The Role of Doppler Ultrassonography in Significant and Borderline Stenosis Definition

Background: The definition of significant stenosis (SS) remains controversial. Methods: We retrospectively reviewed 1,040 consultations. SS was defined in the presence of clinical and echo-Doppler (DDU) criteria: Qa <500 mL/min or Qa decrease >25%; RI >0.7 in the feeding artery or absolute minimal luminal stenosis diameter <2.0 mm. Stenosis without any additional criteria were considered borderline stenosis (BS). Results: Two hundred twenty-one arteriovenous fistulas (AVFs) were included: 58.8% had SS, 18.6% had BS, and 22.6% had no dysfunctional access (ND). SS had a significantly higher thrombotic events than BS and ND (13.1 vs. 4.4%, p = 0.018). The annual thrombosis rate was 0.007, 0.037, and 0.004 in the ND, SS, and BS, respectively. AVF cumulative survival at 5 years was significantly lower in SS (89.5%) compared to BS (100%) and ND (97.4%; p = 0.03). BS had an HR for AVF failure of 1.1, p = 0.955, while the SS presented an HR of 5.9, p = 0.09. Conclusion: AVF clinical monitoring with additional DDU criteria appear to be appropriate for therapeutic referral.

Radio-cephalic arteriovenous fistula recovered with drainage through the brachial vein

Dysfunction of arteriovenous access for hemodialysis is a challenge for the vascular surgeon. Some patients have complex vascular access with problems that are difficult to solve. Careful analysis of the vascular network with ultrasound and dissection of the veins during surgery can help to identify the best option for each access. We introduce and discuss the case of creation of a radio-cephalic fistula with outflow into the brachial vein in 64-year-old hemodialysis male patient. This technique enables extending fistula patency, arterializing the brachial vein, and improves cost efficiency.

Congenital Ocular Motor Apraxia

Purpose

Congenital ocular motor apraxia is a rare disease characterized by defective or absent voluntary and optically induced horizontal saccadic movements. Jerky head movements or thrusts on attempted lateral gaze are a compensatory sign. Most affected children have delayed motor and speech development. Cases associated with systemic diseases, neurologic maldevelopment, metabolic deficits, and chromosomal abnormalities have been described.

Methods

Case report and review of the scientific literature.

Results

The authors describe the ophthalmologic, pediatric, and neurologic evaluations and follow-up of a child with impaired horizontal saccades, jerky head movements, and delayed motor and speech development.

Conclusions

Congenital ocular motor apraxia is an uncommon disorder of ocular motility. Even so, ophthalmologists should be aware of the developmental delay and the other associated conditions, in order to grant the patients the multidisciplinary assistance they often require.

Giant Ruptured Common Iliac Artery Infected Aneurysm

INTRODUCTION

Saccular mycotic aorto-iliac aneurysms are extremely rare and when presented with ruptured, they are an important life- threatening condition.

METHODS

We present a 52 years old male transferred from another Hospital and admitted to the emergency room with a ruptured iliac artery aneurysm.

RESULTS

He complained of persistent fever and abdominal discomfort that swiftly established as hemorrhagic shock. Imagiological study with angioCT revealed a ruptured left common iliac artery saccular aneurysm with 90mm. The patient was instantaneously and successfully submitted to endoaneurismorraphy, common and external iliac artery ligation and construction of an extra anatomic bypass, right to left femoro-femoral 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.

CONCLUSION

Long term antibiotics along with aggressive surgical debridement of the infected tissue and vascular revascularization with an extra anatomic bypass remain the most definitive solution while endovascular aneurysm repair may generally constitute a bridge life-saving procedure in mycotic infected aneurysms. 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.

Aneurysmal Degeneration of the Brachial Artery after Vascular Access Creation: Surgical Treatment Results

True peripheral artery aneurysms proximal to a longstanding arteriovenous fistula is a well-recognized complication. Late aneurysmal degeneration is rare. This study analyzed the characteristics, therapeutic options, and outcomes of true donor brachial artery aneurysms (DBAA) after arteriovenous fistula (AVF) for hemodialysis. We retrospectively collected the data of patients with DBAA after AVF creation, surgically repaired between January 2001 and September 2015. We excluded patients with pseudoaneurysms, anastomotic aneurysms, and infected aneurysms. We recorded patient's demographics, type of access, aneurysm characteristics, symptoms, treatment, and follow-up. Ten patients were treated for aneurysmal degeneration of the brachial artery. Average aneurysm diameter was 37.5 mm. All cases had, at least, one previous distal AVF, ligated or thrombosed, at the time of diagnosis. The first access was created in mean 137 months before the diagnosis of DBAA. Nine patients had previous medical history of renal transplant and were under immunosuppressive therapy. All patients were symptomatic at the time of diagnosis. In all cases, the treatment was aneurysmectomy followed by interposition bypass. One patient developed a postoperative hematoma with the need of surgical drainage. At 50 months of follow-up, one patient was submitted to percutaneous angioplasty due to an anastomotic stenosis. No other complications occurred during the entire follow-up period (mean: 69 months). The pathogenesis underlying DBAA remains unclear. Increased blood flow after AVF creation, immunosuppressive therapy, and ligation/thrombosis of the AVF may contribute to aneurysm formation. Surgical treatment by aneurysmectomy and bypass, with autogenous conducts, is a safe and effective option.

Radio-cephalic fistula recovered with drainage to forearm basilic vein

Dysfunction problems with vascular access are a concern to patients and dialysis units. The vascular surgeon should analyse such dysfunction and perform a careful assessment of the vascular network in order to find new fistula layouts. We introduce and discuss the case of creation of a radio-cephalic fistula with outflow into the forearm basilic vein through rotation of the forearm basilic vein toward the cephalic vein in the forearm of an 88-year-old hemodialysis male patient. This technique enables extending fistula patency and improves cost efficiency.

The Keystone Perforator Island Flap and its Use in Complex Defects of the Trunk: a Case Report

Complex defects of the trunk present a reconstructive challenge and conservative treatment is frequently unsuccessful. Perforator flaps have become a common option for this problem. The keystone perforator island flap (KPIF) is a fasciocutaneous advancement flap, based on randomly located perforators vessels, whose dissection and exposure is not required. Designed in a curvilinear trapezoidal shape, it allows primary closure of large defects, while avoiding secondary defects and minimizing the need for more complex pedicled flaps or microsurgical reconstructive techniques. The clinical case of a 52-year-old male with stable coronary artery disease and severe aortic stenosis, with severe left ventricular dysfunction, who underwent coronary artery bypass graft surgery and aortic valve replacement is presented. During the post-operative period, he developed anterior mediastinitis and presented a large median sternotomy wound dehiscence, refractory to medical treatment and surgical debridement. The patient underwent reconstruction of the defect with a bilateral KPIF and application of VAC therapy, with favorable outcome. The KPIF is an useful and reliable reconstruction technique for complex defects, that has shown shorter operative times, lower risk of total flap necrosis, reduced donor-site morbidity and favorable aesthetic results, making it a good option in patients with multiple comorbidities.

Food and pathogen adaptations in the Angolan Namib desert: Tracing the spread of lactase persistence and human African trypanosomiasis resistance into southwestern Africa

OBJECTIVES

We investigated the frequency distribution and haplotype diversity of human African trypanosomiasis (HAT) resistance and lactase persistence (LP) variants in populations from the Angolan Namib to trace the spread of these genetic adaptations into southwestern Africa.

MATERIALS AND METHODS

We resequenced two fragments of the LCT enhancer and the APOL1 gene and genotyped flanking short tandem repeat loci in six groups with different subsistence traditions living in the Angolan Namib, and in a comparative dataset including other populations from Africa and Europe. LP in the Angolan Namib is represented by the -14010*C allele, which is associated with a predominant haplotype that is shared with other southern and eastern African populations. While LP was found to be more frequent in foragers than in pastoralists, the frequencies of the two APOL1 variants associated with HAT-resistance (G1 and G2) did not differ between the two groups. The G1 allele is mostly associated with a single widespread haplotype. The G2 allele is linked to several haplotypes that are molecularly related to haplotypes found in other African Bantu-speaking populations. The putatively archaic G3 variant displayed more intra-allelic diversity in Africa than in Europe.

DISCUSSION

The LP adaptation was carried to southern Africa by non-Bantu speaking pastoralists from eastern Africa, but an obvious link between its presence in southern Angola and groups speaking languages of the Khoe-Kwadi family, as previously found in other areas, could not be confirmed. The presence of APOL1 variants G1 and G2 is linked to the Bantu expansions. Our results suggest that the G3 variant was retained in modern humans by incomplete lineage sorting.

Abstract P4-01-04: Immunohistochemical and histological features of mammographic dense and non-dense tissue in breast cancer patients

Objective: We investigated immunohistochemical and histological composition of dense and non-dense breast tissue in 18 women undergoing mastectomy as the initial treatment for breast cancer. Materials and Methods: In each mammogram, we localized the dense and the non-dense areas. We used a localization technique based on a linear approximation method with interpolation of mammogram images and breast pictures. The selected areas were retrieved during mastectomy and analyzed. Results: Estrogen and progesterone receptors, Ki-67 and CD-34, were equally expressed in both tissues, as well as the percentage composition of fat. The percentage compositions of brownish spots among dense and non-dense tissues were significantly different (p = 0.0226). The number of terminal ductal lobular units was higher for dense than for non-dense breast tissues (p = 0.0019). In the non-dense breast tissue, there were no proliferative lesions with atypia, while we found flat epithelial atypia in 3 of the dense areas evaluated. Proliferative lesions without atypia and non-proliferative lesions were found in both tissues, but they were more frequent in dense than in non-dense breast tissues (23.5% vs 11.8%, p = 0.0455, and 17.6% vs 2.9%, p = 0.0253, respectively). Fibrosis was more frequently extensive or moderate in dense tissue, while it was predominantly mild in non-dense tissue (p = 0.03). Conclusion: There was no difference in the expression of the estrogen and progesterone receptors, Ki-67 and CD-34, in the dense and non-dense tissue areas in breast-cancer women. In addition, both stroma fibrosis and epithelial proliferation were responsible for higher mammographic density.

Citation Format: dos Santos CC, Marshall P, Torresan R, Tinóis E, Duarte G, Teixeira S. Immunohistochemical and histological features of mammographic dense and non-dense tissue in breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-01-04.

[Acute mesenteric ischemia: the importance of early diagnosis and aggressive revascularization]

AIM

Despite the advances in diagnostic and therapeutic approaches, acute mesenteric ischemia (AMI) remains associated with a dismal prognosis. The goal of this study was to review and report our department's experience in the surgical treatment of AMI and to identify predictive factors of postoperative morbidity and mortality.

MATERIALS AND METHODS

We performed a retrospective analysis of the patients that underwent surgical revascularization after embolic or thrombotic AMI, between January 2008 and December 2015. Patient's comorbidities/cardiovascular risk factors, chosen diagnostic and therapeutic strategies, and postoperative complications were studied.

RESULTS

Fifteen patients (66.7% female) were treated, with a mean age of 68.6±16.3 years (41-88). The most common cause of AMI was embolism (n=9; 60%). The most prevalent cardiovascular risk factor was hypertension (86.7%). All patients complained of abdominal pain, and in 66.7% of cases leukocytosis and elevated lactate dehydrogenase levels were observed. All patients were studied with abdomino-pelvic CT angiography. The mean ischemic time was 27.9±29.5 hours (3-96 hours). Midline laparotomy was performed in 14 patients [thromboendarterectomy of the superior mesenteric artery (SMA) (n=1; 6.7%); embolectomy of the SMA (n=8; 53.3%); mesenteric bypass (n=3; 20%); retrograde PTA and stenting of the SMA (n=2; 13.3%)]. One patient (6.7%) underwent thromboaspiration and catheter fibrinolysis. Four patients required enterectomy (26.7%). Second-look surgery was performed in 9 patients (60%). The 30-day mortality rate was 33%.

CONCLUSIONS

A serum lactate level above 2 mmol/L on admission may be associated with an unfavorable prognosis. Early diagnosis, referral, and rapid revascularization are critical for therapeutic success in AMI.

Dynamic footprint of sequestration in the molecular fluctuations of osteopontin

The sequestration of calcium phosphate by unfolded proteins is fundamental to the stabilization of biofluids supersaturated with respect to hydroxyapatite, such as milk, blood or urine. The unfolded state of osteopontin (OPN) is thought to be a prerequisite for this activity, which leads to the formation of core-shell calcium phosphate nanoclusters. We report on the structures and dynamics of a native OPN peptide from bovine milk, studied by neutron spectroscopy and small-angle X-ray and neutron scattering. The effects of sequestration are quantified on the nanosecond- ångström resolution by elastic incoherent neutron scattering. The molecular fluctuations of the free phosphopeptide are in agreement with a highly flexible protein. An increased resilience to diffusive motions of OPN is corroborated by molecular fluctuations similar to those observed for globular proteins, yet retaining conformational flexibilities. The results bring insight into the modulation of the activity of OPN and phosphopeptides with a role in the control of biomineralization. The quantification of such effects provides an important handle for the future design of new peptides based on the dynamics-activity relationship.

[Renal artery embolism: thromboaspiration and catheter directed thrombolysis - A successful case]

Renal artery embolism is a rare event and is associated with high risk of hypertension and functional renal loss. We report the clinical case of a renal artery embolism, which was treated using a combination of thromboaspiration and catheter directed thrombolysis, as well a short literature review on this subject. A 60-year-old male with previous medical history of atrial septal defect surgical repair and cardiac pacemaker was presented in the Emergency Department with complains of abdominal pain and vomiting. Patient had suspended oral anticoagulation to undergo a dental surgical procedure. The Angio-CT scan revealed a left renal artery occlusion, suggestive of embolism, with infarction of the ipsilateral kidney. We underwent, 36 hours after the beginning of complains, a left renal artery recanalization with recovery of renal perfusion, using percutaneous thromboaspiration and catheter directed thrombolysis. Renal scintigraphy, at the end of first month, showed left kidney differential function of 38.9%. In the follow-up period (32 months), serum creatinine levels stabilized at 1 mg/dL (1.59 at the admission). Percutaneous interventions, including thromboaspiration and catheter directed thrombolysis, can be used effectively to treat renal artery embolism. Clinical suspicion, lenght of evolution and previous development of a collateral circulation network are key factors to achieve a therapeutic success.

[Subclavian Steal Syndrome and Cerebral Hypoperfusion during Hemodialysis: A case report]

Subclavian steal syndrome is caused by retrograde vertebral artery flow "stealing" vertebrobasilar perfusion. We report the clinical case of a 53 year-old dialysis dependent woman with several cardiovascular risk factors, who had episodes of vertebrobasilar insufficiency and resting pain of the left upper extremity, during hemodialysis sessions, through a left arm brachiobasilic arteriovenous fistula. Noninvasive studies demonstrated a preoclusive stenosis at the origin of left subclavian artery, together with a stenosis on the left internal carotid artery superior to 70% and reversion of flow in the left vertebral artery. The patient underwent endarterectomy and Dacron patch angioplasty of the left internal carotid artery and carotid-subclavian ePTFE bypass, with total resolution of the previously described clinical presentation.