Elevation Transposition Method for Superficialization of the Basilic Vein Achieves Better Patency Rate than Tunnel Transposition.

BACKGROUND: To compare the tunnel transposition and elevation transposition methods used for superficialization of the basilic vein in terms of complication and patency rates. METHODS: This retrospective study included patients who underwent 2-stage basilic vein transposition between August 2016 and December 2019. Patients were categorized into brachial-basilic fistula tunnel transposition (n = 32) and elevation transposition (n = 21) groups using medical records. Primary patency was defined as a conduit that remains patent without any re-intervention to maintain patency. Primary assisted patency was defined as a conduit that has undergone intervention to maintain patency but has never been thrombosed. RESULTS: The distribution of baseline characteristics was similar between the 2 groups. Coronary artery disease was the only variable that was significantly different between the tunnel transposition and elevation transposition groups (31.1% vs. 4.8%, P = 0.035). The tunnel transposition group had a greater amount of blood loss (P < 0.001) and a longer period of hospitalization (P = 0.002) than the elevation transposition group. The rates of suture repair to stop bleeding from the conduit was significantly different between the tunnel transposition and elevation transposition groups (31.8% vs. 4.8%, P = 0.035), whereas those of other complications were not significantly different. The elevation transposition group had a significantly higher primary patency rate than the tunneled transposition group (P = 0.033); however, primary assisted patency was achieved in all patients (100%) in both groups. CONCLUSION: Elevation transposition might be a more reliable method than tunnel transposition for superficialization of a basilic venous fistula.

A prospective randomized study of stent graft placement after balloon angioplasty versus balloon angioplasty alone for the treatment of hemodialysis patients with prosthetic graft outflow stenosis.

BACKGROUND: Hemodialysis graft outflow stenosis is a significant complication occurring in hemodialysis patients with prosthetic grafts for vascular access. Balloon angioplasty remains the first-line endovascular treatment of this complication, although covered stent graft implantation after balloon angioplasty also appears to be an effective and promising treatment. The aim of this study was to evaluate the efficacy and durability of stent graft placement after balloon angioplasty in comparison to balloon angioplasty alone for the treatment of graft outflow stenosis in hemodialysis patients. METHODS: We conducted a prospective randomized study of 98 patients with clinically significant dialysis graft outflow stenosis treated in the vascular surgery section of a tertiary medical center. The patients were randomized into two groups; 49 patients were treated with stent graft placement after balloon angioplasty, and 49 patients were treated with balloon angioplasty alone. All patients underwent angiography of the graft site at 3 and 6 months after intervention, and restenosis rates were compared between the two groups. In addition, the duration of postintervention primary patency in the two groups was recorded and analyzed. RESULTS: The postintervention restenosis rate of the stent graft placement group was superior to that seen in the balloon angioplasty alone group (9% vs 69% at 3 months [P < .0001] and 29% vs 72% at 6 months [P < .0001]). The mean postintervention primary patency duration was 380.22 ± 28.54 days for the stent graft placement group and 151.08 ± 16.79 days for the balloon angioplasty alone group (P < .0001). CONCLUSIONS: The use of stent grafts in hemodialysis patients with graft outflow stenosis yielded superior results compared with the results seen in hemodialysis patients treated with balloon angioplasty alone. Patients treated with stent grafts after balloon angioplasty had a lower restenosis rate and a longer duration of postintervention primary patency. The placement of a stent graft after balloon angioplasty appears to be an optimal therapeutic approach for the treatment of hemodialysis patients with graft outflow stenosis.

Treatment of infected abdominal aortic aneurysm caused by Salmonella.

BACKGROUND: We reviewed the outcomes of patients treated for nontyphoidal Salmonella-infected abdominal aortic aneurysm (AAA) treatment at a single center. METHODS: This was a retrospective chart review of 26 patients with nontyphoidal Salmonella-infected AAA. Four patients underwent medical therapy alone, while 22 patients underwent surgical therapy. Revascularization method selection was dependent on preoperative antibiotic response in the surgical therapy group. RESULTS: The in-hospital mortality rate for the surgical therapy group was 14%, while the rate for the medical therapy group was 100%. Overall survival for the surgical therapy group was 82%, while the reinfection rate was 9%. In the surgical therapy group, 2 patients had periaortic abscesses and underwent in situ prosthetic graft replacement; none developed graft-related complications or died in the hospital. Kaplan-Meier analysis and log-rank testing revealed no significant differences in graft-related complication and overall survival rates between in situ prosthetic graft group and extra-anatomic bypass group. Salmonella choleraesuis had a higher antimicrobial resistance rate than other isolates. The predictors of survival were clinical presentation of abdominal pain and receiving surgical therapy. CONCLUSIONS: If patients with Salmonella-infected AAAs have good responses to preoperative antibiotic therapy, in situ prosthetic graft replacement is a viable revascularization method, even in the situation of periaortic abscess presentation formation.

A single-center study of vascular access sites for intravenous ports.

PURPOSE: This study evaluated the use of intravenous ports and provides a guide related to clinical decision making. METHODS: This study retrospectively reviewed 1505 patients who had received intravenous ports at Chang Gung Memorial Hospital in 2006. The relationships between the complications and entry routes were assessed. The intervention-free periods were also determined and compared. The patients were followed up until June 2010. RESULTS: Of the 1543 procedures performed, 412 were reinterventions to treat complications, most of which corresponded to fewer than 0.1 episodes per 1000 catheter-days; these were not associated with any particular entry route. There was a higher catheter fracture rate when the right subclavian vein was chosen as the entry vessel (p < 0.05). The intervention-free period ranged from 207 to 533 days. CONCLUSION: The subclavian vein is not recommended for the use of intravenous ports. There is not only a higher risk of iatrogenic pneumothorax or hemothorax using this entry route but also a higher fracture rate, which may be caused by pinch-off syndrome. The greater saphenous vein should only be considered when the patient has superior vena cava syndrome. However, a higher incidence of infection and a lower device survival rate should be expected with this location.

Analysis of chest X-ray plain film images of intravenous ports inserted via the superior vena cava.

PURPOSES: The optimal tip position for an intravenous port and the angle between the locking nut and the catheter are still debatable. This study evaluates the use of chest X-ray plain films for screening patients with potential intravenous port complications. METHODS: We reviewed, retrospectively, 1505 patients who had an intravenous port implanted between January 1 and December 31, 2006 at Chang Gung Memorial Hospital, and were followed up until June 30, 2010. Of the 1119 patients with an intravenous port implanted via the superior vena cava (SVC), 279 underwent re-interventions for complications. There were four different types of single lumen port, and entry vessels on the right side were utilized as the predominant entry sites through the vessel cut-down method for catheter cannulation. The anatomic catheter tip was confirmed on the postero-anterior view of plain chest X-ray films. We used the Picture Arching and Communicating System (PACS) (GE, Fairfield, CT, USA) to record the angle and distance in degrees and centimeters, respectively. RESULTS: The tracheal carina was seen easily on the chest X-ray plain film and the location of the catheter tip and the angle between the locking nut and the catheter were identified. The location of the catheter tip was significantly related to migration (p < 0.0001). The cut-off value of the receiver operating characteristic (ROC) curve for location and migration was 0.68 cm below the carina. The area under the curve (AUC) was 0.8385 and had favorable predictive power. CONCLUSION: The ideal position of an intravenous port to avoid migration is 0.68 cm below the carina. For surgeons, a quantified reference may minimize technical errors. Patients with shallow tip location should be followed up regularly and aggressive intervention initiated for any intravenous port malfunction.

Long-term efficacy and risk factors of balloon-assisted maturation for radial-cephalic arteriovenous fistula with small-caliber veins.

INTRODUCTION: Balloon angioplasty maturation (BAM) is a salvage method for autologous arteriovenous fistula (AVF) maturation failure. AVF creation using small-diameter veins is considered to have poor outcomes. Therefore, this study aimed to explore the long-term patency of small-diameter veins (≤3 mm) using BAM. METHODS: BAM was performed if the fistula failed to mature and function adequately to provide prescribed dialysis. FINDINGS: Out of 61 AVFs, 22 AVFs successfully matured without further intervention (AVF group) and 39 AVFs failed to mature. Except for 1 patient who required peritoneal dialysis, the remaining 38 patients received salvage BAM, and 36 of those successful matured (BAM group). Kaplan-Meier analysis revealed no significant differences between the AVF and BAM groups in terms of primary functional patency (p = 0.503) and assisted functional patency (p = 0.499). Compared with the AVF group, the BAM group had similar assisted primary functional patency (1-year: 94.7% vs. 93.1%; 3-year: 88.0% vs. 93.1%; 5-year: 79.2% vs. 88.3%). In addition, there were no significant difference between groups in the duration of primary functional patency and assisted primary functional patency (p > 0.05). Multivariate analyses showed that vein diameter and number of BAM procedures were independent predictors of primary functional patency in the AVF group and BAM group, respectively. Patient with 1 mm increase in vein size had 0.13-fold probability of having decreased duration of patency (HR = 0.13, 95% CI: 0.02-0.99, p = 0.049), while patients who received two times of BAM procedures were 2.885 as likely to have decreased duration of primary functional patency (HR = 2.885, 95% CI: 1.09-7.63, p = 0.033) than patients who received one BAM procedure. DISCUSSION: BAM is a relatively effective salvage management option with an acceptable long-term patency rate, even for small cephalic veins.

High pulse pressure predicts primary arteriovenous fistula failure within 1 year.

BACKGROUND: The arteriovenous fistula is the preferred access route for hemodialysis, although its high primary failure rate remains a clinical challenge. Multiple studies have attempted to determine the risk factors for primary arteriovenous fistula failure; however, none have identified pulse pressure as a potential predictive marker. High pulse pressure is a surrogate poor arterial compliance endpoint and leads to inferior cardiovascular outcomes. Our aim was to determine whether elevated pulse pressure indicates poor arteriovenous fistula maturation. METHODS: We retrospectively reviewed 274 patients who underwent an arteriovenous fistula index operation between September 1, 2018 and May 31, 2019. Demographic, clinical data, and operative parameters were collected and analyzed. The maximum follow-up period was 365 days. Arteriovenous fistula failure was defined as the inability to achieve functional use during the follow-up period. We identified risk factors for arteriovenous fistula failure by performing a multivariate logistic regression analysis using backward elimination procedures. RESULTS: A total of 274 patients were included in the study. The patients' average age was 61.3 ± 14.0 years, approximately half of the patients (n = 161, 58.8%) were male, and the majority had hypertension. At the end of the follow-up period, 68 (24.8%) had arteriovenous fistula failure. The proportion of patients with pulse pressure values of >60 mmHg was significantly higher in the failure group than in the maturation group (66.0% vs 80.9%; p = 0.021). A PP value of >60 mmHg (odds ratio = 2.25; 95% confidence interval = 1.14-4.42; p = 0.019) and coronary artery disease or myocardial infarction (odds ratio = 1.97; 95% confidence interval = 1.01-3.84; p = 0.045) were found to be independent risk factors for primary arteriovenous fistula failure. CONCLUSIONS: High pulse pressure is an independent risk factor for primary arteriovenous fistula failure.

Treatment of primary infected aortic aneurysm without aortic resection.

BACKGROUND: We sought to determine the safety and efficacy of two different treatment strategies for patients with primary infected aortic aneurysms, including antibiotic treatment alone and endovascular aneurysm repair (EVAR) with aggressive antibiotic treatment, as alternatives to the established treatment of open surgical repair. METHODS: We conducted a retrospective chart review of patients who were treated for infected aortic aneurysm without undergoing aortic resection from January 2000 to December 2010 at a single institution. RESULTS: A total of 40 patients underwent traditional open repair during the study period. Sixteen patients with infected aortic aneurysm (11 men; median age, 70; range, 44-80 years) were identified as not having undergone aortic resection during the 11 years reviewed in the study. Nine patients received antibiotic treatment only (group I) and seven patients underwent EVAR with aggressive antibiotic treatment (group II). Salmonella species were isolated from seven patients in group I, and oxacillin-resistant Staphylococcus aureus was isolated from the remaining two patients. In group II, six patients had blood culture results showing Salmonella species and one patient had a blood culture result showing Escherichia coli. Group I (7 of 9 patients; 78%) had a higher hospital mortality rate than group II (0%; P = .003). Mean follow-up among survivors was 10 ± 15 months (range, 1-37 months). One patient in group II developed a reinfection episode (14%). There was no significant difference between group I (67%; SE, 27.2%) and group II (86%; SE, 13.2%) in the 3-month survival rates (log-rank, P = .39). CONCLUSIONS: Our results support the premise that EVAR is beneficial for the patients with infected aortic aneurysm. Treating an infected aortic aneurysm with antibiotics alone could not stop aneurysm expansion and eradicate the aortic infection before the aneurysm ruptures. For the patients with infected aortic aneurysms who have limited life expectancy and multiple comorbidities, EVAR with aggressive antibiotic treatment should be considered preferentially over antibiotic treatment alone.

In situ versus extra-anatomic reconstruction for primary infected infrarenal abdominal aortic aneurysms.

BACKGROUND: There is no standard procedure for revascularization after infected infrarenal abdominal aortic aneurysm resection. This study examines the outcomes of two contemporary methods. METHODS: We retrospectively reviewed medical records for patients who underwent repair of infected infrarenal abdominal aortic aneurysms from January 1998 to December 2007 at a single institution. Patients with infected prosthetic aortic grafts were excluded. RESULTS: Twenty-eight patients (22 men; mean age, 65 ± 12) had in situ graft (group I, n = 13) or extra-anatomic bypass (group II, n = 15), with a mean follow-up of 22 months. Mean hospital lengths of stay were 36 ± 16 days for group I and 46 ± 17 days for group II. Overall perioperative mortality was 5 of 28 (18%), comprising 1 of 13 in group I (8%) and 4 of 15 in group II (27%; P = .333). No early or late vascular-related complications occurred in group I. In group II, three patients had early vascular-related complications, including, graft infection, graft occlusion and ischemia colitis, and five patients had late vascular-related complications, including graft infection and graft occlusion. One patient ultimately lost a limb. Group I had a 0% late complication rate vs 33% in group II (P = .044). For cumulative survival rates, Kaplan-Meier analysis and log-rank testing revealed no significant differences between groups I and II. CONCLUSION: In situ graft revascularization is viable in afebrile patients or patients who have good response to preoperative antibiotic therapy. Extra-anatomic bypass grafting for infected infrarenal abdominal aneurysm resection has a similar long-term survival rate and should be considered in patients who are unsuitable for in situ graft revascularization; however, the postoperative complication rate is higher. Further prospective study with large patient populations is needed to determine the selection criteria for using in situ revascularization as alternative methods for treatment of infected abdominal aneurysms.

Surgical outcome for mycotic aortic and iliac anuerysm.

BACKGROUND: The present study was designed to review surgical outcomes for mycotic aneurysm of the aortic or iliac arteries at a single center. METHODS: The study was based on retrospective chart review of patients undergoing operation for mycotic aneurysm. RESULTS: From January 1998 to December 2007, 56 patients received surgical treatment for mycotic aneurysm of the aortic or iliac arteries. Aneurysm sites included the aortic arch (n=5), proximal thoracic aorta (n=4), distal thoracic aorta (n=5), paravisceral aorta (n=5), juxtarenal aorta (n=4), infrarenal aorta (n=30), and iliac arteries (n=3). Salmonella was the leading pathogen (n=34). Nineteen patients with suprarenal lesions underwent in situ prosthetic graft replacement (n=17), extra-anatomic bypass (n=1), or endovascular aneurysm repair (EVAR) (n=1), and 37 patients with infrarenal lesions underwent the same procedures (n=16, 20, and 1, respectively). Overall in-hospital mortality was 23%. After discharge, four patients (7%) developed reinfection that led to fatal sepsis. Graft infection developed after three in situ prosthetic grafts (9%) and one extra-anatomic bypass (5%). Patients with suprarenal aortic lesions had poorer in-hospital (34%) and late (16%) mortality rates than those with infrarenal lesions (p=0.025). Those with suprarenal lesions also had a lower cumulative survival rate (p=0.016). CONCLUSIONS: The location of mycotic aneurysm was the determinant of mortality. Mycotic aneurysm of the suprarenal aorta has poor prognosis and requires alternative surgical treatment.

Catheter fracture of intravenous ports and its management.

BACKGROUND: Intravenous ports are widely used for oncology patients. However, catheter fractures may lead to the need for re-intervention. We aimed to identify the risk factors associated with catheter fractures. METHODS: Between January 1 and December 31, 2006, we retrospectively reviewed the clinical data and plain chest films of 1,505 patients implanted with an intravenous port at Chang Gung Memorial Hospital. Different vascular sites were compared using the chi-square or Fisher's exact test for categorical variables, and the t test was used for continuous variables with normal distribution; P < 0.05 was considered statistically significant. RESULTS: There were 59 and 1,448 procedures in the fracture and non-fracture groups, respectively. Monovariate analysis revealed that the risk factors for catheter fracture were as follows: large angle (P < 0.0001), female gender (P < 0.0008), subclavian route (P < 0.0001), and port type Arrow French (Fr.) 8.1 (P < 0.0001). Because these risk factors showed no interaction effects, they were all considered independent risk factors. When all factors were considered together, all risk factors, except angle and age, retained their statistical significance. CONCLUSIONS: Most catheter fractures were caused by material weakness. If catheter fracture is confirmed, further intervention for port and catheter removal is recommended. Female gender, intravenous port implantation via the subclavian route, and the Arrow Fr. 8.1 port were found to be risk factors. Patients with these risk factors should be monitored closely to avoid catheter fractures.

Predictors of outcome after open repair of ruptured abdominal aortic aneurysms.

BACKGROUND: To determine predictors associated with early hospital death, 30-day mortality, and long-term survival after open surgical treatment of ruptured abdominal aortic aneurysms (RAAAs). METHODS: A retrospective chart review of 127 consecutive patients who received open surgical treatment of a RAAA at Chang Gung Memorial Hospital, Taiwan, from February 1994 to May 2007. Data recorded included patient characteristics, medical history, perioperative variables, and outcomes. RESULTS: There were 104 men and 23 women with a mean age of 70 ∓ 12 years in the analysis. Patients with RAAAs were classified into two groups; 100 (78.7%) patients were classified as group I (hemodynamically stable), and 27 (21.3%) patients were classified as group II (hemodynamically unstable at arrival). The 30-day mortality was 22% for group I and 74.1% for group II. Multivariate analysis identified age > 75 years old (odds ratio [OR], 0.083; 95% confidence interval [CI] 0.02-0.36), hemodynamically unstable state (OR, 0.081; 95% CI 0.016-0.4), blood transfusion > 5 L (OR, 0.14; 95% CI 0.038-0.54), intraperitoneal rupture (OR, 7.2; 95% CI 1.4-36), urine output < 0.5 mL/kg/min (OR, 22; 95% CI 4.6-110), and suprarenal cross-clamping (OR, 0.083; 95% CI 0.019-0.36) as incremental risk factors for 30-day mortality. CONCLUSION: Significant predictors of mortality in patients with RAAAs include hemodynamically unstable state, age > 75 years old, intraperitoneal rupture, low intraoperative urine output, and suprarenal cross-clamping.

Balloon angioplasty versus surgical revision for thrombosed dialysis graft outlet stenosis after graft thrombectomy.

BACKGROUND: It is important to correct underlying graft outlet stenosis after thrombectomy of dialysis grafts. This study retrospectively reviewed patients who received dialysis graft thrombectomy at this institution to compare the effectiveness of 2 different methods. METHODS AND RESULTS: A total of 289 dialysis graft thrombectomy procedures performed during 2001-2003 were retrospectively reviewed. The results of 163 cases in balloon angioplasty group were compared with those of 129 patients who underwent outlet revision. Patient characteristics between the 2 groups were similar with regard to demographic characteristics and comorbidities (P > .05). The mean primary patency of balloon and revision groups are 7.23 +/- 7.38 and 8.35 +/- 9.53 (months), respectively. Survival curves for each group were calculated by Kaplan-Meier method. There was no difference between 2 groups regarding graft patency. CONCLUSIONS: The result of dialysis graft outlet balloon angioplasty was comparable to that of surgical revision. Considering the invasiveness, balloon angioplasty should be considered when treating thrombosed dialysis grafts.

Patency rates of cuffed and noncuffed extended polytetrafluoroethylene grafts in dialysis access: a prospective, randomized study.

BACKGROUND: Although autogenous arteriovenous fistulae are the optimal route for dialysis access, extended polytetrafluoroethylene (ePTFE) grafts continue to be the preferred access for patients without suitable superficial veins. Among the common complications related to dialysis grafts, thrombosis due to graft outlet stenosis is the most frequently encountered clinical problem. A cuffed graft was designed to eliminate the outflow turbulence to reduce outlet stenosis and to enhance the clinical patency of ePTFE grafts. We conducted a prospective, randomized study to compare the clinical outcomes of cuffed ePTFE grafts and noncuffed grafts in dialysis access. METHODS: Between November 2004 and October 2005, 89 ePTFE grafts were implanted for hemodialysis access in the upper extremities of end-stage renal patients. Graft selection was randomized, with patients receiving a cuffed graft (Venaflo) or a regular noncuffed graft (Stretch Gore-Tex). All patients were monitored for signs of thrombosis or other complications. Primary and secondary graft patency was analyzed by using a life-table analysis, and the log-rank test was applied to compare graft patencies. RESULTS: Demographic data for both groups were similar without statistical difference. The primary patency rates and secondary patency rates at 12 months after implantation were 56% and 91% for cuffed grafts, and 41% and 78% for noncuffed grafts, respectively. The cuffed group outperforms the noncuffed group regarding primary and secondary patencies statistically. However, the incidence of other complications that required further surgery was similar in both groups. CONCLUSIONS: This investigation revealed that the cuffed ePTFE graft, which was designed to decrease graft outlet stenosis, may enhance the clinical patency rates of dialysis grafts.

Surgical thrombectomy for thrombosed dialysis grafts: comparison of adjunctive treatments.

BACKGROUND: Vascular surgeons often encounter dialysis graft failure in hemodialysis patients during their daily practice. Despite advances in percutaneous treatment, there remains a role for surgical thrombectomy of thrombosed dialysis grafts. This study was designed to investigate the long-term outcome of dialysis graft thrombectomy and to examine the indications for and effectiveness of therapies adjuvant to Fogarty thrombectomy. METHODS: Surgical outcomes of 590 consecutive dialysis graft thrombectomies performed between 2001 and 2003 were retrospectively reviewed. The 590 cases were classified into four groups based on the procedure performed adjuvant to Fogarty thrombectomy: group A, surgical thrombectomy by Fogarty thrombectomy catheter alone; group B, thrombectomy plus intraoperative angioplasty of graft outlet; group C, thrombectomy plus sequential balloon angioplasty in subsequent intervention; group D, thrombectomy plus graft outlet surgical revision. Age, gender, co-morbidity, and primary patency of grafts were reviewed and analyzed. RESULT: The four groups exhibited similar demographic features and comorbidities (p>0.05). Mean primary patency in the four groups was 1.99+/-4.02, 7.21+/-7.61, 8.35+/-9.53, and 7.26+/-6.99 (months), respectively. Survival curves for each group were determined by Kaplan-Meier methods. Primary patency in group A was statistically inferior to all of the other three groups, whereas groups B, C, and D did not significantly differ with regard to graft patency. CONCLUSIONS: Surgical thrombectomy alone is inadequate for treating a thrombosed dialysis graft. The underlying graft outlet stricture requires direct surgical revision or balloon angioplasty during surgery or intervention in the angiography suite to ensure long-term patency of the graft.

Aortic dissection in a young patient without any predisposing factors.

Aortic dissection is rare in the pediatric and young adult population. We hereby present a case of a 17-year- old male patient, without any predisposing factors, who developed an aortic dissection. The initial presentation was acute abdominal pain with massive retroperitoneal hematoma. His clinical condition deteriorated rapidly, did not respond to surgical hemostasis, and died within 36 hours of admission. The major autopsy finding was dissection of the descending aorta, extending from 2 cm distal from the origin of the left Subclavian artery. Microscopically, the aortic sections showed intimal thickening and tearing, medial smooth muscle loss, which was replaced by fibrous tissue, fragmentation of elastic lamellae with widening of interlamellar spaces, and cystic medial degeneration. The morphological features represented degenerative changes of the aorta, which were unusual in such a young patient. The pathophysiology, predisposing factors and relevant reports in the literature of aortic dissection in young patients are reviewed.

Impact of cuffed, expanded polytetrafluoroethylene dialysis grafts on graft outlet stenosis.

BACKGROUND: The objective of this study was to determine prospectively the difference between the graft outlet strictures of a polytetrafluoroethylene (ePTFE) graft with a cuff at the graft-vein anastomosis (Venaflo; Bard industries, Tempe, Ariz.) and that of the regular ePTFE graft (Stretch Gore-Tex; Gore, Flagstaff, Ariz.) placed for hemodialysis access. METHODS: Between January and April 2005, 36 consecutive patients (average age: 63.3 years) underwent ePTFE graft implantation (36 implantations) for hemodialysis at the Vascular Surgery Section of Chang Gung Memorial Hospital. The patients of the study cohort were randomly assigned to two groups based on the graft used: cuffed graft group (Venaflo graft) and non-cuffed standard graft group (Gore-Tex graft). Each patient underwent antegrade venography at the 3-month follow-up to demonstrate the graft outlet stricture. Results of the graft outlet angiography analysis were examined, and all medical records were reviewed at end of the study. The degree of the graft outlet stenosis was compared between the two groups. RESULTS: Average stenosis of the cuffed graft group and non-cuffed (standard) graft group were 22.76 +/- 26.37%% and 44.95 +/- 27.48%%, respectively; the difference between the two groups was statistically significant (P < 0.05). CONCLUSIONS: The graft outlet stricture of cuffed ePTFE grafts for hemodialysis 3 months after implantation was less severe than that for the standard ePTFE graft. The correlation between the stricture level and dialysis graft patency requires further clarification.

Experience with early postoperative feeding after abdominal aortic surgery.

BACKGROUND: Abdominal aortic surgery is a form of major vascular surgery, which traditionally involves long hospital stays and significant postoperative morbidity. Experiences with transit ileus are often encountered after the aortic surgery. Thus traditional postoperative care involves delayed oral feeding until the patients regain their normal bowel activities. This report examines the feasibility of early postoperative feeding after abdominal aortic aneurysm (AAA) open-repair. METHODS: From May 2002 through May 2003, 10 consecutive patients with infrarenal AAA who underwent elective surgical open-repair by the same surgeon in our department were reviewed. All of them had been operated upon and cared for according to the early feeding postoperative care protocol, which comprised of adjuvant epidural anesthesia, postoperative patient controlled analgesia, early postoperative feeding and early rehabilitation. The postoperative recovery and length of hospital stay were reviewed and analyzed. RESULTS: All patients were able to sip water within 1 day postoperatively without trouble (Average; 12.4 hours postoperatively). All but one patient was put on regular diet within 3 days postoperatively (Average; 2.2 days postoperatively). The average postoperative length of stay in hospital was 5.8 days. No patient died or had major morbidity. CONCLUSIONS: Early postoperative feeding after open repair of abdominal aorta is safe and feasible. The postoperative recovery could be improved and the length of stay reduced by simply using adjuvant epidural anesthesia during surgery, postoperative epidural patient-controlled analgesia, early feeding, early ambulation, and early rehabilitation. The initial success of our postoperative recovery program of aortic repair was demonstrated.

Reconstruction using a pericardial tube and ringed Gore-Tex graft for malignant superior vena cava syndrome: report of two cases.

Superior vena cava (SVC) syndrome caused by malignant tumors in the upper mediastinum is not uncommon. Radiation therapy or endovascular treatment with stenting is the first choice of treatment to relieve symptoms. However, surgical treatment may be considered when the less invasive treatment modalities failed. In this report, we present two cases of severe symptomatic SVC syndrome as a result of invasive thymomas, which were treated successfully using a composite graft made by pericardial tube and ringed polytetrafluorethylene (PTFE) graft. Symptoms soon subsided after operation. The patients were symptom free at 8 months and 24 months after the surgical management, respectively. In this report, we also reviewed reports in the literature relating to the surgical management in SVC syndrome. Based on our limited experience in these cases, we think that bypass with pericardial tube could be an effective palliative treatment technique offering durable clinical symptom relief for SVC symptoms caused by malignant tumors in certain cases.