Unique report of iliocaval endovascular reconstruction successfully enabling a kidney transplant

Patients with end-stage renal disease and iliocaval venous obstruction are normally nonviable recipients of kidney transplantation. We report a case of a 34-year-old male patient who has been receiving hemodialysis as renal replacement therapy for 6 years due to immunoglobulin A nephropathy. Past medical history included multiple central venous catheter infections and catheter-associated thrombosis. Iliac confluence and inferior vena cava occlusion previously excluded the patient from the renal transplantation list. The exhaustion of venous access sites was already documented. After multidisciplinary discussion, the patient was proposed for endovascular iliocaval reconstruction aiming for a future kidney transplant. Iliocaval recanalization was achieved through bilateral femoral access. Inferior vena cava and iliac angioplasty were performed. A dedicated venous stent was deployed in the inferior vena cava, followed by a double-barrel reconstruction of the iliac confluence. Successful iliocaval recanalization was accomplished. Five months after kidney transplantation was performed with a deceased donor graft in the right iliac fossa. The postoperative period was uneventful. After 12 months, the patient remained free from kidney replacement therapies with a serum creatinine level of 1.3 mg/dL. To the best of our knowledge, this is the first clinical description of a successful kidney transplant in a patient with a previous iliocaval reconstruction.

Use of a Paclitaxel Drug-Eluting Stent for the Treatment of Hemodialysis Access Outflow Stenosis

PURPOSE

To evaluate the outcomes and durability of drug-eluting stents (DESs) for the treatment of hemodialysis access outflow stenosis.

MATERIAL AND METHODS

A single-center retrospective analysis was conducted of all patients with hemodialysis vascular access outflow stenosis treated with a paclitaxel-coated DES (Eluvia; Boston Scientific, Marlborough, Massachusetts) between January 2020 and July 2022. A total of 34 DESs were implanted to treat outflow stenosis in 32 patients. Primary target lesion patency after stent deployment was the main outcome. Comparison between the time interval free from target lesion reintervention (TLR) after previous plain balloon angioplasty (PBA) and that after stent deployment for the same target lesion was considered a secondary outcome.

RESULTS

The primary patency at 6, 12, and 18 months was 63.1%, 47.6%, and 41.7%, respectively. The secondary patency rate was 100% at 18 months. The median time interval free from TLR increased from 4.1 to 11.9 months (P < .001). No adverse events were observed during the median follow-up period of 387 days.

CONCLUSIONS

The patency rates after use of DES for hemodialysis access outflow stenosis were comparable with results for drug-coated balloons and stent grafts, addressing recoil and minimizing the risk of jailing by a covered stent.

Unveiling the Potential Distribution of the Highly Threatened Madeira Pipistrelle (Pipistrellus maderensis): Do Different Evolutionary Significant Units Exist?

The isolation of islands has played a significant role in shaping the unique evolutionary histories of many species of flora and fauna, including bats. One notable example is the Madeira pipistrelle (Pipistrellus maderensis), which inhabits the Macaronesian archipelagos of the Azores, Madeira, and the Canary Islands. Despite the high biogeographic and conservation importance of this species, there is limited information on its ecology and evolutionary history across different archipelagos. In our study, we employed species distribution models (SDMs) to identify suitable habitats for the Madeira pipistrelle and determine the environmental factors influencing its distribution. Additionally, we conducted molecular comparisons using mitochondrial DNA data from various Macaronesian islands. Molecular analyses provided compelling evidence for the presence of distinct Evolutionary Significant Units on the different archipelagos. We identified distinct haplotypes in the populations of Madeira and the Canary Islands, with a genetic distance ranging from a minimum of 2.4% to a maximum of 3.3% between samples from different archipelagos. In support of this, SDMs highlighted relevant dissimilarities between the environmental requirements of the populations of the three archipelagos, particularly the climatic niche. Our research demonstrates that deeper investigations that combine ecological, morphological, and genetic areas are necessary to implement tailored conservation strategies.

Outflow Rescue of Elbow-Blockade Forearm Arteriovenous Fistulas: Outcomes of Open Surgical Techniques

BACKGROUND

Venous scarring at the elbow is a common problem that can cause early and late forearm arteriovenous fistula (AVF) dysfunction in hemodialysis patients. However, any effort to prolong the long-term patency of distal vascular accesses could benefit the patient's survival, maximizing the use of restricted venous patrimony. This study aims to report a single-center experience in the recovery of distal autologous AVF with venous outflow obstruction at the elbow using different surgical techniques.

METHODS

Retrospective observational study of all patients treated at a single vascular access center from January 2011 to March 2022, with dysfunctional forearm AVFs presenting with outflow stenosis or occlusions at the elbow treated by open surgery, using 3 different surgical techniques. Demographics and clinically relevant data were collected. Evaluated endpoints included primary, assisted primary, and secondary patency rates at 1 and 2 years.

RESULTS

Twenty-three patients with elbow-blocked outflow forearm AVFs have been treated with a mean age of 64 ± 15 years. The majority (96%) had a radiocephalic fistula. The median time from vascular access creation to intervention was 34.5 months (12-216 months). A total of 24 procedures have been performed using 3 different surgical techniques for bypassing the obstructed venous outflow at the elbow. Technical success was achieved in 96% of the surgically treated patients. Primary and secondary patency rates at 1 year were 67.4% and 89.4%, respectively, and 52.9% and 82.0% at 2 years, with a median follow-up of 19 months (6-92 months).

CONCLUSIONS

AVFs outflow stenosis or occlusions at the elbow not amenable to endovascular therapy could lead to vascular access abandonment. Our study demonstrates multiple surgical solutions to avoid this adverse outcome. Elbow venous outflow surgical reconstruction seems effective for distal vascular access preservation. Close surveillance is essential for timely endovascular treatment of newly developed stenosis at the venous drainage.

Asymptomatic Hypogastric Arteriovenous Fistula Detected 40 Years After Shotgun Injury

84-year-old male, with a history of firearm incident with accidental gunshot shooting, and multiple projectile injuries, 40 years prior. No advanced medical treatment was required at the time. A CT was recently performed for unrelated reasons, and the scout view shows multiple projectiles, a total of 50, scattered in the thoracoabdominopelvic region as well as the lower limbs. CT angiography exposed CT's scout view of the multiple projectiles scattered. an arteriovenous fistula in posterior branches of the hypogastric artery with moderate dilations of the superior gluteal vein. The patient was completely asymptomatic and had no findings suggestive of AVF-related cardiac failure. Physical examination was unremarkable. Conservative treatment without further imagiological follow-up was decided, if patient continued asymptomatic.

Resisted Inspiration: A New Technique to Aid in the Detection of CSF-Venous Fistulas

We describe a technique termed "resisted inspiration" that could be used during myelography to decrease superior vena cava venous pressure and increase lumbar CSF pressure, potentially aiding in the detection of CSF-venous fistulas.

Angiosarcoma of a Femoropopliteal Bypass Thrombosed Vein Graft

BACKGROUND

Angiosarcoma is a rare subtype of malignant vascular tumours which has been only anecdotally described in patients submitted to lower limb revascularization.

CASE PRESENTATION

This paper reports a patient previously submitted to a femoropopliteal bypass using autologous great saphenous vein (GSV). Nine years after the initial surgery, a primary angiosarcoma of the thrombosed vein graft was diagnosed, requiring en bloc surgical resection. Rampant metastatic spread was documented despite primary tumour surgical resection with a dismal outcome within months.

CONCLUSIONS

Malignant transformation of autologous vein for lower limb revascularization is extremely rare and anecdotally described in the literature. It is a poorly studied complication with an aggressive behaviour. This report further reinforces the need for early recognition of this pathology.

MAMMALS IN PORTUGAL: A data set of terrestrial, volant, and marine mammal occurrences in Portugal

Mammals are threatened worldwide, with ca. 26% of all species being included in the IUCN threatened categories. This overall pattern is primarily associated to habitat loss or degradation, and human persecution for terrestrial mammals, and pollution, open net fishing, climate change and prey depletion for marine mammals. Mammals play a key role in maintaining ecosystems functionality and resilience, and therefore information on their distribution is crucial to delineate and support conservation actions. MAMMALS IN PORTUGAL is a publicly available data set compiling unpublished geo-referenced occurrence records of 92 terrestrial, volant, and marine mammals in mainland Portugal and archipelagos of Azores and Madeira that includes 107,852 data entries between 1873 and 2021 (72% of the data occurring in 2000 and 2021). The methods used to collect the data were: live observations/captures (42%), sign surveys (38%), camera trapping (16%), bioacoustics surveys (4%) and radio-tracking and inquiries that represent less than 1% of the records. The data set includes 13 types of records: 1) burrows | soil mounds | tunnel, 2) capture, 3) colony, 4) dead animal | hair | skulls | jaws, 5) genetic confirmation, 6) inquiries, 7) observation of live animal, 8), observation in shelters, 9) photo trapping | video, 10), predators diet | pellets | pine cones/nuts, 11) scat | track | ditch, 12) telemetry and 13) vocalization | echolocation. The spatial uncertainty of most records ranges between 0 and 100 m (76%). Rodentia (n = 34,754) has the highest number of records followed by Chiroptera (n = 18,858), Carnivora (n = 18,594), Lagomorpha (n = 17,679), Cetartiodactyla (n = 11,568) and Eulipotyphla (n = 6400). The data set includes records of species classified by the IUCN as threatened (e.g., Oryctolagus cuniculus (n = 12,407), Monachus monachus (n = 1512), and Lynx pardinus (n = 197)]. We believe that this data set may stimulate the publication of other European countries data sets which would certainly contribute to ecology and conservation-related research, and therefore assisting on the development of more accurate and tailored conservation management strategies for each species. There are no copyright restrictions; please cite this data paper when the data are used in publications.

Ruptured arteriovenous fistula pseudoaneurysm treatment by balloon-assisted direct percutaneous thrombin injection

We present the case of a male patient on hemodialysis with a ruptured pseudoaneurysm in a brachiocephalic arteriovenous fistula (AVF) and with edema and pain in the right arm attended to in the emergency department. An ultrasonographic scan identified a ruptured pseudoaneurysm with hemorrhagic infiltration of the arm muscular tissues. We performed a percutaneous ultrasound-guided thrombin injection with an angioplasty balloon inflated in the lumen of the AVF achieving the pseudoaneurysm thrombosis. After 6 months of follow-up, the patient's arteriovenous access remains functional. Percutaneous ultrasound-guided thrombin injection assisted by an angioplasty balloon may be a good alternative to surgical intervention in the treatment of symptomatic growing pseudoaneurysms of the arteriovenous fistula with the benefit of preserving the vascular access.

SURGICAL TREATMENT OF A SPONTANEOUS RUPTURE OF A MYCOTIC ANEURYSM

Saccular mycotic aorto-iliac aneurysms are rare but, when ruptured, they are an important life-threatening condition. We present the case of a 52 years-old male transferred from another hospital and admitted to the emergency room with a ruptured iliac artery aneurysm. He complained of persistent fever and abdominal discomfort that swiftly established as hemorrhagic shock. Image study with computed tomographic angiography revealed a ruptured left common iliac artery saccular aneurysm. The patient was instantaneously and successfully submitted to endoaneurismorraphy of the hypogastric artery, common and external iliac artery ligation and construction of an extra anatomic bypass, right to left femorofemoral bypass. Blood culture revealed a Streptococcus anginosus and the patient received appropriate targeted antibiotics. Post-operative period was uneventful and the patient discharged ten days after admission. He has now eleven months of follow up with no intercurrences. Even though surgical approach carries a relative risk of perioperative morbidity, it is a feasible and durable solution for extreme situations like the one here described.

Emergency Repair of a Ruptured Para-Renal Abdominal Aortic Aneurysm in a Patient with a Functional Renal Graft: A Case Report and Review of the Literature

INDRODUCTION

Rupture of and abdominal aortic aneurysm (AAA) in a kidney transplant patient is a rare and rarely reported event. Emergent treatment can be challenging and should achieve effective aortic repair while minimizing ischemic damage to the renal graft during aortic cross-clamping. Several renal protective measures have been proposed such as permanent or temporary shunts, renal cold perfusion and general hypothermia.

CASE REPORT

We report the effective treatment of a para-renal AAA in a patient with a functional renal allograft. A temporary extra-corporeal axillofemoral shunt was constructed to maintain graft's perfusion during open surgical repair. EVAR was not an option due to a short aortic neck. The postoperative period was complicated by colon ischemia and aortic graft infection. At 3 years follow-up the patient was well and graft's function was unchanged.

CONCLUSION

This case is a reminder that renal graft protection must be accounted for when AAA rupture occurs in kidney transplant patients. We reviewed the literature to find previously reported cases and how they were managed.

Salvage of a Near-Total Penile Amputation following Urinary Fistulization and Carbapenemase-Producing Klebsiella pneumoniae Infection with a Composite ALT Flap and Vascularized Fascia Lata

Reconstruction of complex penile defects is always challenging, as some defects are not possible to reconstruct with skin or mucosa grafts, and even local flaps may be precluded in complex wounds. We present a case of a 63-year-old otherwise healthy man, who underwent transurethral resection of the prostate for benign prostatic hyperplasia. After the procedure, he developed panurethral necrosis with consequent stricture. Three urethroplasties for reconstruction of the bulbar and distal urethra using buccal mucosa grafts, a preputial flap, and penile skin were performed by urology team in different institutions, but serious urinary fistulization and carbapenemase-producing Klebsiella pneumoniae (KPC) infection translated in a chronic wound, urethra necrosis, and near-total penile amputation. A composite anterolateral thigh flap and vascularized fascia lata were used with success together with a perineal urethroplasty in different stages, improving the ischemic wound condition. The extended segment of fascia lata was used for Buck's fascia replacement and circumferential reinforcement to cover the erectile bodies of the penis. The postoperative period was uneventful and after 12 months, there were no signs of recurrence or wound dehiscence. He was able and easily adapted to void in a seated position through the perineal urethrostomy that was made. To the best of our knowledge, this procedure has not been reported previously as a salvage procedure in a fistulizated and KPC infected penis, but it may be considered to avoid penile amputation in chronic infected and intractable wounds.

Jejunojejunal Intussusception After Roux-en-Y Gastric Bypass and Abdominoplasty: A Rare Association or a Mere Coincidence?

Small bowel intussusception is a rare complication after Roux-en-Y gastric bypass, with few cases reported, and none in the immediate post-operative period of an abdominoplasty. We report the case of a 42-year-old woman, with an history of a laparoscopic Rouxen-Y gastric bypass, who developed small bowel occlusion secondary to a retrograde jejunojejunal intussusception in the second post-operative day of an abdominoplasty. This is the first report of a small bowel intussusception after Roux-en-Y gastric bypass in the post-operative period of an abdominoplasty. Doubts remain about the possible causal effect abdominoplasty might have in small bowel intussusception after Roux-en-Y gastric bypass.

Arterial percutaneous angioplasty in hemodialysis access: Endovascular treatment of hand ischemia

BACKGROUND

Hemodialysis access-induced distal ischemia consists of symptomatic extremity malperfusion after vascular access creation. It is usually caused by discordant vascular resistance, with arteriovenous shunting of a high blood volume from arterial into venous system and subsequent hand hypoperfusion. Less often, hemodialysis access-induced distal ischemia is caused by arterial stenosis. In these cases, access frequently has normal/low flow, radial pulse is usually absent and not recoverable with vascular access digital compression, diabetes is often present, and percutaneous transluminal angioplasty can be critical for access and limb salvage.

METHODS

Retrospective study conducted between June 2011 and February 2018 of patients with vascular access submitted to arterial percutaneous transluminal angioplasty for limb-threatening ischemia.

RESULTS

Twenty-nine patients were referred for arterial angiography after hemodialysis access-induced distal ischemia diagnosis and physical examination or ultrasound findings suggestive of arterial disease. In 11 patients, percutaneous transluminal angioplasty was not technically feasible. Among 18 treated patients, 83.3% had diabetes and 60% had skin ulcerations. Target arteries were radial (11), brachial (7), axillar (2), ulnar (2), and subclavian (1). Clinical success, defined as arteriovenous maintenance and wound healing/pain resolution, was observed in 12 patients (66.7%). Concomitant procedures included adjuvant banding (n = 2) and finger amputation (n = 1), and one reintervention was performed. No intra- or postoperative complications were reported.

CONCLUSION

Hemodialysis access-induced distal ischemia is a serious complication of hemodialysis vascular access, with multifactorial etiology. Correct and timely diagnosis is crucial for maintaining access and limb salvage. Percutaneous transluminal angioplasty is a minimally invasive procedure that may be effective and long-lasting in carefully selected patients with ischemic complaints.

Giant chondrosarcoma of the chest wall: a rare surgical challenge

The chest wall chondrosarcoma (CWC) is a rare slowly growing primary tumor of the chest wall with an incidence of <0.5 per million person-years. We present the case of a giant CWC that caused a mass effect on the mediastinum, heart, and lung. Large tumors with thoracic structures compression may be life threatening, and its resection and subsequent chest wall reconstruction represent a significant multidisciplinary surgical challenge. In this case, despite the large tumor dimensions, the preoperative planning—sparing key reconstructive options without compromising the tumor resection—allowed a complete en bloc tumor excision of a grade III chondrosarcoma with negative histologic margins. Successful reconstruction of the large full-thickness chest wall defect, with a latissimus dorsi muscle flap and methyl methacrylate incorporated into a polypropylene mesh in a sandwich fashion, was accomplished. Patient recovery was uneventful with good functional and aesthetic outcomes, and no evidence of recurrence at 1.5 years follow-up. This case report illustrates the main clinical, radiological, and histologic features of a CWC while discussing the surgical goals and highlighting the principles for chest wall reconstruction following extensive resection of a large and rare entity.

Fournier's gangrene: a review of reconstructive options

Introduction

Fournier’s gangrene is a rapidly progressive necrotizing fasciitis of the genital and perineal tissues with a high mortality rate. Early diagnosis and treatment with fluid resuscitation, surgical debridement and wide-spectrum antibiotics are essential in the management of Fournier’s gangrene. After primary treatment, reconstructive surgery is often necessary for coverage of soft-tissue defects. This review article aims to provide an overview of the main reconstructive procedures used in Fournier’s gangrene.

Material and methods

A literature search was performed on the subject of reconstructive surgery in Fournier’s gangrene.

Results

Techniques of reconstructive surgery for soft-tissue defects following Fournier’s gangrene include skin grafts, local advancement flaps, scrotal flaps, multiple fasciocutaneous and myocutaneous flaps, and testicular transposition. The surgical goal is to achieve the best functional and cosmetic result possible with minimal morbidity. Advantages and disadvantages of each technique and potential indications are discussed.

Conclusions

Characteristics of the defect, patient preference and surgeon experience should guide the choice of reconstructive procedure. Further comparative studies are needed to optimize results.

Impaired decision-making and time perception in individuals with stroke: Behavioral and neural correlates

Several studies have demonstrated that stroke subjects present impairment of functions related to decision-making and timing, involving the information processing in the neural circuits of the cerebellum in association with the prefrontal cortex. This review is aimed to identify the gaps, and demonstrate a better understanding of decision-making and timing functions in the patients with stroke. Electronic literature database was searched and the findings of relevant studies were used to explore the mechanisms of decision-making and timing in patients with stroke, as well as the circuit connections in timing mediated by prefrontal cortex and cerebellum. A literature review was conducted with 65 studies that synthesized findings on decision-making and time perception in individuals with stroke. Types of neurobiological modalities in this study included: Relationships among decision-making, time perception, related cognitive aspects (such as discrimination tasks, verbal estimation, bisection tasks, time production and motor reproduction), and motor control. We demonstrate that the timing processes are important for the performance in cognitive tasks and that the cerebellum and prefrontal cortex are involved in decision-making and time perception. In the context, the decision-making is impaired in stroke patients has a great impact on executive functions, and this seems to be important in determining neurobiological aspects relevant to the time interval interpretation.

Dupuytren's disease: where do we stand?

Dupuytren’s disease is a fibroproliferative disease that involves collagen deposition, leading to hand contractures that ultimately affect hand mobility and grip strength.

It is a benign disorder but can cause high morbidity by limiting daily activities.

Many factors have been proposed for its aetiology: namely genetics, smoking, alcohol intake and diabetes. However, there is still controversy as to the main aetiological cause of the disease.

Treatment is not yet uniform around the world and still varies with the surgeon’s experience and preference.

In this review, the authors review the pathogenesis and treatment options for Dupuytren’s disease in an attempt to summarize the current state of the art.

Cite this article: EFORT Open Rev 2019;4:63-69. DOI: 10.1302/2058-5241.4.180021.

Abstract P5-15-04: Oncotype DX cost effectivity to a Brazilian public hospital

Introduction: The Oncotype DX was associated to 14% of adjuvant chemotherapy administration to Hormonal Receptor positive (HR+) and HER2 negative, T1N0 or T2N0 breast cancer patients at Tailor X trial recently published (RS&gt;25)

Objective: To describe the adjuvant chemotherapy administration to a Brazilian public hospital for HR+ HER2 negative, T1N0 or T2N0 breast cancer patients. And the estimate the cost effectivity of Oncotype DX in our low income scenary.

Materials and Methods:This retrospective cross-sectional study was conducted at the Oncology Division of the Women's Hospital - CAISM of the State University of Campinas (UNICAMP), Brazil. All patient data were found from the hospital records from 2007 to 2009. It was included T1N0 and T2N0 HR+/HER2 negative breast cancer patients. Patients submitted to neoadjuvant treatment were excluded.

We calculate the final cost of different types of chemotherapy used and the potential impact to oncotype DX introduction in this scenary.

Results: It was found 109 patients records. 66% (72/109) had received adjuvant chemotherapy. 35% (38/109) had AC (X6), 29% (32/109) had CMF (X6) and 2% (2/109) had AC-T (X4). The total cost for chemotherapy scheme were; AC (X6) US$ 346,9; CMF (X6), US$300,6; ACT (X4), US$395,9. The total cost of chemotherapy was US$ 23.596,83 to 72 patients. If we consider 14% (15/109) of adjuvant chemotherapy associate to a Oncotype DX use (Tailor X RS&gt;25), It would reduce adjuvant chemotherapy administration to 15 patients. The chemotherapy cost would be US$ 4588,27. In our scenary, It could save US$ 19.008,56. Nevertheless, the Oncotype Dx cost to Brasil is US$ 3.200,00 for each test. To 109 patients the total cost would be (109 X US$ 3.200,00) US$ 348.800,00. Therefore, the total cost for Oncotype DX program plus adjuvant chemotherapy for our patients would be US$ 348.800,00 + US$ 4.588,27= US$ 353.388,27. While in the real situation we had spent US$ 23.596,83. The total estimate cost would be 15 times more.

Conclusion: At the moment, because of the assay high cost and the low cost of the adjuvant chemotherapy to HR+, HER2 negative T1N0 and T2N0, It would be difficult to consider Oncotype DX cost-effective to Brazilian public heath system. Even considering many advantages to spare chemotherapy to this population.

Citation Format: Cabello C, de Andrade RN, Cabello TF, Teixeira S, da Costa LS, Ramalho S. Oncotype DX cost effectivity to a Brazilian public hospital [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-15-04.

Application of experimental design methodology to optimize antibiotics removal by walnut shell based activated carbon

Three-level Box-Behnken experimental design with three factors (pH, temperature and antibiotic initial concentration) combined with response surface methodology (RSM) was applied to study the removal of Metronidazole and Sulfamethoxazole by walnut shell based activated carbon. This methodology enabled to identify the effects of the different factors studied and their interactions in the response of each antibiotic. The relationship between the independent variable (sorption capacity) and the dependent variables (pH, temperature and antibiotic concentration) was adequately modelled by second-order polynomial equation. The pH factor exerted a significant but distinct influence on the removal efficiency of both antibiotics. The removal of Metronidazole is favoured by increasing pH values, with the maximum value obtained for pH 8 - upper limit of the study domain; while Sulfamethoxazole displays a maximum value around 5.5, with a decrease in the extent of adsorption as the pH increases. The best conditions, predicted by the model, for the removal of the antibiotic Sulfamethoxazole (106.9 mg/g) are obtained at a temperature of 30 °C, initial concentration of 40 mg/L and a pH value of 5.5. For the antibiotic Metronidazole, the highest removal value (127 mg/g) is expected to occur at the maximum levels attributed to each of the factors (pH = 8, C_in = 40 mg/L, T = 30 °C). The results of isotherm experiments (at 20 °C and pH 6) displayed a good agreement with the models predictions. The maximum sorption capacity, estimated by the Langmuir model, was 107.4 mg/g for Metronidazole and 93.5 mg/g for Sulfamethoxazole.