscopic disease. We discuss the secondary splenic involvement of ovary cancer, dissemination route, prognosis and role of splenectomy as treatment modality in this unusual recurrence site in ovary cancers.

[Laparoscopic cholecystectomy: day case procedure]. / Colecistectomia laparoscópica: cirurgia de ambulatório.

We describe a retrospective analysis of 105 patients who underwent day-case laparoscopic cholecystectomy to evaluate the safety of this procedure. Selection criteria included surgical indications and admission/exclusion criteria for day-case surgery. We analysed: causes of overnight stay and readmission, need of medical or nursing care after discharge, degree of patient satisfaction and insatisfaction reasons. This study has demonstrated a low rate of overnight stay and readmission and a high degree of patient satisfaction for this procedure. We concluded that in selected patients, laparoscopic cholecystectomy as a day-case surgery is a safe procedure.